Colporrhaphy compared with mesh or graft-reinforced vaginal paravaginal repair for anterior vaginal wall prolapse: a randomized controlled trial.

OBJECTIVE: To report 2-year outcomes of a randomized controlled trial comparing standard anterior colporrhaphy with reinforced vaginal paravaginal repair using xenograft or synthetic mesh in women with symptomatic anterior vaginal wall prolapse. METHODS: Women with stage II or greater anterior prolapse were randomly assigned to three groups: anterior colporrhaphy, paravaginal repair with porcine dermis, or polypropylene mesh. Outcomes of prolapse stage, quality of life, degree of bother, and sexual symptoms were assessed by blinded examiners and validated measures at 2 years. Anatomic failure was defined as anterior prolapse at stage II or greater. Composite failure was defined as symptoms of "bulge" and anterior prolapse at stage II or greater. Power calculations determined 33 participants per arm would detect a 40% difference in anatomic success between standard and grafted repair. χ, Mann-Whitney U, and Student's t tests were used for comparisons. RESULTS: Of the 99 participants enrolled, 78 (79%) completed a minimum of 2-year follow-up. Those with mesh had a significantly lower anatomic failure rate (18%) than both the porcine (46%, P=.015) and colporrhaphy groups (58%, P=.002). All groups had statistically similar reductions in their prolapse and urinary symptom subscale scores. Composite failure was not statistically different between groups: 13% colporrhaphy, 12% porcine, and 4% mesh. Two reoperations for anterior prolapse occurred in the porcine group. Mesh erosion rates were 14% for the mesh group. CONCLUSION: Vaginal paravaginal repair with polypropylene mesh has the lowest anatomic failure rate when compared with that with xenograft and anterior colporrhaphy without differences in composite failures. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT0139171. LEVEL OF EVIDENCE: I.

Maternal ethnicity influences on neonatal respiratory outcomes after antenatal corticosteroid use for anticipated preterm delivery.

OBJECTIVE: To explore the influence of maternal ethnicity on neonatal outcomes after antenatal corticosteroid administration. METHODS: A retrospective review of ethnicity, maternal factors, and neonatal birth outcomes was performed for preterm births at a single institution. Cases were limited to women who received antenatal corticosteroids. The impact of ethnicity on specific neonatal respiratory outcomes and mortality was analyzed by bivariate comparisons and by logistic regression analysis. RESULTS: Complete ethnicity data were obtained for 548 women. Controlling for gestational age at delivery, diabetes, whether the subject completed a course of steroids, and the dosing of the steroids, logistic regression demonstrated that ethnicity was independently associated with respiratory distress syndrome (compared to Caucasians: African-Americans OR 0.49 (95% CI 0.29-0.85); Filipinos OR 0.45 (95% CI 0.21-0.96). CONCLUSIONS: Ethnicity is independently associated with neonatal respiratory outcomes after antenatal corticosteroid use. Perhaps individualized dosing of antenatal corticosteroids is needed to further improve neonatal outcomes.

Can urethral mobility be assessed using the pelvic organ prolapse quantification system? An analysis of the correlation between point Aa and Q-tip angle in varying stages of prolapse.

OBJECTIVES: To determine whether the Pelvic Organ Prolapse-Quantification (POP-Q) system can be used as a replacement for Q-tip testing to assess urethral mobility in women. METHODS: We performed a retrospective review of a clinical database of 1490 patients presenting to a urogynecology clinic. The evaluation included both Q-tip straining angle and POP-Q examination. Urethral hypermobility was defined by the Q-tip test as a straining angle of 30 degrees or greater relative to the horizontal. The correlation between point Aa of the POP-Q system and the maximal Q-tip straining angle was determined using the Spearman correlation coefficient. RESULTS: The mean age of the 1490 patients was 59.5 +/- 13.1 years; the median parity was 2. A total of 62 patients (4.2%) reported prior surgery for incontinence or prolapse. The mean Q-tip straining angle was 44.7 degrees +/- 21.8 degrees. The point Aa values were +3 to -3 cm (median -2). The correlation coefficient between the Q-tip straining angle and point Aa was 0.54 (P <0.001). Urethral hypermobility was observed in 93.3% patients with stage 3 prolapse, 92.5% with stage 2, 88.9% with stage 1, and 55.8% with stage 0. Only in patients with stage 4 prolapse was urethral hypermobility observed 100% of the time. CONCLUSIONS: The correlation between point Aa of the POP-Q and the Q-tip straining angle was moderately strong when analyzed across all degrees of prolapse. However, urethral hypermobility could not be reliably predicted from POP-Q measurement alone. Therefore, the Q-tip test remains an essential part of the urogynecologic evaluation.

