Mid-urethral sling revision for mesh exposure-long-term outcomes of two surgical techniques from a comparative clinical retrospective cohort study.

OBJECTIVE: To compare vaginal closure with versus without sling excision in the management of vaginal sling exposure following mid-urethral sling (MUS). DESIGN: Clinical retrospective cohort study. SETTING: Tertiary urogynaecological centre in Australia. POPULATION: Women with urodynamic stress urinary incontinence (SUI) who had a MUS (n = 2823) during 1999-2017 with a follow-up period up to December 2018. Thirty-three women (1%) had sling exposure and 31 required surgical intervention (1%). METHODS: Clinical review with analysis of surgical database and patient records. MAIN OUTCOME MEASURES: The primary outcome was successful closure and resolution of exposure-related symptoms without the need for re-surgery. Secondary outcomes were repeat procedure and recurrent incontinence following revision. RESULTS: Mean follow up was 103 months. Of the 20 women with a primary excision and closure approach, 19 had successful closure. Seven of 11 women with simple vaginal closure without excision needed another surgery for recurrent mesh exposure. Recurrence of stress incontinence did not occur in any of the four who had 'successful' closure without excision. Of those who had sling division/removal without a concomitant stress continence procedure, 32% (7/22) required further surgery. CONCLUSION: Sling excision and repair have better outcomes with less recurrence of sling exposure compared with simple closure. Following sling removal, one of three women will develop SUI recurrence and require surgery. TWEETABLE ABSTRACT: #Slingexcision &repair leads to less recurrence of exposure versus #simpleclosure for #slingmeshexposure.

Extraperitoneal uterosacral suspension technique for post hysterectomy apical prolapse in 472 women: results from a longitudinal clinical study.

OBJECTIVES: The study aims to evaluate the long-term results of the extraperitoneal uterosacral ligament suspension (bilateral) technique in women with apical prolapse following hysterectomy. DESIGN: Longitudinal clinical follow up conducted between June 2002 and December 2017. SETTING: Tertiary urogynaecology centre in Melbourne, Australia. POPULATION: A total of 472 women with symptomatic vault prolapse who underwent bilateral extraperitoneal uterosacral ligament suspension (EPUSLS). Of these patients, 61% (287/472) had previously had a procedure for pelvic organ prolapse (POP). METHODS: Follow up using structured, standardised questionnaires and examination by POP-Q and Baden-Walker system pre- and postoperatively. MAIN OUTCOME MEASURES: Functional and anatomical results and surgical complications. RESULTS: Mean follow-up duration was approximately 5 years. The objective success rate at vaginal cuff support was 89% (420/472). Only 4% needed revision surgery for vault recurrence. There was improvement in bladder, bowel, and sexual symptoms after the procedure. Mesh exposure rate was 17% (of the 138 having mesh augmentation), with the majority of cases managed conservatively or with minor interventions. The ureteric injury rate was 1% and mainly occurred in patients operated early on in the series. No women had buttock pain. CONCLUSION: EPUSLS is an effective, suture-based procedure for vault prolapse with few complications even on long-term follow up. This technique avoids the need to open the peritoneum vaginally and has a low risk of ureteric injury and gluteal pain. TWEETABLE ABSTRACT: Bilateral extraperitoneal USL suspension of vault is effective with low morbidity and a high success rate.

The effects of mode delivery on postpartum sexual function: a prospective study.

OBJECTIVE: To determine the effect of mode of delivery and perineal injury on sexual function at 6 and 12 months postpartum. DESIGN: Prospective cohort study. SETTING: Tertiary women's hospital in Melbourne, Australia. POPULATION: A cohort of 440 primigravid women. METHODS: The Female Sexual Function Index (FSFI) was completed at first visit (7-19 weeks of gestation), and at 6 and 12 months postpartum. MAIN OUTCOME MEASURES: A statistically significant difference in total FSFI or domain scores over time according to mode of delivery or perineal injury. RESULTS: In this cohort 54% of women had a normal vaginal delivery, 21% had an instrumental delivery, and 25% gave birth by caesarean section. No difference was found in total FSFI or domain scores according to mode of delivery over time between antenatal assessment and 12 months postpartum. Pain was decreased in the caesarean group only at 6 months postpartum. All groups showed pain scores at 12 months that were comparable with antenatal levels. For those who gave birth vaginally, 27% had an intact perineum, 50% had an episiotomy, and 6%, 14%, and 3% had first, second, and third-degree tears, respectively. The only differences between groups were found over time according to perineal injury at 6 months in the arousal domain. At 12 months, total FSFI and domain scores were no different to initial scores. CONCLUSIONS: At 12 months postpartum sexual function has returned to early pregnancy levels, irrespective of mode of delivery or perineal injury.

