A comparative evaluation of the effect of eugenol exposure time on the bond strength of an etch-and-rinse and a self-etch adhesive to dentin: An in vitro study.

Aim: The study aimed to comparatively evaluate the effect of eugenol exposure time on the micro-shear bond strength (µ-SBS) of etch-and-rinse and a self-etch adhesive to dentin. Materials and Methods: One hundred and twelve teeth samples were prepared from bisectioning 56 freshly extracted human mandibular molars and were randomly divided into 14 subgroups of 8 samples each (n = 8). Three subgroups containing eugenol and a noneugenol-based restorative material were placed on the dentin surface and left for 24 h, 7 days, and 14 days, respectively, and were compared to a control. Two bonding systems were evaluated: one being etch-and-rinse and the other self-etch adhesive. The µ-SBS were calculated and expressed in MPa. Statistical Analysis: The data were analyzed using mixed model analysis of variance. The level of statistical significance was set at 5%. Results: There was a statistically significant reduction in the µ-SBS values when the self-etch adhesive was used, after the removal of eugenol-containing cement placed for 24 h. However, the reduction in the µ-SBS values after 7 days or 14 days was not significant. Conclusion: Exposure to eugenol containing temporary cement for 24 h significantly reduces the µ-SBS of self-etching adhesives to dentin. However, exposure for 1 week or more has minimal effects.

Risk factors for pelvic organ prolapse recurrence following colpocleisis: A meta-analysis.

BACKGROUND: Studies aimed to assess risk factors for pelvic organ prolapse (POP) recurrence following colpocleisis with nonconclusive results. OBJECTIVE: To investigate risk factors for POP recurrence following colpocleisis. SEARCH STRATEGY: MEDLINE, PUBMED, Embase, Web of Science, and Cochrane databases were systematically searched. SELECTION CRITERIA: Experimental and non-experimental studies investigating POP recurrence following colpocleisis. DATA COLLECTION AND ANALYSIS: We assessed the association between preoperative and postoperative physical examination findings, demographics and medical history, and the risk of recurrence following colpocleisis. MAIN RESULTS: A total of 954 studies were identified, of which five studies comprising 2978 patients were eligible for analysis. Both preoperative and postoperative genital hiatus length were significantly longer in the recurrence group (mean difference [MD] 0.48, 95% confidence interval [CI] 0.01-0.94, P = 0.04, I2 = 0% and MD 1.15, 95% CI 0.50-1.81, P = 0.005, I2 = 0%; respectively). Preoperative total vaginal length (TVL) did not differ between groups (MD 0.05, 95% CI -0.40 to 0.50, P = 0.83, I2 = 6%), postoperative TVL was found significantly longer in the recurrence group (MD 0.07, 95% CI -0.03 to 1.38, P = 0.04, I2 = 68%). Both preoperative and postoperative perineal body did not differ between groups. Women with a previous POP surgery were more likely to experience recurrence following colpocleisis (relative risk 2.09, 95% CI 1.18-3.69, P = 0.01, I2 = 0%). Patient's age and previous hysterectomy did not affect recurrence rates. CONCLUSION: Wider preoperative and postoperative genital hiatus as well as longer post-operative TVL and previous POP surgery were associated with a higher risk for recurrence following colpocleisis, highlighting the importance of appropriate patient selection and surgical technique in minimizing this risk.

When Do Women with Second Trimester Pregnancy Loss Need Repeated Doses of Misoprostol? Insights from a Teaching Hospital.

BACKGROUND: Cases of second trimester pregnancy loss can be treated either pharmacologically or by surgical evacuation. Misoprostol, an E1-prostaglandin analog, is used to facilitate the evacuation of the uterus. OBJECTIVES: To determine the risk factors associated with patients who were treated with five or more repeated doses of misoprostol. METHODS: We conducted a retrospective study of patients treated with vaginal misoprostol at our institution between December 2016 and October 2021 for second trimester pregnancy loss. RESULTS: In total, 114 patients were eligible for analysis; 83 were treated with < 5 doses and 31 with ≥ 5. We recorded each case in which repeated doses were administered, irrespective of predetermined conditions such as gravidity, parity, maternal age, or gestational age. Moreover, cases of five or more misoprostol dosing were not associated with an increased complications rate, except for the increased duration of hospitalization (3.1 vs. 2.2 days, P-value < 0.01). CONCLUSIONS: Repeated dosing could not be predicted before treatment among those treated with vaginally administered misoprostol for second trimester pregnancy loss. However, low complication rates of repeated dosing may reassure both physicians and patients regarding safety, efficacy, and future fertility.