Vaginal paravaginal repair with porcine dermal reinforcement: correction of advanced anterior vaginal prolapse.

OBJECTIVE: The objective of the study was to determine the efficacy of the vaginal paravaginal repair using porcine dermal graft reinforcement for the correction of advanced anterior vaginal prolapse. STUDY DESIGN: One hundred eleven women underwent reinforced vaginal paravaginal repair between September 2001 and January 2004 and met our inclusion criteria. Postoperatively patients were evaluated at 6 weeks, 6 months, and yearly thereafter. Objective cure was defined as point Ba -1 or less. RESULTS: Eighty-nine of the 111 (80%) patients were available for follow-up. Mean age of patients was 59.5 +/- 11.6 years (range 26 to 82), mean body mass index was 29 +/- 5.5 (range 20 to 44), and median parity was 3 (range 0 to 15). Mean follow-up was 24 +/- 10.1 months (range 6 to 44) with minimum follow-up required for cure of 12 months. Overall cure rate was 78% (68 of 89). Data were analyzed using the Wilcoxon rank test. CONCLUSION: The reinforced vaginal paravaginal repair procedure is safe and effective for correction of advanced anterior vaginal prolapse.

Suburethral sling materials: best outcome with autologous tissue.

OBJECTIVE: This study was undertaken to assess the outcome of suburethral slings by type of sling material. STUDY DESIGN: A retrospective review of women who underwent a suburethral sling between January 1997 and January 2003 with autograft, allograft or xenograft materials. Objective failure was defined as urinary leakage with cough stress testing at any time after 3 months, postoperatively. Objective cure was defined as no leakage with a standing cough stress test with at least 200 mL bladder volume at a minimum of 12 months postoperatively. Data were analyzed using Student t, Wilcoxon rank sum, and Kaplan-Meier survival tests. RESULTS: A total of 241 women were included in this study: 78 received autograft, 80 received allograft, and 83 received xenograft. Objective failure was 36% and 46% for allograft and xenograft, respectively compared with 13% for autograft (P < .001). CONCLUSION: Autograft has a significantly higher cure rate when used for suburethral slings.

Anterior vaginal wall hammock with fascia lata for the correction of stage 2 or greater anterior vaginal compartment relaxation.

PURPOSE: We determined the efficacy of the anterior vaginal wall hammock (AVWH) using fascia lata for the correction of anterior vaginal compartment relaxation. MATERIALS AND METHODS: A total of 58 patients with stage 2 or greater anterior vaginal compartment relaxation underwent an AVWH procedure with autologous or allograft fascia lata from June 1998 to March 2001. Patients were evaluated preoperatively with a history and pelvic organ prolapse quantitative examination. Postoperatively patients were evaluated at 6 weeks, 6 months and yearly thereafter with pelvic organ prolapse quantitative staging of the anterior, middle and posterior compartments. Objective cure was defined as stage 0 or 1 relaxation. Subjective cure was defined as no symptoms of pelvic pressure or a vaginal bulge. RESULTS: Of the 69 (89%) patients who underwent surgery 58 were available for followup. Median age of the population was 61.9 years and median followup was 24.7 months (range 12 to 57). There were 11 objective failures (19%) in the anterior compartment, of which 1 (2%) was symptomatic. Two patients (4%) had enteroceles that required surgical correction. Of the patients 16 (28%) had new onset or worsening stage 2 posterior relaxation at a median of 15.2 months postoperatively, including 7 (12%) who were symptomatic and underwent subsequent repair. CONCLUSION: The AVWH procedure with fascia lata is safe and effective for correcting stage 2 or greater anterior compartment relaxation. The whole pelvic floor must be evaluated and repaired to minimize the progression of prolapse of the middle and posterior compartments.