De-Intensification from Basal-Bolus Insulin Therapy to Liraglutide in Type 2 Diabetes: Predictive Value of Mean Glycaemia during Fasting Test.

BACKGROUND: Successful conversion from insulin therapy to glucagon-like peptide 1 receptor agonist (GLP-1RA) with basal insulin in well-controlled patients has already been demonstrated. However, the data concerning individuals with poor glycaemic control are scarce. The aim of this work was to assess the success rate of insulin therapy to liraglutide transition in poorly controlled diabetes in a real-world clinical setting and to define predictors of success. We are the first to present the method of a fasting test as a way to identify the patients at higher risk of failure after treatment de-intensification. METHODS: The retrospective observational study analyzed data of 62 poorly controlled obese diabetic patients on high-dose insulin therapy, who were subjected to a 72 h fasting test during hospitalization and subsequently switched to liraglutide ± basal insulin therapy. During the fasting, all antidiabetic treatment was discontinued. Patients were classified as responders if they remained on GLP-1RA treatment after 12 months. Non-responders restarted the basal-bolus insulin (BBI) regimen. Development of glycated hemoglobin (HbA1c) and body weight in both groups, alongside with parameters associated with the higher risk of return to the BBI regimen, were analyzed. RESULTS: A total of 71% of patients were switched successfully (=responders). Responders had more significant improvement in HbA1c (-6.4 ± 19.7 vs. -3.4 ± 22.9 mmol/mol) and weight loss (-4.6 ± 7.1 vs. -2.5 ± 4.0). Statistically significant difference between groups was found in initial HbA1c (75.6 ± 17.9 vs. 90.5 ± 23.6; p = 0.04), total daily dose of insulin (67.6 ± 36.4 vs. 90.8 ± 32.4; p = 0.02), and mean glycaemia during the fasting test (6.9 ± 1.7 vs. 8.6 ± 2.2 mmol/L; p < 0.01). CONCLUSIONS: This study confirms that therapy de-intensification in poorly controlled patients with a BBI regimen is possible. Higher baseline HbA1c, total daily insulin dose, and mean glucose during fasting test are negative predictive factors of successful therapy de-escalation.

Pilsner Modification of Mesh Sacrohysterocolpopexy (PiMMS): An Initial Report on Safety and Efficacy.

INTRODUCTION AND HYPOTHESIS: It is reported that up to 60% of women would prefer to spare their uterus during pelvic organ prolapse (POP) repair surgery. A reliable hysteropexy technique is therefore crucial. We aimed to describe the safety profile and initial core patient-reported and clinical outcomes of the Pilsner modification of laparoscopic mesh sacrohysterocolpopexy (PiMMS) in comparison with the laparoscopic sacrohysterocolpopexy technique (standard laparoscopic sacrohysterocolpopexy [sLSH]) previously used in our unit. METHODS: This was a retrospective cohort study conducted in a single tertiary referral urogynecological center. All patients who underwent laparoscopic mesh sacrohysterocolpopexy between 1 January 2015, and 31 January 2022 were included in the study. Follow-up clinical, patient-reported, and imaging outcomes at the 12-month follow-up time point are presented. RESULTS: A total of 87 patients were included. Of these, 49 (56.3%) and 38 (43.7%) underwent sLSH and PiMMS respectively. Low numbers of perioperative complications were found in both groups with no mesh-related complications reported following PiMMS up to 12 months postoperatively. There were no apical compartment failures in either group. There were 8 (17.0%) vs 1 (2.7%) anterior compartment failures (Ba ≤ -1) in the sLSH and PiMMS groups respectively (p = 0.07) at 12 months. At the 1-year follow-up, 42 (89.4%) patients reported a Patient Global Impression of Improvement score of ≤ 2 in the sLSH groups compared with 35 (94.6%) patients following PiMMS. CONCLUSIONS: The PiMMS technique seems to have comparable safety profile and patient-reported outcomes with the sLSH technique. However, there is a trend toward reduced anterior compartment failures with this modification. The findings of this preliminary report need to be re-evaluated in a well-powered prospective study.

