A comparison of the use of mesh to native tissue in the management of vaginal vault prolapse.

Vaginal vault prolapse afflicts millions of women and evokes significant psychosocial and pelvic floor dysfunction. The risk factors and modalities of conservative management are discussed in this study. There remains controversy in the optimal surgical management. This review serves to study the clinical conundrum of the decision-making process to utilize the mesh and the approach. In-depth evaluation of mesh-related postsurgical complications as compared to those associated with the native tissue is explored.

How long do we have to treat overactive bladder syndrome (OAB)? A questionnaire survey of Canadian urologists and gynecologists.

INTRODUCTION: Overactive bladder syndrome (OAB) is a highly prevalent and costly condition worldwide with negative impact on health-related quality of life. Although many guidelines exist and anticholinergics are considered to be the mainstay of pharmacological treatment, data are lacking regarding optimal treatment duration. Therefore, the aim of this study was to determine practice patterns of Canadian urologists and gynecologists regarding duration of OAB pharmacotherapy. METHODS: A 14-question survey was designed and survey links (English and French) were sent by email to all practicing urologists and gynecologists registered with the Canadian Urological Association and the Society of Obstetricians and Gynecologists of Canada via the associations' email lists. The SurveyMonkey website served as platform where responses were collected and stored. RESULTS: A total of 301 physicians completed the questionnaire; 250 respondents (83%) prescribe anticholinergics or beta-3-adrenoceptor agonist (mirabegron) in their practice, and 202 (81%) start patient treatment with the lowest recommended medication dose. One hundred and twelve respondents (45% of those who prescribe OAB medications) classified OAB pharmacotherapy as a lifelong management strategy, whereas 130 (52% of those who prescribe OAB medications) think that OAB pharmacotherapy should be administered for a defined time period. Six-month and one-year time periods of drug treatments are the most commonly chosen answers given by physicians who treat their patients for a defined duration. CONCLUSION: There is general agreement among Canadian urologists and gynecologists that OAB treatment should be started with the lowest recommended medication dose. A slim majority of respondents think that OAB pharmacotherapy should be administered for a defined duration.

No. 358-Intravaginal Laser for Genitourinary Syndrome of Menopause and Stress Urinary Incontinence.

OBJECTIVE: This technical bulletin reviews the evidence relating to risks and benefits of using intravaginal laser technology in the management of genitourinary syndrome of menopause and stress urinary incontinence. INTENDED USERS: Gynaecologists, urogynaecologists, urologists, and other health care professionals who assess, counsel, and provide care for women with genitourinary syndrome of menopause and stress urinary incontinence. TARGET POPULATION: Adult women with genitourinary syndrome of menopause and stress urinary incontinence seeking complementary or alternative treatment options to topical estrogen, non-hormonal vaginal moisturizers, physiotherapy, intravaginal devices, and surgery. OPTIONS: The discussion relates to intravaginal laser treatments for genitourinary syndrome of menopause compared with topical estrogen and that for stress urinary incontinence. OUTCOMES: The outcomes of interest are objective and subjective rates of response to treatment, histologic outcomes, and procedural complications. EVIDENCE: PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words "genitourinary syndrome of menopause," "vaginal laser," "topical estrogen," and "urogenital atrophy." Results were restricted to English and human research. Articles were included until the end of September 2016. Clinical practice guidelines and guidelines of specialty societies were reviewed. Included studies were observational or prospective cohort when available. Only publications with study groups larger than or equal to 20 individuals were included, and non-peer-reviewed papers were excluded. VALIDATION METHODS: The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework. BENEFITS, HARMS, AND/OR COSTS: It is expected that this technical bulletin will benefit patients with genitourinary syndrome of menopause by ensuring treating physicians are aware of all treatment options including the potential benefit and associated risk with intravaginal laser therapy. This should guide patient informed consent before such procedures are undertaken. There are no direct harms or costs identified with the implementation of this guideline. SPONSORS: The SOGC. SUMMARY STATEMENTS: RECOMMENDATIONS.

No. 351-Transvaginal Mesh Procedures for Pelvic Organ Prolapse.