Where to for pelvic organ prolapse treatment after the FDA pronouncements? A systematic review of the recent literature.

INTRODUCTION: With the publication of the updated US Food and Drug Administration (FDA) communication in 2011 on the use of transvaginal placement of mesh for pelvic organ prolapse (POP) it is appropriate to now review recent studies of good quality on POP to assess the safety and effectiveness of treatment options and determine their place in management. METHODS: A systematic search for studies on the conservative and surgical management of POP published in the English literature between January 2002 and October 2012 was performed. Studies included were review articles, randomized controlled trials, prospective and relevant retrospective studies as well as conference abstracts. Selected articles were appraised by the authors regarding clinical relevance. RESULTS: Prospective comparative studies show that vaginal pessaries constitute an effective and safe treatment for POP and should be offered as first treatment of choice in women with symptomatic POP. However, a pessary will have to be used for the patient's lifetime. Abdominal sacral colpopexy is effective in treating apical prolapse with an acceptable benefit-risk ratio. This procedure should be balanced against the low but non-negligible risk of serious complications. The results of native tissue vaginal POP repair are better than previously thought with high patient satisfaction and acceptable reoperation rates. The insertion of mesh at the time of anterior vaginal wall repair reduces the awareness of prolapse as well as the risk of recurrent anterior prolapse. There is no difference in anatomic and subjective outcome when native tissue vaginal repairs are compared with multicompartment vaginal mesh. Mesh exposure is still a significant problem requiring surgical excision in approximately ≥ 10 % of cases. The ideal mesh has not yet been found necessitating more basic research into mesh properties and host response. Several studies indicate that greater surgical experience is correlated with fewer mesh complications. In women with uterovaginal prolapse uterine preservation is a feasible option which women should be offered. Randomized studies with long-term follow-up are advisable to establish the place of uterine preservation in POP surgery. CONCLUSION: Over the last decade treatment of POP has been dominated by the use of mesh. Conservative treatment is the first option in women with POP. Surgical repair with or without mesh generally results in good short-term objective and functional outcomes. However, basic research into mesh properties with host response and comparative studies with long-term follow-up are urgently needed.

Persistence of urgency and urge urinary incontinence in women with mixed urinary symptoms after midurethral slings: a multivariate analysis.

OBJECTIVE: To determine risk factors for persistence of urgency or urge urinary incontinence following midurethral sling surgery. DESIGN: Prospective cohort study. SETTING: Tertiary referral Urogynaecology Unit. SAMPLE: A total of 754 consecutive women with stress urinary incontinence (SUI) and urgency; and 514 women with SUI and urge urinary incontinence (UUI) who underwent midurethral sling with a mean follow up of 50 months. METHODS: Women with persistent urgency or UUI at long-term follow up were compared with those whose symptoms had resolved, using multivariate analysis to determine the risk factors for persistent symptoms. MAIN OUTCOMES MEASURES: Odd ratios (OR) of independent risk factors for persistent urgency or UUI. RESULTS: Persistent urgency (304/754, 40%) and UUI (166/514, 32%) were common. Coexistent detrusor overactivity (OR 2.04, 95% CI 1.39-3.01), baseline symptom severity (OR 1.41, 95% CI 1.10-1.78) and age (OR 1.03, 95% CI 1.02-1.04) increased the risk of persistent urgency, while transobturator sling surgery (OR 0.61, 95% CI 0.39-094) and concomitant prolapse surgery (OR 0.54, 95% CI 0.38-0.75) decreased the risk. For UUI detrusor overactivity (OR 1.86, 95% CI 1.18-2.93), baseline symptom severity (OR 1.88, 95% CI 1.38-2.56), previous incontinence surgery (OR 2.18, 95% CI 1.28-3.70) increased the risk of persistence, whereas apical prolapse surgery (OR 0.33, 95% CI 0.15-0.70) decreased the risk. Women were more likely not to recommend surgery when they experienced persistent urgency (15.8% versus 2.7%, P < 0.0001) or UUI (24.7% versus 2.9%, P < 0.0001). CONCLUSIONS: Urodynamic parameters, baseline urgency symptom severity, midurethral sling route and concomitant prolapse operation are important predictors of persistent urgency or UUI following midurethral sling.