A Comprehensive Evaluation of Sexual Life in Women After Laparoscopic Sacrocolpopexy using PISQ-IR.

INTRODUCTION AND HYPOTHESIS: Although laparoscopic sacrocolpopexy is a recommended procedure for sexually active women, its full impact on sexual life remains underexplored. This study is aimed at comprehensively assessing changes in the quality of sexual life and the prevalence of dyspareunia in women 1 year after laparoscopic sacrocolpopexy. METHODS: This prospective observational study enrolled women undergoing laparoscopic sacrocolpopexy for pelvic organ prolapse stage≥ 2. Included were women with a completed Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA Revised (PISQ-IR) questionnaire before and at 1 year after surgery. Individual domains of the PISQ-IR were compared separately. Dyspareunia, single summary PISQ-IR and PISQ-12 scores were additionally compared in sexually active women. Statistical analyses included paired signed rank, Wilcoxon, Median, Chi-squared, and Fisher tests (p < 0.05). RESULTS: Between February 2015 and December 2019, a total of 333 women were included. Mean age was 61.0 ± 11.2 and 141 (42%) reported being sexually active at baseline. At 12 months postoperatively, sexual activity was preserved in 110 (78%) of these women and an additional 26 women (14%) became sexually active. Both single-summary PISQ-IR (3.4 vs 3.6, p < 0.01) and PISQ-12 (36.0 vs 38.1, p < 0.01) scores increased significantly. The only variable that was associated with deteriorated scores postoperatively was a higher BMI. Individual domain analyses revealed significant improvement in condition-specific and condition-impact domains, except for the desire domain, which deteriorated. Prevalence of dyspareunia decreased post-surgery from 21.8% to 16.4%, p < 0.05. Newly sexually active women were older, had shorter vaginal length preoperatively, but lower PISQ-IR scores postoperatively than sexually inactive women pre- and postoperatively. Women ceasing sexual activity were older and had lower preoperative PISQ-IR scores than sexually active women pre- and postoperatively. CONCLUSIONS: Although the overall rate of sexually active women and sexual desire declined 12 months after sacrocolpopexy, overall sexual function scores improved and the prevalence of dyspareunia decreased.

Importance of vaginal packing after laparoscopic sacrocolpopexy - retrospective study.

OBJECTIVE: To compare the subjective and objective results of laparoscopic sacrocolpopexy (LSC) with and without the introduction of a vaginal packing one year after surgery. Methodology: This is a retrospective cohort study of 125 women after laparoscopic sacrocolpopexy operated on in 2013-2016 with complete annual follow-up. Patients with a total hysterectomy were excluded from the study. Basic patient characteristics, preoperative POP-Q and surgery data were collected. The subjective outcome of the surgery was assessed using the PGI-I (patient global impression of improvement). The anatomic outcome of the surgery was evaluated using the composite definition of surgical failure based on POP-Q (Ba ≥ -1, C ≥ -3, Bp ≥ -1). Patients were divided into two groups according to whether or not they had vaginal packing after surgery. Statistical analysis was performed using c2, Wilcoxon and Fischer test according to the distribution of normality. Results: A total of 125 women were enrolled in the study; 48 (38.4%) after LSC, 58 (46.4%) with concomitant supracervical hysterectomy and 19 (15.2%) after sacrohysterocolpopexy. Vaginal packing was introduced for 24-48 hours after surgery in 86 (68.8%) women. The groups did not differ in age, body mass index, smoking or preoperative pelvic organ prolapse quantification system. We did not observe statistically significant differences in PGI-I first year after surgery. The difference in anatomic surgical failure did not reach statistical significance, although more failures were observed in the group without packing (12.8 vs. 3.5%; P = 0.09). The mean C-point value one year after surgery was lower in the non-tamponade group (-7 vs. -7.5; P < 0.009). No mesh extrusion or serious complications were recorded in the monitored group. Conclusion: Vaginal packing after LSC probably does not affect patient satisfaction after surgery, however, it may be associated with better anatomical outcome one year after the surgery. The results of the study must be confirmed by a more detailed prospective evaluation.