Predictors of Surgical Failure of Open Burch Colposuspension Versus Retropubic Midurethral Sling for Stress Urinary Incontinence.

OBJECTIVE: To identify and compare long-term predictors for 'surgical failures' in matched groups of Midurethral sling (MUS) and Burch colposuspension (BC). METHODS: A secondary analysis of patients with urodynamic stress incontinence who were treated either by open BC or retropubic MUS. The study had a cohort of 1344 women with a ratio of 1:3 (BC: MUS). We defined surgical success or failure by combining Patient Reported Outcome Measures and the need for repeat surgery. Risk factors for failure identified by multivariate analysis. RESULTS: Of the 1344 women included, 336 had BC, and 1008 had MUS. Patients were followed-up for 13.1 and 10.1 years, and the rate of failure was 22% and 20%, for BC and MUS, respectively (P = 0.35). Significant predictors for MUS failure were Body mass index (BMI) > 30, preoperative anticholinergic medication use, smoking, diabetes, and previous surgery for incontinence (Hazard ratio 3.6, 2.6, 2.5, 1.8, 2.3, respectively). BMI > 25, preoperative use of anticholinergic medication, age > 60, previous surgery for incontinence, and loss of follow-up>5 years (Hazard ratio: 3.2, 2.8, 2.6, 2.5, 2.1, respectively), were significant predictors of BC failure. CONCLUSION: This study shows similar predictors for surgical failure for BC and MUS, with high BMI, mixed urinary incontinence, and previous continence procedures being the most important.

Counseling for stress urinary incontinence in the era of adverse publicity around mesh usage: Results from a large-sample global survey.

OBJECTIVE: To investigate doctors' opinions of the use of synthetic mesh for the treatment of stress urinary incontinence (SUI) and the effect on patient's attitude following recent adverse publicity and legal findings. METHODS: Electronic survey approved by International Urogynecological Association (IUGA) and American Urogynecologic Society (AUGS), distributed to their members. RESULTS: A total of 593 respondents completed the survey. The preferred initial surgical treatment for SUI was retropubic midurethral sling (MUS) (62%), followed by trans-obturator MUS (19%), mini-slings (10%), and then bulking agents (5%). Despite prolongation of consultation, most respondents (87%) believed that clinicians should provide a patient information leaflet (PIL) for their patients. However, only 70% of respondents were doing this. Most participants would use either the IUGA PIL or their institution PIL (61%). Only 8% felt that patients have a positive preconception of synthetic mesh for SUI. Eighty-three per cent of respondents had not changed their recommendations for treatment and the consent process. A logistic regression model identified preferences of certain geographic areas as predictors of consenting practices. CONCLUSION: Despite the negative publicity and the current medicolegal litigation involving MUS for SUI treatment, the majority of respondents still prefer this as the initial surgical treatment. Most clinicians value PIL in the surgical consent process.

Consequences of the COVID-19 pandemic on the postpartum course: Lessons learnt from a large-scale comparative study in a teaching hospital.

OBJECTIVE: To evaluate the consequences of COVID-19 pandemic restrictions on the postpartum course. METHODS: A retrospective cross-sectional study compared women who gave birth between March and April 2020 (first wave), between July to September 2020 (second wave), and a matched historical cohort throughout 2017-2019 (groups A, B, and C, respectively). Primary outcomes were postpartum length of stay (LOS), presentations to the emergency department (ED), and readmissions 30 days or longer after discharge. Following Bonferroni correction, p < 0.016 was considered statistically significant. RESULTS: In total, 3377 women were included: 640, 914, and 1823 in groups A, B, and C, respectively. LOS after birth (both vaginal and cesarean) was shorter in groups A and B compared to the control group (2.28 ± 1.01 and 2.25 ± 0.93 vs 2.55 ± 1.10 days, p < 0.001). Rates of ED presentations 30 days after discharge were higher in groups C and B compared to group A (6.63% and 6.45% vs 3.12%, p = 0.006). Rates of readmissions 30 days after discharge were 0.78%, 1.42%, and 1.09% (groups A, B, and C, respectively), demonstrating no statistical difference (p = 0.408). CONCLUSION: During the COVID-19 pandemic, there was a reduction or no change in rates of ED presentations and readmissions, despite the shortened LOS after delivery. A shift in policy regarding the postpartum LOS could be considered.

Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence-results from a large comparative study.