A prospective randomised double-blind controlled trial evaluating the effect of trans-sacral magnetic stimulation in women with overactive bladder.

Overactive bladder (OAB) is a prevalent condition with 16% of adults having one or more symptoms that significantly affect quality of life. Transcutaneous electrical nerve stimulation and neuromodulators have had success in treating OAB but are expensive, invasive, and sometimes cumbersome. We developed an alternative neuromodulatory technique that involves electromagnetic stimulation of the sacral nerve roots with a portable electromagnetic device to produce trans-sacral stimulation of the S3 and S4 sacral nerve roots. The aim of this study was to evaluate the impact of this device on OAB symptoms in women with a prospectively randomised double-blind controlled study. Following a power analysis, women with symptoms of OAB were prospectively recruited with ethical approval for randomisation to an active treatment (n = 33) or placebo group (n = 30) in a double-blind trial. The patient, at home, used the belt device daily for 20 min over 12 weeks. Outcome measures included a 3-day voiding diary, 1 h pad test, visual analogue score (VAS) for symptom impact (0-100%), Kings Health Questionnaire (KHQ) and Australian Quality of Life questionnaire (AQOL) at baseline, 6 and 12 weeks. Overall, no difference was found between groups for any of the research questions. Specifically, we were unable to demonstrate any difference between the active and sham device groups in frequency, nocturia, urinary leakage, or quality of life, nor was there any evidence of a placebo effect. The quality of the data was high with the number of missing observations (especially for disease specific KHQ and general AQOL) being few. This attempt to promote trans-sacral electromagnetic neuromodulation with a specially created device was ineffective on the symptoms of OAB.

Laparoscopic versus open Burch colposuspension: a randomised controlled trial.

OBJECTIVE: To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. DESIGN: Randomised surgical trial with single blinding. SETTING: Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. POPULATION: Two hundred women with urodynamic stress incontinence (USI). METHODS: The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. MAIN OUTCOME MEASURES: Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. RESULTS: There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P< 0.0001) but was associated with less blood loss (P = 0.03), less pain (P = 0.02), and quicker return to normal activities (P = 0.01). CONCLUSION: LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes. To compare perioperative characteristics, short-term, and long-term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence. Randomised surgical trial with single blinding. Three tertiary level teaching hospitals involving seven surgeons of varying skill levels. Two hundred women with urodynamic stress incontinence (USI). The two groups were treated in identical fashion, except for the laparoscopic or open approach to surgery. Attempts were made to blind the subjects and the observers obtaining outcome data to treatment group. Analyses were adjusted for surgeon experience. Absence of USI 6 months following surgery, postoperative pain, time spent in hospital, and time to return to activities of normal daily living. There were no significant differences in objective and subjective measures of cure and in patient satisfaction at 6 months, 24 months, or 3-5 years of follow up between laparoscopic and open colposuspension groups. Laparoscopic colposuspension took longer time to perform (87 versus 42 minutes, P < 0.0001) but was associated with less blood loss (P= 0.03), less pain (P= 0.02), and quicker return to normal activities (P= 0.01). LBC has significant advantages over traditional OBC, without any apparent compromise in short-term and long-term outcomes.

Transdermal posterior tibial nerve laser therapy is not effective in women with interstitial cystitis.