Laparoscopic sacrocolpopexy in the management of recurrent pelvic organ prolapse.

OBJECTIVES: We set out to assess long-term anatomical and functional outcomes in women after laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse. METHODS: All women with a history of pelvic organ prolapse surgery operated between 2005 and 2022 were enrolled in this retrospective observational study. The indication for recurrent POP surgery was a symptomatic stage II and above pelvic organ prolapse. The data from objective urogynecologic examination and subjective patient assessment using validated questionnaires were collected. The last follow-up information was evaluated. The outcomes were compared with preoperative state using Student t-test and Wilcoxon test, p<0.05 was considered significant. RESULTS: 39 women were enrolled in the study. The rate of perioperative complications was very low; no significant hemorrhage, ureteral damage or conversion to laparotomy were observed. The mean follow-up was 40 ± 26.8 months. The postoperative course was not complicated by bowel incarceration, pelvic infection or mesh exposure. We observed a statistically significant elevation of all POP-Q points and decrease in all mean scores of PFDI, PFIQ, Wexner and VAS prolapse bother postoperatively. Improvement in stress urinary incontinence, anal incontinence and constipation was found. CONCLUSIONS: Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse is a safe and effective surgery regardless of the type of the original repair performed. It provides good subjective and anatomical outcomes with a lasting effect on the quality of life in a long-term follow-up.

Impact of laparoscopic sacrocolpopexy (LSC) on sexual function in women with advanced stages of pelvic organ prolapse (POP): A five-year prospective study.

OBJECTIVE: To compare patients undergoing laparoscopic sacrocolpopexy (LSC) for pelvic organ prolapse (POP), in terms of sexual function and surgical anatomical outcomes more than 5-years follow up period. STUDY DESIGN: This is a cohort study of prospectively collected data that includes all women who underwent LSC between July 2005 and December 2021 at a tertiary care center. A total of 228 women were enrolled in this study. Patients completed a validated quality of life questionnaires and were evaluated using the POP-Q, the PFDI-20, PFIQ-7 and the PISQ-12 scores. Patients were divided preoperatively if they are sexually active or not and postoperatively according to the sexual improvement after POP surgery. RESULTS: There was a statistically significant improvement in the PFDI, PFIQ and POPQ score. There was no significant improvement in the PISQ-12 score with more than 5 years follow-up. 76.1 % of patients who were not sexually active preoperatively resumed their sexual activity after the surgery. CONCLUSION: The anatomical correction of a pelvic organ prolapse and pelvic floor disorders by laparoscopic sacrocolpopexy allowed a significant proportion (over ¾) of the women to resume sexual activity whom had not previously been sexually active. However, PISQ 12 scores did not alter significantly in those who were sexually active prior to surgery. Sexual function is a very complex issue affected by multitude of factors among which prolapse seems to be less important.

Long-term development of surgical outcome of laparoscopic sacrohysteropexy with anterior and posterior mesh extension.