BACKGROUND: There are few adequately powered long-term trials comparing midurethral sling and Burch colposuspension. Recent concerns about synthetic mesh with new stringent clinical and research governance support the need for evidence to facilitate shared decision making. OBJECTIVE: This study aimed to compare long-term outcomes of open Burch colposuspension with the retropubic midurethral sling. STUDY DESIGN: A matched cohort study of 1344 women with urodynamic stress incontinence (without intrinsic sphincter deficiency) who underwent surgery for stress urinary incontinence. Women had either open Burch colposuspension or the retropubic midurethral sling, from January 2000 to June 2018, in a tertiary center. Follow-up was by chart review and one-time phone follow-up until 2019, using a dedicated database. Primary outcomes were the presence or absence of stress urinary incontinence on follow-up, the success of index surgery based on response to validated questionnaires of patient-reported outcomes, and retreatment rates. Secondary outcomes are described below. Matching (1:3) was done at baseline to avoid confounding. RESULTS: The study included 1344 women who had either Burch colposuspension (336) or retropubic midurethral sling (1008). Mean follow-up was 13.1 years for Burch colposuspension and 10.1 years for retropubic midurethral sling. In the Burch colposuspension group, 83.0% of patients (279 of 336) reported no ongoing stress urinary incontinence at the time of the latest follow-up vs 85.0% (857 of 1008) in the retropubic midurethral sling group (P=.38). Success in terms of the latest reported International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (defined as International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score of ≤6) where these data were available were similar within both groups: 76.0% (158 of 208 where this was available) in Burch colposuspension vs 72.1% (437 of 606 where this was available) in retropubic midurethral sling (P=.32). Where this information was available, success defined by a Patient Global Impression of Improvement of "very much improved" and "much improved" was similar between Burch colposuspension and retropubic midurethral sling groups (84.1% [243 of 289] vs 82.0% [651 of 794]; P=.88). Where data were available, 88.1% of women (178 of 202) in the Burch colposuspension group said they were very likely to recommend the surgery to family or a friend vs 85.0% (580 of 682) in retropubic midurethral sling (P=.30).Overall, 3.6% needed repeat incontinence procedures (13 in Burch colposuspension group [3.8%] vs 35 in retropubic midurethral sling group [3.5%]; P=.73). The incidence of mesh exposure was 1.0 %. Notably, 1 Burch colposuspension patient had a suture in the bladder during follow-up; 5 patients have reported long-standing pain across the study population. Overall, 51 women reported new-onset overactive bladder symptoms on follow-up: 10 of 336 (3.0%) had Burch colposuspension and 41 of 1008 (4.1%) had retropubic midurethral sling (P=.41). The need for future prolapse surgery per index procedure was 3.3% after Burch colposuspension vs 1.1% postretropubic midurethral sling (P=.01). Moreover, 9 of the 11 patients who needed a prolapse repair after Burch colposuspension required a posterior repair. The incidence of long-term severe voiding difficulty needing self-catheterization was similar in both groups (0.3% in Burch colposuspension and 0.5 % in retropubic midurethral sling group; P=1.00). CONCLUSION: This study shows no difference in success, patient satisfaction, or complications between Burch colposuspension and retropubic midurethral sling, although the risk of posterior compartment prolapse operations after Burch colposuspension is increased. Reoperation rates for incontinence were similar in both groups. Chronic pain was a rare outcome.

Extraperitoneal high vaginal cuff suspension at the time of vaginal hysterectomy for advanced uterovaginal prolapse: Results of a modified McCall technique from a longitudinal clinical study.

BACKGROUND: Women with high-grade uterovaginal prolapse have a greater risk of recurrent prolapse after pelvic organ prolapse surgery. Royal College of Obstetricians and Gynaecologists guidelines have recommended sacrospinous suspension (sacrospinous fixation) at the time of vaginal hysterectomy, whenever there is a marked uterovaginal prolapse. We have modified the McCall culdoplasty by placing sutures extraperitoneally, higher and more lateral into the uterosacral/cardinal ligaments to re-support the vaginal cuff at the time of a vaginal hysterectomy. AIMS: To evaluate the results of a modified technique of McCall high culdoplasty and native tissue repair at time of vaginal hysterectomy in women with advanced uterovaginal prolapse. MATERIAL AND METHODS: Longitudinal clinical follow-up conducted between 2000-2018, in a tertiary urogynaecology centre for patients presenting with stage 3-4 uterovaginal prolapse, who underwent vaginal hysterectomy and modified McCall vault suspension. RESULTS: There were 176 cases meeting the inclusion criteria. Mean follow-up was 19.35 months. There were 25 recurrences (14%) of ≥ stage 2 (76% not symptomatic). Twelve of these recurrences (48%) occurred in anterior compartment, six (25%) posterior, three (12%) combined anterior/posterior, two (8%) combined posterior/central and one case had recurrence in all compartments. Only six cases (3%) required another surgical procedure for symptomatic prolapse, all with an enterocele recurrence. CONCLUSIONS: Our described modified McCall technique incorporates high extraperitoneal approach to apical resuspension along with closure of any existing large hiatal defects of the levator plate at the time of vaginal hysterectomy for advanced uterine prolapse has excellent outcomes and extremely low complication rates and avoids the need for sacrospinous fixation.