OBJECTIVE: This guideline reviews the evidence related to the risks and benefits of using transvaginal mesh in pelvic organ prolapse repairs in order to update recommendations initially made in 2011. INTENDED USERS: Gynaecologists, residents, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with pelvic organ prolapse. TARGET POPULATION: Adult women with symptomatic pelvic organ prolapse considering surgery and those who have previously undergone transvaginal mesh procedures for the treatment of pelvic organ prolapse. OPTIONS: The discussion relates to transvaginal mesh procedures compared with other surgical options for pelvic organ prolapse (mainly about vaginal native tissue repairs and minimally about other alternatives such as biological and absorbable vaginal mesh and abdominally placed surgical mesh). OUTCOMES: The outcomes of interest are objective and subjective success rates and intraoperative and postoperative complications, such as adjacent organ injury (urinary, gastrointestinal), infection, hematoma/bleeding, vaginal mesh exposure, persistent pain, dyspareunia, de novo stress urinary incontinence, and reoperation. EVIDENCE: PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words pelvic organ prolapse/surgery*, prolapse/surgery*, surgical mesh, surgical mesh*/adverse effects, transvaginal mesh, and pelvic organ prolapse. RESULTS: were restricted to English or French language and human research. Articles obtained through this search strategy were included until the end of June 2016. Pertinent new studies were added up to September 2016. Grey literature was not searched. Clinical practice guidelines and guidelines of specialty societies were reviewed. Systematic reviews were included when available. Randomized controlled trials and observational studies were included when evidence for the outcome of interest or in the target population was not available from systematic reviews. New studies not yet included in systematic reviews were also included. Only publications with study groups larger than 20 individuals were selected because this criterion was used in the largest meta-analysis referenced in this guideline. A total of 1470 studies were obtained; after selecting only applicable studies and excluding duplicates, 68 manuscripts were reviewed and included. VALUES: The content and recommendations were drafted and agreed upon by the principal authors and members of the Urogynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. The Summary of Findings is available upon request. BENEFITS, HARMS, AND/OR COSTS: It is expected that this guideline will benefit women with pelvic organ prolapse by ensuring that health care providers are aware of outcomes related to transvaginal mesh procedures and steps in the management of related complications. This should guide patient-informed consent before such procedures are undertaken. The benefits clearly outweigh the potential harms or costs of implementation of this guideline, although no direct harms or costs are identified. GUIDELINE UPDATE: Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations. SUMMARY STATEMENTS: RECOMMENDATIONS.

Collagenoma and voiding dysfunction as complications of periurethral bulking.

Peri-urethral bulking agents are used as a management option for selected patients with stress urinary incontinence (SUI). We present a case of urinary retention and a large firm para-urethral vaginal mass as a complication of peri-urethral collagen injections 3 years before presentation. The patient was managed successfully with complete surgical resection of the mass. Subsequent recurrent SUI was managed using a rectus fascial sling.

Outcomes of trocar-guided Gynemesh PS™ versus single-incision trocarless Polyform™ transvaginal mesh procedures.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to compare rates of success, mesh exposure, and surgical re-intervention after trocar-guided Gynemesh PS™ and trocarless Polyform™ transvaginal mesh procedures. METHODS: We conducted a retrospective cohort study of all transvaginal mesh procedures performed at our centers between January 2008 and May 2012. Multiple logistic regression models were used to explore the binary outcomes of objective and subjective success rates, as well as mesh exposure and re-intervention rates, between the two procedures after adjustment for patient's age, parity, body mass index, smoking status, previous hysterectomy, previous prolapse surgery, and follow-up time. RESULTS: We included 103 transvaginal mesh procedures (47 trocar-guided Gynemesh PS™ and 56 trocarless Polyform™). In both groups, Pelvic Organ Prolapse Quantification (POP-Q) scores were significantly improved after the procedure. Median follow-up was 340 days and interquartile range (IQR) 152-644. Objective success rates were 55.3 % (26/47) in the trocar group and 60.7 % (34/56) in the trocarless group (p = 0.9), whereas subjective success was 83.0 % (39/47) and 94.6 % (53/56), respectively (p = 0.1). The adjusted odds of developing mesh exposure were significantly less after trocarless transvaginal mesh procedures compared to trocar-guided ones [odds ratio (OR) 0.16, 95 % confidence interval (CI) 0.03-0.97]. Surgical re-interventions, aimed mostly at treating recurrent prolapse, mesh exposure, and latent stress urinary incontinence, were also significantly less frequent after trocarless procedures [5 patients (8.9 %) requiring re-intervention versus 15 (31.9 %), respectively, adjusted OR 0.15, 95 % CI 0.04-0.60]. CONCLUSIONS: Trocar-guided Gynemesh PS™ and trocarless Polyform™ transvaginal mesh systems result in similar objective and subjective success rates. The newer Polyform™ mesh results in significantly fewer mesh exposures and surgical re-interventions.

Transvaginal mesh procedures for pelvic organ prolapse.

OBJECTIVE: To provide an update on transvaginal mesh procedures, newly available minimally invasive surgical techniques for pelvic floor repair. OPTIONS: The discussion is limited to minimally invasive transvaginal mesh procedures. EVIDENCE: PubMed and Medline were searched for articles published in English, using the key words "pelvic organ prolapse," transvaginal mesh," and "minimally invasive surgery." Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis, and articles were incorporated in the guideline to May 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table 1). BENEFITS, HARMS, AND COSTS: Counselling for the surgical treatment of pelvic organ prolapse should consider all benefits, harms, and costs of the surgical procedure, with particular emphasis on the use of mesh. RECOMMENDATIONS: 1. Patients should be counselled that transvaginal mesh procedures are considered novel techniques for pelvic floor repair that demonstrate high rates of anatomical cure in uncontrolled short-term case series. (II-2B) 2. Patients should be informed of the range of success rates until stronger evidence of superiority is published. (II-2B) 3. Training specific to transvaginal mesh procedures should be undertaken before procedures are performed. (III-C) 4. Patients should undergo thorough preoperative counselling regarding (a) the potential serious adverse sequelae of transvaginal mesh repairs, including mesh exposure, pain, and dyspareunia; and (b) the limited data available comparing transvaginal mesh systems with traditional vaginal prolapse repairs or with traditional use of graft material in the form of augmented colporrhaphy and sacral colpopexy. (III-C) 5. Until appropriate supportive data are available, new trocarless kits should be considered investigative. (III-C).