INTRODUCTION AND HYPOTHESIS: Long-term durability and functional outcome of laparoscopic sacrohysteropexy (LSH) remains to be confirmed. We set out to assess the development of surgical outcome in women with increasing minimal follow-up. METHODS: All women after LSH with anterior and posterior mesh extension operated for advanced apical uterine prolapse at Geoffroy Saint-Hilaire clinic from July 2005 to June 2020 were enrolled in this retrospective study. Last known follow-up information was used for the analysis and allocation into groups. The surgical success was defined as no prolapse beyond hymen, no symptomatic recurrence or no retreatment. Functional outcome was evaluated from validated questionnaires and presence of pelvic floor disorders. The outcomes were compared with preoperative state using chi-square and Fisher's test; p < 0.05 was considered significant. RESULTS: In total, 270 patients after LSH with a follow-up of up to 14.5 years were enrolled and divided into groups according to their last follow-up length: ≥ 1 year 242, ≥ 3 years 112, ≥ 5 years 76, ≥ 7 years 45 and ≥ 10 years 18 women. Increase of minimal follow-up was associated with gradual decrease in surgical success. Rates of stress urinary incontinence were unchanged by the surgery, while anal incontinence and constipation rates decreased significantly; 14.5% of women were operated on for SUI in the follow-up. The PFDI-20, PFIQ-7 and VAS bother scores decreased significantly regardless of minimal follow-up length. CONCLUSIONS: LSH with anterior and posterior mesh extension is a safe, effective and durable surgery with a positive long-term effect on quality of life. Although the surgical success gradually decreases, LSH remains a surgical success in most women.

Relationship between urethrovesical junction mobility changes and postoperative progression of stress urinary incontinence following sacrospinous ligament fixation - a subanalysis of a multicentre randomized study.

OBJECTIVES: The study aimed to assess the relationship between urethrovesical junction (UVJ) descent and development of de novo stress urinary incontinence (SUI) and postoperative progression of preexisting SUI following surgery for pelvic organ floor prolapse using the method of sacrospinal fixation (SSF). This was a secondary analysis of the SAME prospective randomized multicentre study (reg. no. NCT03053479) comparing three approaches to surgery for apical defects - sacropexy, SSF and transvaginal mesh. METHODS: The subanalysis included 81 patients with apical defects managed by SSF, either right-sided (N = 14, 17.3%) or bilateral (N = 67, 82.7%). Postoperative follow-up was assessed at 3 months (N = 59), 12 months (N = 47) and 24 months (N = 30). UVJ mobility at rest and with maximum effort, the Valsalva manoeuvre was determined using a standardized 3D/ 4D transperineal ultrasound protocol proposed by Dietz et al. De novo SUI and postoperative progression of preexisting SUI were ascertained from history. RESULTS: Preoperative demographic data (N = 81) were as follows: BMI 27.3 kg/ m2 (16.8-44.5), age 67.0 years (31-85), and parity 2 (1-6). Concomitant anterior repair was performed in 65.4%. Postoperative progression of SUI was 45.8% at 3 months, 21.3% at 12 months, and 23.3% at 24 months. There were significant differences between preoperative and postoperative UVJ descent values at 3, 12 and 24 months (P < 0.0001). Correlations between UVJ descent at 3, 12 and 24 months postoperatively and de novo SUI or progression of preexisting SUI at 3, 12 and 24 months postoperatively were not statistically significant (P = 0.051-0.883). Correlations between differences (preoperative UVJ descent minus UVJ descent at 3, 12 and 24 months postoperatively) and de novo SUI or progression of preexisting SUI at 3, 12 and 24 months postoperatively were not statistically significant (P = 0.691-0.779). CONCLUSIONS: The study showed significant changes in UVJ descent values preoperatively and at 3, 12 and 24 months after SSF. There were no significant correlations between UVJ descent and de novo SUI and postoperative progression of preexisting SUI following surgery for pelvic organ floor prolapse at 3-, 12- and 24-month follow-up. There were no signifi cant correlations between differences (preoperative UVJ descent minus UVJ descent at 3, 12 and 24 months postoperatively and de novo SUI and postoperative progression of preexisting SUI following surgery for pelvic organ floor prolapse at 3-, 12- and 24-month follow-up.

Timing of caesarean section and its impact on levator ani musle avulsion at the first subsequent vaginal birth - a pilot study.

