Impact on Sexual Function and Wish for Subsequent Pregnancy after Uterus-Preserving Prolapse Surgery in Premenopausal Women.

(1) Background: Pelvic organ prolapse (POP) affects millions of women globally, impacting their quality of life and potentially influencing family planning decisions. This study aimed to assess the impact of uterus-preserving prolapse surgery on the sexual function, desire for children, and pregnancy outcomes in premenopausal women with symptomatic POP. (2) Methods: A survey study was conducted among patients who underwent sacrospinous hysteropexy at a tertiary hospital between 2001 and 2021. Telephone interviews were performed to gather data on sexual function, desire for children, and satisfaction with surgical outcomes. (3) Results: The study included 33 premenopausal women, revealing diverse factors influencing sexual activity and desire for children following surgery. While most of the participants expressed a desire for children after surgery, sexually inactive individuals were more likely to report an unfulfilled desire for children. Fear of incontinence during sexual activity emerged as a significant concern for the sexually inactive participants. (4) Conclusions: The study highlights the need for comprehensive counselling and tailored interventions to address the multifaceted needs of women with POP. Further research is warranted to highlight the long-term implications of uterus-preserving surgeries on women's health and well-being.

Comparison of Vaginal Pessaries to Standard Care or Pelvic Floor Muscle Training for Treating Postpartum Urinary Incontinence: a Pragmatic Randomized Controlled Trial.

Introduction: To compare three conservative treatment options, standard care, pelvic floor muscle training (PFMT), and vaginal pessaries, for postpartum urinary incontinence (UI) that are accessible to most patients and practitioners in a generalizable cohort. Materials and Methods: A multicenter, open-label, parallel group, pragmatic randomized controlled clinical trial comparing standard care, PFMT, and vaginal cube pessary for postpartum urinary incontinence was conducted in six outpatient clinics. Sample size was based on large treatment effects (Cramers' V > 0.35) with a power of 80% and an alpha of 0.05 for a 3 × 3 contingency table, 44 patients needed to be included in the trial. Outcomes were analyzed according to the intention-to-treat principle. Group comparisons were made using analysis of variance (ANOVA), Kruskal-Wallis, and chi-square test as appropriate. P < 0.05 was considered statistically significant. Results: Of the 516 women screened, 111 presented with postpartum UI. Of these, 52 were randomized to one of three treatment groups: standard care (n = 17), pelvic floor muscle training (n = 17), or vaginal cube pessary (n = 18). After 12 weeks of treatment, treatment success, as measured by patient satisfaction, was significantly higher in the vaginal pessary group (77.8%, n = 14/18), compared to the standard care group (41.2%, n = 7/17), and the PFMT (23.5%, n = 4/17; χ 2 2,n = 52  = 14.55; p = 0.006, Cramer-V = 0.374). No adverse events were reported. SUI and MUI accounted for 88.4% of postpartum UI. Conclusion: Vaginal pessaries were superior to standard care or PFMT to satisfyingly reduce postpartum UI symptoms. No complications were found.

Subjective Long-Term Outcomes After Vaginal Native Tissue Hysteropexy: Cohort Study.

IMPORTANCE: There are still doubts about long-term satisfaction rates of native tissue uterine preserving surgical techniques for pelvic organ prolapse. OBJECTIVE: The objective of this study was to compare long-term subjective success rates and satisfaction rates between vaginal sacrospinous hysteropexy (SSHP) and vaginal hysterectomy with uterosacral ligament suspension (VH-USLS). STUDY DESIGN: This was a retrospective single-center, observational matched cohort study in women receiving either SSHP or VH-USLS between 2004 and 2021. Primary outcome was overall subjective success (combined outcome of absence of bulge nor retreatment, and satisfaction with operation) at least 12 months after surgery. Satisfaction with the operation was defined as a combined Patient Global Impression of Improvement rating ≤ 2 and a patient satisfaction score ≥7. RESULTS: Of 583 patients, 192 patients could be matched (SSHP, 96; VH-USLS, 96), with 55% (SSHP, 60; VH-USLS, 45) participating at the telephone interview. Mean follow-up time was 77 months for VH-USLS, and 36 months for SSHP, respectively. No difference in overall subjective success rates was found between the groups (45% VH-USLS and 51% SSHP; P = 0.54). Overall satisfaction was similar between both groups (70% vs 71%, P = 0.90). Logistic regression found no influence of duration of follow-up and the overall subjective success rate. Both procedures would be recommended to a relative or friend by a large majority of patients (88% vs 85%, P = 0.761). Operative time and hospitalization time were significantly shorter in the SSHP group. No serious complications were reported. CONCLUSIONS: Overall success rates did not differ between both procedures after at least 1 year of follow-up with relatively high satisfaction rates. Sacrospinous hysteropexy had shorter operative time and shorter duration of hospitalization.