PURPOSE: Interstitial cystitis (IC) is a debilitating condition which causes irritative bladder symptoms, pain and a decrease in health status. The pathophysiology is poorly understood so therapeutic options are diverse. Percutaneous posterior tibial nerve stimulation is an effective treatment and pulsed transdermal laser stimulation is an established technique for pain management. We evaluated the efficacy of transdermal laser stimulation of the posterior tibial nerve for patients with IC. MATERIALS AND METHODS: Women meeting the National Institutes of Health National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC were prospectively recruited and randomized to treatment (29) or placebo (27) cohorts in a double-blind trial. At home the patient performed laser therapy daily for 30 seconds over the SP6 acupuncture point for 12 weeks. Measures at baseline and at 84-day followup included the 7-day voiding diary, the Interstitial Cystitis Problem Index, Interstitial Cystitis Symptom Index and RAND 36-Item Health Survey questionnaires. RESULTS: There were no significant differences between the treatment and control cohorts on any of the measures. However, there was a significant decrease between baseline and 12-week followup in the amount voided, symptom problems and severity, and on all 8 SF-36 scales. There was no significant effect of fluid intake. CONCLUSIONS: This study demonstrated no difference between the active and sham device. However, it is interesting that treatment and control cohorts experienced similar improvements, suggesting that the control cohort improvements may have been due to participants' belief that they were receiving active treatment from the stimulator. These findings provide support for investigating placebo effects in randomized trials.

Differentiating stress urinary incontinence from urge urinary incontinence.

Urinary incontinence (UI) is any involuntary leakage of urine and can be further defined according to the patient's symptoms or complaints. Stress urinary incontinence (SUI) is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. Urge urinary incontinence (UUI) is characterized by the complaint of involuntary leakage accompanied by or immediately preceded by urgency. Mixed urinary incontinence (MUI) is the presence of both SUI and UUI symptoms. In order to effectively treat UI, an accurate diagnosis is necessary since treatment of SUI or UUI is very different. Assessment obtaining a detailed medical history includes making general assessments taking into account quality of life (QoL), performing an appropriate physical examination with cough stress test; and simple investigations namely a urinary diary, urine analysis and post-void residual assessment and, occasionally, simple urodynamics. These assessments should suffice to commence conservative treatment. Multichannel urodynamics are required in patients presenting with more complicated UI and prior to surgery.

Genital prolapse: vaginal versus abdominal route of repair.

In the presence of an ageing population, we can expect to see a dramatic increase in the prevalence of genital prolapse including vault and recurrent vaginal prolapse. The best approach for managing upper genital prolapse remains controversial. We review the surgical management of genital prolapse, with a focus on comparing the vaginal and abdominal approaches.

Iliococcygeus or sacrospinous fixation for vaginal vault prolapse.

OBJECTIVE: To compare iliococcygeus (prespinous) and sacrospinous fixation for vaginal vault prolapse. METHODS: Between 1994 and 1998, 78 women underwent sacrospinous colpopexy and 50 underwent iliococcygeus fixation for the management of symptomatic vaginal vault prolapse. A matched case-control study was designed to compare the two approaches. The matched variables included age, parity, body mass index, degree of vault prolapse, menopause, sexual activity, constipation, previous prolapse or continence surgery, stress incontinence, and length of review. Thirty-six matched pairs were isolated, resulting in a study with a power of 50% to detect a 20% difference in the success rates between the two groups. RESULTS: The subjective success rate for the iliococcygeus group was 91%; it was 94% for the sacrospinous group (P =.73). The objective success rate was 53% and 67% (P =.36), and the patient satisfaction with surgery was 78 of 100 and 91 of 100 (P =.01) on a visual analogue scale. The mean length of postoperative follow-up was 21 months for the iliococcygeus group and 19 months for the sacrospinous group (P =.52). The recovery time was 54 days in the iliococcygeus group and 39 days in the sacrospinous group (P =.04). No significant difference was seen in the incidence of postoperative cystoceles or damage to the pudendal neurovascular bundle. CONCLUSION: Sacrospinous and iliococcygeus fixation are equally effective procedures for vaginal vault prolapse and have similar rates of postoperative cystocele, buttock pain, and hemorrhage requiring transfusion. The sacrospinous ligament fixation should not be discarded in favor of the iliococcygeus fixation in the management of vaginal vault prolapse.

Percutaneous sacral nerve root neuromodulation for intractable interstitial cystitis.