OBJECTIVE: The aim of this multicentric observational study was to explore the impact of the timing of cesarean section (SC) on levator (MLA - levator ani musle) avulsion at the first subsequent vaginal birth. METHODS: All women after term vaginal birth following a cesarean section (VBAC) for their second delivery at the Departments of Gynecology and Obstetrics, Faculty of Medicine, Charles University and University Hospital in Pilsen and the 1st Faculty of Medicine, Charles University and General Hospital in Prague, between 2012 and 2016 were identified. Hospital database and surgical notes were used to collect basic characteristics of the patients including the indication and course of their previous delivery. These women were divided into two groups according to indication of prior SC in the previous delivery to women with elective SC and acute SC. All participants were invited for a 4D pelvic floor ultrasound to assess levator trauma. Levator avulsion and the levator hiatus area were assessed off-line from the stored pelvic floor volumes. Data were statistically assessed. RESULTS: A total of 356 women had a VBAC for their second delivery during the study period. Of these, 152 (42.7%) attended the ultrasound examination and full data were available for 141 women for statistical analyses. These were further divided into 80 women after acute SC and 61 women after elective SC. The levator avulsion rate was higher in the elective SC subgroup, but the difference was not significant (26.3 vs. 41.0%, P = 0.0645). No statistical differences in urogenital hiatus enlargement and ballooning were observed. CONCLUSION: VBAC is associated with a significantly higher rate of levator ani avulsion compared to the first vaginal birth in nulliparous women. However, it seems that risk of levator ani avulsion doesnt depend on the timing of SC in previous labor. More studies are needed to confirm the results of this pilot study.

Outcomes of sacrocolpopexy/sacrohysteropexy with mesh placement targeted to affected compartment.

OBJECTIVE: No recommendation regarding the number of meshes to be implanted in laparoscopic genital prolapse surgery exists. Is it necessary to implant a mesh into a compartment that is not affected to prevent its prolapse in the follow-up? Our objective was to compare the long-term outcomes of laparoscopic sacrocolpopexy according to compartments where mesh was implanted. STUDY DESIGN: This is a retrospective cohort study of 328 patients after laparoscopic sacrocolpopexy at our centre in 7/2005 - 3/2021. 294 patients with perioperative data and POP-Q and/or prolapse symptoms in mean follow-up of 42.8 months was available for the outcome analysis. Surgical failure was defined as prolapse beyond hymen, subjective recurrence or retreatment. The women were divided into four groups depending on compartments, where the mesh was implanted. Group A - anterior, group P - posterior, Group AP - compound of patients with anterior or posterior single arm mesh placement and (B), with anterior and posterior arm placement. Groups AP and B were compared for feasibility of single compartment mesh implantation. Comparison of groups A and P allowed assessment of non-inferiority of single anterior vs. posterior compartment placement. The data were compared using Wilcoxon Two Sample test, Chi-square test or Fishers Exact test, p-value < 0.05 was considered statistically significant. RESULTS: A single compartment mesh implantation was associated with shorter operating time and hospital stay and comparable incidence of complications. A statistically significant difference in all POP-Q points in favour of group B was observed, however, with comparable rate of prolapse beyond hymen(6.3%AP vs. 7.8%B). Similar frequency of surgical failure (17.5%AP vs. 13.8%B) and incidence of de novo pelvic floor disorders or pain was observed. Comparison of groups A and P showed higher suspension of point C in group P(-2.6 vs. -4.0, p < 0.05) with no difference in points Ba, Bp, surgical failure rate and de novo pelvic floor disorders. CONCLUSION: Implantation of a single sheet of mesh was not associated with inferior outcome to implantation of mesh to both compartments. Laparoscopic sacrocolpopexy with a single mesh arm placed into the affected compartment along with apical suspension does not induce a de novo prolapse in unoperated compartment.

Laparoscopic synthetic mesh explantation after sacrohysteropexy.