Long-term adherence to pessary use in women with pelvic organ prolapse: A retrospective cohort study.

PURPOSE OF THE RESEARCH: Vaginal pessary use is an established, non-surgical treatment option for pelvic organ prolapse. While satisfaction rates are initially high, they seem to decline over time. We aimed to determine the median duration of pessary use among our patients and to evaluate reasons for discontinuation. METHODS: All patients who were treated with a vaginal pessary for pelvic organ prolapse between 2007 and 2022 at our institution (a maximum observation period of 15 years) were included in this retrospective cohort study. Data were collected from the in-house electronic databases and the date of pelvic floor surgery was defined as the primary endpoint. In case of no documented surgery, the date of the last follow-up visit (for patients lost to follow-up or who discontinued pessary use without subsequent surgery) or the date of final data collection (for those with presumed continued pessary use) was used as the primary endpoint. Duration of pessary use is represented by Kaplan-Meier curves. Effects of possible confounders were investigated by Cox regression models. A Cox regression model was evaluated for patients with the three most common types of pessary: ring, cube and shell. A chi-square test was performed to compare therapy adherence according to pessary type. PRINCIPAL RESULTS: Data of 779 patients could be included in the statistical analysis. The estimated median duration of pessary use was 173 weeks (95 % CI 104-473) - approximately 3.3 years. Overall, 30 % of patients opted for surgical therapy and the majority of them did so within 4 months of initiation of pessary use (median time: 19 weeks, 95 % CI 16-26). In 5 % of cases a discontinuation of pessary use without subsequent surgery was documented and 18 % were lost to follow-up before a planned visit, thus leaving 47 % of our patients with presumed continued pessary use. Possible confounding factors for discontinuation of pessary use were tested but were found to be non-significant (body mass index, Pelvic Organ Prolapse - Quantification score, pelvic floor training, age, parity, menopausal status, nicotine consumption, incontinence or size of pessary). Reasons for discontinuation of pessary use were documented in 51 % of patients: unspecified patient wish (23 %), pessary use tiredness (10 %), general dissatisfaction with pessary therapy (7 %), unspecified reasons (5 %), pessary self-change not possible (1 %), erosion, bleeding, pain (2 %); none of the pessary types fitted (2 %). CONCLUSIONS: According to our data, almost half of our patients with pelvic organ prolapse and pessary therapy continued pessary use until a maximum follow-up time of 15 years, whereas about one-third of patients finally opted for surgical repair (a majority of these within 4 months after pessary therapy initiation). The remaining patients were either lost to follow-up or discontinued pessary use without subsequent surgery. The stated reasons for discontinuation of pessary use were mostly non-specific, but only 1 % reported that pessary self-change was not possible. Erosion bleeding or pain was documented in only 2 % of cases as reason for discontinuation. This information helps clinicians to inform their patients with pelvic organ prolapse about expected pessary therapy success and strengthens individual counselling. Furthermore, our data indicates vaginal pessary use for pelvic organ prolapse is feasible and safe for all women and that therapy adherence can extend beyond 5 years.

Sacrospinous Hysteropexy Versus Prolapse Hysterectomy with Apical Fixation: A Retrospective Comparison over an 18 Year Period.