PURPOSE: We evaluated the efficacy of percutaneous sacral nerve root neuromodulation in women with refractory interstitial cystitis. MATERIAL AND METHODS: We prospectively evaluated 15 consecutive women with a mean age of 62 years who had refractory interstitial cystitis to determine the efficacy of percutaneous stimulation of the S3 sacral roots. The mean duration of symptoms before evaluation was 5.2 years. All women fulfilled the National Institute of Arthritis, Diabetes and Digestive and Kidney Diseases criteria for the diagnosis of interstitial cystitis and were unresponsive to standard oral or intravesical therapy. The response to treatment was assessed using pain scores, urinary diary variables and quality of life surveys. RESULTS: Mean voided volume during treatment increased from 90 to 143 ml. (p <0.001). Mean daytime frequency and nocturia decreased from 20 to 11 and 6 to 2 times (p = 0.012 and 0.007, respectively). Mean bladder pain decreased from 8.9 to 2.4 points on a scale of 0 to 10 (p <0.001). As indicated by the Short Urinary Distress Inventory and SF-36 Health Survey, the quality of life parameters of social functioning, bodily pain and general health significantly improved during the stimulation period. Of the women 73% requested to proceed to complete sacral nerve root implantation. CONCLUSION: Women with intractable interstitial cystitis respond favorably to percutaneous sacral stimulation with significant improvement in pelvic pain, daytime frequency, nocturia, urgency and average voided volume. Permanent sacral implantation may be an effective treatment modality in refractory interstitial cystitis but further long-term evaluation is required.

Urinary levels of substance P and its metabolites are not increased in interstitial cystitis.

OBJECTIVES: To determine whether interstitial cystitis is associated with the increased release of substance P from the bladder wall into urine, by measuring urinary excretion rates of substance P and its metabolites in women with interstitial cystitis and in a control group of women with stress incontinence and normal bladder function. PATIENTS AND METHODS: Catheter urine was collected from 13 patients and 10 controls during a water diuresis ( approximately 10 mL/min) before and after instilling the bladder with 100 mL of water. The contribution of the bladder wall to urinary substance P peptides was assessed by measuring the change in substance P peptide levels after 2 min of bladder stasis before and after instillation. RESULTS: Absolute substance P excretion rates were similar in patients with interstitial cystitis and controls; 2 min of bladder stasis reduced the substance P excretion rate (P = 0.03) and increased the excretion rate of substance P metabolites (P = 0.01). CONCLUSIONS: The release of substance P from the bladder wall was not increased in patients with interstitial cystitis.

A prospective evaluation of the pathogenesis of detrusor instability in women, using electron microscopy and immunohistochemistry.

OBJECTIVE: To characterize the types of detrusor smooth muscle junctions in the bladders of women with detrusor instability and in a control group without, and to assess whether there are differences in the cell junctions between these groups. PATIENTS AND METHODS: The study included 13 women with detrusor instability (median age 57 years, range 32-86) and 11 control women (median age 50 years, range 33-62). Bladder biopsies were taken from each participant, processed for electron microscopy and immunohistochemistry (using a labelled antibody to vinculin) and analysed by investigators who were unaware of the patients' diagnoses. RESULTS: Adherens (intermediate) junctions in classic and rudimentary forms were present in all biopsies from patients and controls. Adherens junctions and dense plaques occupied almost the complete cell border in most samples. Complete immunohistochemistry was possible in seven patients and five controls. In almost every detrusor smooth muscle cell studied, there was staining of the entire cell border with labelled antibody to vinculin in all biopsies. CONCLUSIONS: This study provides evidence against an ultrastructural basis for idiopathic detrusor instability based on possible differences in detrusor smooth muscle intercellular junctions. Virtually the entire cell membrane of detrusor smooth muscle fibres is occupied by adherens junctions in classic and rudimentary forms, and with dense plaques present in samples from women with an unstable bladder and from controls. There was no junction detected in those with instability that was not present in the control group. The adherens junctions in the bladder facilitate mechanical coupling between cells.

Pathophysiology of interstitial cystitis.

Despite being described over 80 years ago, interstitial cystitis remains a disease of undetermined aetiology and poor treatment outcomes. Generally agreed diagnostic criteria of this condition, which occurs primarily in females, are frequency, urgency and pain, a low-capacity hypersensitive bladder, and mucosal haemorrhages and tearing on bladder distention. Although current theories of pathophysiology are predominantly conjecture, important elements of the disease process are increased afferent and efferent neuronal activity, an excess of inflammatory mediators, increased epithelial permeability and possibly reduced bladder vascularity. Improved treatment outcome will follow a better understanding of pathophysiology.