INTRODUCTION: In this video, we present a case of rectal and bladder injury, which occurred during laparoscopic mesh removal following sacrohysteropexy treated 6 months later with a laparoscopic pectopexy. METHODS: We present the case of a 66-year-old woman with a prolapse recurrence after sacrohysteropexy. During the laparoscopic explantation of the mesh, we detected a fixation of the mesh to the bladder and the rectum rather than a fixation to the vaginal walls. Consequently, bladder and rectal injuries occurred during the dissection and were diagnosed and repaired immediately. Due to bowel injury, the treatment of the prolapse was postponed. Six months later, a laparoscopic pectopexy was performed to avoid complications during the repeated dissection of the promontory. The postoperative recovery after the pectopexy was uncomplicated with no short-term prolapse recurrence or postoperative complications. CONCLUSION: Laparoscopy appears to be an efficient approach to mesh explantation. Futhermore, laparoscopic pectopexy seems to be a good approach to secondary prolapse reconstruction after sacrohysteropexy mesh explantation avoiding complications during repeated dissection of the promontory.

Contribution of ultrasound examination in the detection of unexpected uterine and adnexal findings in reconstructive surgery for pelvic organ prolapse.

Objective: Current urogynaecology practice allows preservation of the uterus in pelvic organ prolapse (POP) surgery, thus not reducing oncologic risk. AIM: The aim of the study was to evaluate the efficacy of ultrasound (USG) in dia-gnosing unexpected uterine and adnexal pathologies in women referred for POP. Furthermore, the benefit of USG examination by a specialist in gynaecology-oncology ultrasound was assessed. MATERIALS AND METHODS: All women after a hysterectomy with or without adnexectomy in the course of a POP surgery at our tertiary centre in 2013-2018 with preoperative USG were enrolled in the study. Women with recurrent uterine bleeding, abnormal cytology, using tamoxifen, or women with already dia-gnosed uterine or adnexal pathology were excluded. RESULTS: 289 women were enrolled in the study - 157 (54.3%) expert USG vs. 132 (45.7%) non-expert USG. Abnormal findings were observed on the cervix in one case (non-expert USG), the endometrium 30 (10.4%) cases - 13 (8.3%) expert vs. 17 (12.9%) non-expert USG, the adnexa three (2.3%) cases (all non-expert USG), and no suspicion of malignancy on myometrium was observed. USG was false negative in four (1.4%) cases - two (1.3%) expert vs. two (1.5%) non-expert USG. Conversely, the examination was false positive in 34 (11.8%) cases - 13 (8.3%) expert vs. 21 (15.9%) non-expert USG. CONCLUSION: The risk of unexpected uterine or adnexal pathologies in POP surgery was 1.4%. The agreement between USG and histopathological benign, abnormal or malign findings was 87.2%. A sonographer specialized in oncologic sonography is able to reduce the number of false positive findings; however, this does not increase the sensitivity of the ultrasound.

Effect of Age on Complications Rate and Surgical Outcomes in Women Undergoing Laparoscopic Sacrohysteropexy and Sacrocolpopexy.

STUDY OBJECTIVE: To compare perioperative and long-term outcomes of laparoscopic sacrohysteropexy/sacrocolpopexy in different groups of age. DESIGN: This was a retrospective cohort study. Patients were evaluated preoperatively and postoperatively (starting from 1 month after surgery and then annually). SETTING: The department of functional pelvic surgery and oncology, a tertiary care center. PATIENTS: All patients who underwent laparoscopic sacrohysteropexy/sacrocolpopexy, between July 2005 and December 2019. INTERVENTIONS: Laparoscopic sacrohysteropexy/sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: The study population was divided into 3 groups, according to age at the time of surgery: group 1, <65 years; group 2, between 65 and 75 years, and group 3, >75 years. The primary outcome was the rate of perioperative complications. The secondary outcome was the comparison of long-term results among the groups. A total of 330 patients were included: in group 1, 183 patients (mean age 53.4 ± 8.2), in group 2, 92 patients (mean age 69.2 ± 2.9), and in group 3, 55 patients (mean age 79.3 ± 3.5). The overall perioperative complications rate (up to 30 days after surgery) was 5.7%. No differences among the groups in operative details and rates of perioperative complications were observed. During the follow-up period, 37 patients (11.2%) presented with prolapse recurrence (objective and/or subjective); the rates of prolapse recurrence and long-term complications were similar among the groups. Similarly, the groups did not differ in postoperative functional results except for postoperative stress urinary incontinence. A surgery for stress urinary incontinence was more common among patients in group 3 (group 1, 13.4%; group 2, 11.9%; group 3, 31.3%; p = .008). CONCLUSION: Laparoscopic sacrohysteropexy/sacrocolpopexy is associated with low rates of perioperative and long-term complications. We did not find a difference in rates of complications and/or long-term outcomes, between different age groups.