BACKGROUND: Pelvic organ prolapse (POP) is a common health problem, with a high lifetime risk for prolapse surgery. Uterine-preserving procedures such as vaginal sacrospinous hysteropexy (SSH) have become an increasingly utilized surgical option for the primary treatment of POP. We wanted to evaluate peri- and postoperative outcome parameters of SSH as an alternative to vaginal hysterectomy with apical fixation. METHODS: A retrospective cohort study was conducted (2003-2021). All patients who underwent primary SSH (study group) for symptomatic POP were matched 1:1 by age and BMI with patients who underwent primary prolapse hysterectomy with apical fixation (control group). RESULTS: A total of 192 patients were included with 96 patients in the each of the SSH and hysterectomy groups. There were no statistically significant differences in baseline characteristics. The SSH group show a significantly shorter mean surgery time (p < 0.001), significantly fewer hospitalization days (p < 0.001), and significantly less intraoperative blood loss (p = 0.033) in comparison to the control group. Neither group had any intraoperative complication, or an intraoperative conversion to other surgical management options. No statistically significant difference was found in postoperative complications as categorized by the Clavien-Dindo classification or in postoperative urogynecological issues (UTI, de-novo, incontinence, residual urine, voiding disorders). Through log regression, none of the confounding factors such as age, BMI, or preoperative POP-Q stage could be identified as independent risk factors for the occurrence of postoperative complications. CONCLUSIONS: Our results confirm that a uterus-preserving technique has many benefits and, thus, should be considered as an additional intermediate step in a long-term treatment plan of pelvic organ prolapse.

Robotically assisted laparoscopic lateral suspension: a step-by-step approach aiming to standardize a novel procedure.

INTRODUCTION AND HYPOTHESIS: The aim of this video is to show a step-by-step approach to robotically assisted laparoscopic lateral suspension for pelvic organ prolapse aiming to standardize this procedure. METHODS: This video shows a robotically assisted laparoscopic approach to a POP-Q stage 3 prolapse with a combined anterior and apical defect. First, the trocars are positioned, with one 8-mm trocar, two lateral trocars 5 cm above the anterior-superior iliac spine, and a 10-mm assistant trocar either paraumbilically or suprapubically. Second, the uterovesical pouch is dissected up to 2 cm above the level of the bladder neck. The mesh is then fixed to the vesicovaginal fascia and to the isthmus uteri. Next, a laparoscopic forceps is inserted retroperitoneally through the lateral trocars and the lateral arms of the mesh are pulled retroperitoneally. The peritoneum of the uterovesical fold is sutured, including round ligament plication. Finally, the lateral arms of the peritoneum are fixed to the peritoneum of the abdominal wall. CONCLUSIONS: Robotically assisted laparoscopic lateral suspension is a safe alternative to laparoscopic and robotically assisted laparoscopic sacropexy and very well suited for uterine-preserving POP surgery. This video contributes to the standardization of this procedure, and we believe our video to be useful in helping urogynecologists to perform this innovative procedure.

Perioperative Techniques for the Use of Botulinum Toxin in Overactive Bladder: Results of a Multinational Online Survey of Urogynecologists in Germany, Austria, and Switzerland.

INTRODUCTION AND HYPOTHESIS: Botulinum toxin (BoNT) is a widely used treatment for overactive bladder (OAB). Despite its common use, no standardized treatment regimen exists so far. The aim of this survey was to evaluate the variation in perioperative treatment strategies among members of the German-speaking urogynecologic societies. MATERIALS AND METHODS: A clinical practice online survey was carried out between May 2021 and May 2022, and all members of the German, Swiss, and Austrian urogynecologic societies were invited to participate. Participants were grouped in two ways. First, they were grouped into (1) urogynecologists with board certification and (2) non-board-certified general obstetricians and gynecologists (OBGYNs). Second, we set a cut-off at 20 transurethral BoNT procedures per year to differentiate between (1) high- and (2) low-volume surgeons. RESULTS: One hundred and six completed questionnaires were received. Our results demonstrated that BoNT is mostly used as a third-line treatment (93%, n = 98/106), while high-volume surgeons used it significantly more often as a first/second-line treatment (21% vs. 6%, p = 0.029). Large variations existed in the use of perioperative antibiotics, preferred sites of injection, the number of injections, and the timing of the measurement of the postvoid residual volume (PVRV). Forty percent of participants did not offer outpatient treatment to patients. Local anesthesia (LA) was mostly used by board-certified urogynecologists (49% vs. 10%, p < 0.001) and high-volume surgeons (58% vs. 27%, p = 0.002). Injections into the trigone were also more often performed by board-certified urogynecologists and high-volume surgeons (22% vs. 3% (p = 0.023) and 35% vs. 6% (p < 0.001), respectively). PVRV was controlled between weeks 1 and 4 by only 54% of participants (n = 57/106). Clean intermittent self-catheterization (CISC) was infrequently taught (26%). CONCLUSIONS: Our survey confirmed that BoNT is widely used by urogynecologists in the three German-speaking countries, but practice patterns vary widely, and no standardized method could be detected, despite interviewing urogynecologic experts. These results clearly demonstrate that there is a need for studies to define standardized treatment strategies for the best perioperative and surgical approach regarding the use of BoNT in patients with OAB.