Delayed presentation of mons pubis abscess formation following MUS-case report and surgical video.

INTRODUCTION AND HYPOTHESIS: Mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) has relatively low complication rates. However, although rare, complications such as bladder wall, prepubic and thigh abscess occur. We present an unusual case of MUS vaginal mesh exposure followed by mons pubis abscess formation occurring 18 years postoperatively because of inadvertent prepubic insertion of the right arm. Our objectives were to raise awareness about such a rare complication and to describe the approach for sling removal. METHODS: A 75-year-old woman presented with gradual swelling on the mons pubis followed by pain with a past history of MUS insertion. Examination revealed a palpable, tender, non-fluctuant mass, extending about 10-15 cm from mons pubis to the right labia. There was a 2 × 2-cm vaginal mesh exposure. Following imaging, an examination under anaesthesia was performed with vaginal exploration and complete removal of the right arm of the MUS and closure of the vagina. RESULTS: Six months postoperatively, all surgical sites had healed well, and there was no recurrent SUI or persistent mesh exposure. CONCLUSIONS: Unusual long-term complications of MUS should be considered and recognized. Thorough evaluation is crucial for informed decision-making related to treatment strategies. The vaginal approach to mesh removal is safe and should be practised by experienced surgeons. Patients should be informed regarding the possibility of incontinence after sling removal.

Video of uterovaginal procidentia repair incorporating a high extraperitoneal uterosacral vault suspension.

INTRODUCTION AND HYPOTHESIS: Women with high-grade uterovaginal prolapse have a higher incidence of levator injury, larger levator hiatal defects, and are at a greater risk of recurrent prolapse after pelvic organ prolapse (POP) surgery. RCOG guidelines have recommended prophylactic sacrospinous suspension at the time of vaginal hysterectomy, whenever there is a marked uterovaginal prolapse. The aim of the video is to describe our surgical approach at the time of surgery for advanced POP, and describe the technique for modified McCall high extraperitoneal vault suspension. METHODS: We have modified the McCall culdoplasty by extending the dissection of the middle portion of the uterosacral/cardinal ligaments so that the sutures can be placed higher and more laterally extraperitoneally to re-support the vaginal cuff at the time of a vaginal hysterectomy. RESULTS: The video highlights the surgical technique used for apical support at the time of surgery for advanced POP. CONCLUSIONS: This video demonstrates our modified McCall technique for vault suspension at the time of vaginal surgery for advanced POP. This technique could be considered an alternative technique to other modes of apical support.

Lightweight transvaginal mesh is associated with lower mesh exposure rates than heavyweight mesh.

INTRODUCTION AND HYPOTHESIS: There has been a scarcity of long-term published data comparing lightweight versus heavier weight transvaginal mesh for prolapse repair. The aim was to ascertain the long-term rates of recurrent prolapse and mesh exposure in a cohort of vaginal repairs utilizing two different weights of transvaginal mesh. METHODS: Data were prospectively collected on all mesh-augmented vaginal prolapse repairs performed with Apogee® or Perigee® mesh kits (IntePro® or IntePro Lite®) at a single centre over an 11-year period, with patients receiving ongoing annual follow-up. A sequential stepwise univariate and multivariate Cox regression analysis was performed to identify variables that were significantly associated with mesh exposure. RESULTS: Eighty-eight women with 113 mesh kits were reviewed from the original cohort of 158 women. The median length of follow-up was 6.4 years (range 1.1-12.5 years). Mesh exposure rate per implant in the IntePro® group was 16/40 (40%) versus 4/73 (5.5%) in the IntePro Lite® group (p < 0.0001). A hazard ratio of 4.2 was identified for mesh exposure for IntePro® versus IntePro Lite® (95% CI 3.0-6.8). There was no difference in rates of recurrent prolapse between the heavy- and lightweight mesh groups. CONCLUSIONS: Lightweight transvaginal mesh is associated with lower mesh exposure rates than heavyweight mesh at a median follow-up of 6.4 years, with no difference in rates of recurrent prolapse.