Musculoskeletal lower back load of accoucheurs during childbirth - A pilot and feasibility study.

INTRODUCTION: Back problems represent one of the leading causes of accouchers' work-related musculoskeletal morbidities. The correct execution of birth-related maneuvers including manual perineal protection is crucial not only for the mother and child but also for obstetricians and midwives to reduce any strain on their musculoskeletal system. Therefore, the overall aim of this study was to test the feasibility of determining the effect of different accouchers' postures (standing and kneeling) on their musculoskeletal system. METHODS: The biomechanical analysis is based on musculoskeletal simulations that included motion recordings of real deliveries as well as deliveries conducted on a birthing simulator. These simulations were then used to determine individual joints' loads. RESULTS: In the kneeling posture, both a low intra-operator variability and a lower average maximum load of the lower back was observed. For the standing position the spine load was reduced by pivoting the elbow on the accouchers' thigh, which in turn was associated with a significantly greater load on the shoulder joint. CONCLUSION: The study demonstrated the feasibility of our technique to assess joints loads. It also provided initial data indicating that a posture that reduces spinal flexion and tilt, achieved in this study by the kneeling, can significantly reduce the strain on the practitioner's musculoskeletal system.

Finite element modeling of maximum stress in pelvic floor structures during the head expulsion (FINESSE) study.

INTRODUCTION AND HYPOTHESIS: Several studies have assessed birth-related deformations of the levator ani muscle (LAM) and perineum on models that depicted these elements in isolation. The main aim of this study was to develop a complex female pelvic floor computational model using the finite element method to evaluate points and timing of maximum stress at the LAM and perineum in relation to the birth process. METHODS: A three-dimensional computational model of the female pelvic floor was created and used to simulate vaginal birth based on data from previously described real-life MRI scans. We developed three models: model A (LAM without perineum); model B (perineum without LAM); model C (a combined model with both structures). RESULTS: The maximum stress in the LAM was achieved when the vertex was 9 cm below the ischial spines and measured 37.3 MPa in model A and 88.7 MPa in model C. The maximum stress in the perineum occurred at the time of distension by the suboocipito-frontal diameter and reached 86.7 MPa and 119.6 MPa in models B and C, respectively, while the stress in the posterior fourchette caused by the suboccipito-bregmatic diameter measured 36.9 MPa for model B and 39.8 MPa for model C. CONCLUSIONS: Including perineal structures in a computational birth model simulation affects the level of stress at the LAM. The maximum stress at the LAM and perineum seems to occur when the head is lower than previously anticipated.

Pelvic organ prolapse and uterine preservation: a cohort study (POP-UP study).