Characteristics of the Urinary Proteome in Women with Overactive Bladder Syndrome: A Case-Control Study.

Despite an estimated prevalence of 13% in women, the exact etiology of non-neurogenic overactive bladder syndrome is unclear. The aim of our study was to gain a better understanding of the pathophysiology of female overactive bladder syndrome by mapping the urinary proteomic profile. We collected urine samples of 20 patients with overactive bladder syndrome and of 20 controls. We used mass spectrometric analysis for label-free quantitation, Swissprot human database for data search, Scaffold for data allocation and the Reactome Knowledgebase for final pathway enrichment analysis. We identified 1897 proteins at a false discovery rate of 1% and significance level p < 0.001. Thirty-seven significant proteins of the case group and 53 of the control group met the criteria for further pathway analysis (p < 0.0003 and Log2 (fold change) >2). Significant proteins of the overactive bladder group were, according to the 25 most relevant pathways, mainly involved in cellular response to stress and apoptosis. In the control group, significant pathways mainly concerned immunological, microbial-protective processes and tissue- elasticity processes. These findings may suggest a loss of protective factors as well as increased cellular response to stress and apoptosis in overactive bladder syndrome.

Uterus preservation is superior to hysterectomy when performing laparoscopic lateral suspension with mesh.

INTRODUCTION AND HYPOTHESIS: We aimed to compare differences between laparoscopic lateral suspension with mesh (LLS) performed with supracervical hysterectomy (LLSHE) and without hysterectomy (LLSUP). METHODS: We retrospectively collected data from women operated by a single surgeon between 2003 and 2011. From a total of 339 women with symptomatic anterior and/or apical pelvic organ prolapse (POP) and an intact uterus, 224 had LLSUP (70.4%) and 94 had LLSHE (29.6%). Three hundred and sixteen patients were examined at 1 year. Primary outcomes were objective and subjective success at 1 year during clinical evaluation. Secondary outcomes were complications (Clavien-Dindo scale) and mesh exposure. Patient satisfaction was evaluated by telephone interview using a 10-point scale and the Patient Global Impression of Improvement Scale (PGI-I). RESULTS: LLSUP and LLSHE did not differ for age (mean 57 and 55 years, respectively), preoperative status, complications, and participation at the interview (52 vs 53%). LLSHE is associated with higher mesh exposure (6.5 vs 1.3%, p = 0.014) and more frequent use of Mersilene. Titanium-coated and noncoated polypropylene was more frequently used in LLSUP. At 1 year, both anatomic success rate for the anterior compartment (98.7 vs 94.6%, p = 0.021) and subjective success rate (83.5 vs 72.8%, p = 0.035) were higher for LLSUP. Without hysterectomy, patients more often improved (90.5 vs 76.5%, p = 0.013) and would more frequently recommend the procedure (94.5 vs 80.4%, p = 0.004). CONCLUSIONS: LLS with or without hysterectomy is a safe technique with high patient satisfaction. The uterus-preserving approach appears to result in better anatomic outcome for the anterior compartment, better subjective outcome, and higher patient satisfaction.

Prevalence of undiagnosed uterine leiomyosarcoma in women undergoing hysterectomy or myomectomy for benign indications.