BACKGROUND: Abdominal and laparoscopic sacro-colpopexy (LSC) is considered the standard surgical option for the management of a symptomatic apical pelvic organ prolapse (POP). Women who have their uterus, and for whom an LSC is indicated, can have a laparoscopic sacro-hysteropexy (LSH), a laparoscopic supra-cervical hysterectomy and laparoscopic sacro-cervicopexy (LSCH + LSC) or a total laparoscopic hysterectomy and laparoscopic sacro-colpopexy (TLH + LSC). The main aim of this study was to compare clinical and patient reported outcomes of uterine sparing versus concomitant hysterectomy LSC procedures. METHODS: A retrospective analysis of clinical, imaging and patient reported outcomes at baseline, 3 and 12 months after LSH versus either LSCH + LSC or TLH + LSC between January 2015 and January 2019 in a tertiary referral urogynecology center in Pilsen, the Czech Republic. RESULTS: In total, 294 women were included in this analysis (LSH n = 43, LSCH + LSC n = 208 and TLH + LSC n = 43). There were no differences in the incidence of perioperative injuries and complications. There were no statistically significant differences between the concomitant hysterectomy and the uterine sparing groups in any of the operative, clinical or patient reported outcomes except for a significantly lower anterior compartment failure rate (p = 0.017) and higher optimal mesh placement rate at 12 months in women who had concomitant hysterectomy procedures (p = 0.006). CONCLUSION: LSH seems to be associated with higher incidence of anterior compartment failures and suboptimal mesh placement based on postoperative imaging techniques compared to LSC with concomitant hysterectomy.

Feasibility and safety of antepartum tactile imaging.

INTRODUCTION AND HYPOTHESIS: Quantitative characterization of the birth canal and critical structures before delivery may provide risk assessment for maternal birth injury. The objective of this study was to explore imaging capability of an antepartum tactile imaging (ATI) probe. METHODS: Twenty randomly selected women older than 21 years with completed 35th week of pregnancy and a premise of vaginal delivery were enrolled in the feasibility study. The biomechanical data were acquired using the ATI probe with a double-curved surface, shaped according to the fetal skull and equipped with 168 tactile sensors and an electromagnetic motion tracking sensor. Software package COMSOL Multiphysics was used for finite element modeling. Subjects were asked for assessment of pain and comfort levels experienced during the ATI examination. RESULTS: All 20 nulliparous women were successfully examined with the ATI. Mean age was 27.8 ± 4.1 years, BMI 30.7 ± 5.8, and week of pregnancy 38.8 ± 1.4. Biomechanical mapping with the ATI allowed real-time observation of the probe location, applied load to the vaginal walls, and a 3D tactile image composition. The nonlinear finite element model describing the stress-strain relationship of the pelvic tissue was developed and used for calculation of Young's modulus (E). Average perineal elastic modulus was 11.1 ± 4.3 kPa, levator ani 4.8 ± 2.4 kPa, and symphysis-perineum distance was 30.1 ± 6.9 mm. The pain assessment level for the ATI examination was 2.1 ± 0.8 (scale 1-4); the comfort level was 2.05 ± 0.69 (scale 1-3). CONCLUSIONS: The antepartum examination with the ATI probe allowed measurement of the tissue elasticity and anatomical distances. The pain level was low and the comfort level was comparable with manual palpation.

Pelvic organ prolapse and uterine preservation: a survey of female gynecologists (POP-UP survey).

BACKGROUND: The aim of this study was to explore the personal views of female gynecologists regarding the management of POP with a particular focus on the issue of uterine sparing surgery. METHODS: A questionnaire based survey of practicing female gynecologists in the Czech Republic, Slovenia and Slovakia. RESULTS: A total of 140 female gynecologists from 81 units responded to our questionnaire. The majority of respondents stated they would rely on a urogynecologist to aid them with their choice of POP management options. The most preferred options for POP management were sacrocolpopexy and physiotherapy. Almost 2/3 of respondents opted for a hysterectomy together with POP surgery, if they were menopausal, even if the anatomical outcome was similar to uterine sparing POP surgery. Moreover, 81.4% of respondents, who initially opted for a uterine sparing procedure, changed their mind if the anatomical success of POP surgery with concomitant hysterectomy was superior. Discussing uterine cancer risk in relation to other organs had a less significant impact on their choices. CONCLUSIONS: The majority of female gynecologists in our study opted for hysterectomy if they were postmenopausal at the time of POP surgery. However, variation in information provision had an impact on their choice.