OBJECTIVE: To determine the prevalence of undiagnosed uterine leiomyosarcoma (LMS) in women undergoing hysterectomy or myomectomy for suspected benign leiomyomas. STUDY DESIGN: Retrospective, single-centre, cohort study. Information for all gynaecological procedures for suspected benign leiomyomas between 1993 and 2016 was extracted from the hospital database. The prevalence of LMS was calculated by surgery type and age group. RESULTS: The prevalence of LMS was 1.7/1000 [one in 603 women; 95% confidence interval (CI) 0.8-3.4] for all procedures combined. The prevalence of LMS was 1.1/1000 (one in 875 women; 95% CI 0.4-2.9) for all hysterectomies combined and 4.2/1000 (one in 240 women; 95% CI 1.4-12.2) for all myomectomies combined. For women aged <50years, the prevalence of LMS was 5.4/1000 (one in 187 women; 95% CI 1.8-15.6) for abdominal hysterectomies, 1.0/1000 (one in 1040 women; 95% CI 0.2-5.4) for laparoscopic hysterectomies, 5.2/1000 (one in 191 women; 95% CI 0.9-29.1) for abdominal myomectomies, 3.0/1000 (one in 332 women; 95% CI 0.5-16.9) for laparoscopic myomectomies and 8.6/1000 (one in 116 women; 95% CI 1.5-47.2) for hysteroscopic myomectomies. CONCLUSIONS: Occult LMS is a rare malignant disease. This study found that the prevalence of LMS was higher in women undergoing myomectomy compared with women undergoing hysterectomy. The highest prevalence of LMS was found in women undergoing hysteroscopic myomectomy.

Patient satisfaction after laparoscopic lateral suspension with mesh for pelvic organ prolapse: outcome report of a continuous series of 417 patients.

INTRODUCTION AND HYPOTHESIS: Sacropexy is considered the gold standard for the treatment of pelvic organ prolapse (POP) although dissection of the promontory may be challenging, particularly in obese women. Laparoscopic lateral suspension with mesh (LLS) could be an alternative. METHODS: LLS provides lateral attachment by fibrosis of a vesicovaginal mesh. Clinical evaluation was performed at 1 year using the simplified POP quantification system (POP-Q). Primary outcomes were objective and subjective cure at 1 year. After a mean of 7.2 years the rates of reoperation and complications were assessed as secondary outcomes. Patient satisfaction was evaluated by telephone interview using a ten-point-scale and the PGI-I scale. Factors predicting satisfaction were determined by logistic regression analysis. RESULTS: A total of 417 patients were treated between 2003 and 2011. At 1 year 78.4% of patients were asymptomatic and anatomic success rates were 91.6% for the anterior compartment, 93.6% for the apical compartment and 85.3% for the posterior compartment. The complication rate of Clavien-Dindo grade III or higher was 2.2%. The mesh exposure rate was 4.3% and the reoperation rate was 7.3%. Of the 417 patients, 214 participated in the telephone interview. Over 85% rated their situation as improved and satisfaction was associated with the absence of concomitant hysterectomy. CONCLUSIONS: LLS is a safe technique with promising results in terms of a composite outcome, low complication rates and high long-term patient satisfaction. However, a randomized controlled trial is needed to establish the technique as an alternative to sacropexy in the treatment of POP in obese and high morbidity patients.

Uterus-preserving laparoscopic lateral suspension with mesh for pelvic organ prolapse: a patient-centred outcome report and video of a continuous series of 245 patients.

INTRODUCTION AND HYPOTHESIS: Changes in the psychological value of reproductive organs have led to a growing interest in uterine-preserving surgery for pelvic organ prolapse (POP). Sacral hysteropexy is considered as gold standard, although dissection of the promontory may be challenging. We show a video and present a report on a series of patients operated by laparoscopic lateral suspension with mesh as an alternative. METHODS: Clinical evaluation was performed using the simplified Pelvic Organ Prolapse Quantification System (POP-Q). Primary outcomes were subjective and objective cure; secondary outcomes were rates for reoperation and complications. We assessed patient's satisfaction in a telephone interview using a visual analogue scale and the Patient Global Impression of Improvement Scale (PGI-I) scale. RESULTS: Two hundred and fifty-four patients were treated between 2004 and 2011 with a median follow-up of 7.5 years. At 1 year 82.7 % of patients were asymptomatic, and anatomic success rates were 88.2 % for the anterior, 86.1 % for the apical and 80.8 % for the posterior compartment; 1.2 % had mesh exposure, and the reoperation rate was 7.4 %. More than 80 % of patients were highly satisfied with the outcome. CONCLUSIONS: Uterine-preserving laparoscopic lateral suspension with mesh is a safe technique with promising results and low complication rates. It may be an alternative to sacral hysteropexy for high-morbidity patients.