Surgical management of urinary stress incontinence - Where are we now?

Mid-urethral sling procedures (MUS) have been the surgical option of choice for most gynaecologists and urologists treating stress urinary incontinence (SUI) in women around the world for almost 20 years, since their introduction in the late 1990s. The evidence suggests that the long-term effectiveness of the MUS is good and similar to the Burch Colposuspension and the fascial pubovaginal slings. The bulking agents are now being put forward as another minimally invasive option for the surgical treatment of SUI. Despite the increasing evidence that the retropubic MUS are more effective in long term and in high failure risk women with recurrent SUI and ISD, the TOT continues to have a high satisfaction and usage worldwide.

A new validated score for detecting patient-reported success on postoperative ICIQ-SF: a novel two-stage analysis from two large RCT cohorts.

INTRODUCTION AND HYPOTHESIS: The Patient Global Impression of Improvement (PGI-I) and International Consultation of Incontinence Questionnaire - Short Form (ICIQ-SF) are validated instruments for the assessment of patient reported outcome measures (PROM) following treatment of stress urinary incontinence (SUI). However, there is a paucity of evidence as to what represents a successful postintervention ICIQ-SF score. To determine the correlation between the postoperative ICIQ-SF scores with the PGI-I outcomes, the latter was considered one of the standard PROM following surgical treatment for SUI. The aim of this study was to determine, and if appropriate validate, an ICIQ-SF cut-off score that can predict a successful PROM as determined by PGI-I. METHODS: Four large datasets yielding 674 ICIQ-SF score/PGI-I outcome data pairs were used in this study for (a) determining and (b) validating the cut-off ICIQ-SF score for a successful PGI-I outcome. Two long-term follow-up datasets were used representing follow-up periods of 3 and 8 years of a randomized controlled trial (RCT) performed between April 2005 and April 2007 in a tertiary urogynaecology centre in Scotland, UK. All patients had urodynamic SUI or mixed urinary incontinence (MUI, with predominant SUI) and were randomized to treatment with either an inside-out or an outside-in transobturator tape (TVT-O or TOT, respectively) as a sole procedure. The datasets yielded 432 ICIQ-SF score/PGI-I outcome data pairs. Successful outcome was defined as "very much improved/much improved" on the PGI-I scale. SPSS v. 22.0 (IBM Corp., Armonk, NY) was used for all statistical analyses. The correlations and cut-off scores generated were then validated on two independent datasets representing the 1-year and 4-year follow-up periods of the multicentre RCT in six units in the UK. The datasets yielded 242 ICIQ-SF score/PGI-I outcome data pairs. All patients had urodynamic SUI or MUI (with predominant SUI) and were randomized to either adjustable single incision minisling (SIMS) or TVT-O. RESULTS: Significant correlations at the 0.01 level (two-tailed) were clearly demonstrated between ICIQ-SF scores at follow up and PGI-I outcomes in terms of success/failure in both the generation and validation datasets. Higher ICIQ-SF scores correlated with a 'poorer' PGI-I score. Using ROC analysis, a postoperative ICIQ-SF score of 6 was validated as approximately 90 % sensitive and 85 % specific for success/failure with a high Cohen's kappa coefficient of 0.83 (95 % CI 0.74 - 0.89). CONCLUSIONS: This two-stage study provided a robust well-validated postoperative ICIQ-SF cut-off score (of 6/21) that is likely to be associated with a patient-reported successful outcome on the PGI-I following surgical treatment with a midurethral sling in women at different stages of follow-up over 1 - 8 years. Such a cut-off score could enable the comparison of results between various studies and serve as a valuable guide for surgeons to counsel patients before and/or after surgical treatment. Our study fills a research gap in providing a way to compare trial results when baseline ICIQ-SF scores are not available.

Long-term outcomes of intravesical dimethyl sulfoxide/heparin/hydrocortisone therapy for interstitial cystitis/bladder pain syndrome.

INTRODUCTION AND HYPOTHESIS: For decades, intravesical dimethyl sulfoxide (DMSO) cocktail therapy has been used for the treatment of interstitial cystitis/bladder pain syndrome (IC/BPS), but little is known about its long-term efficacy. We aimed to assess the long-term efficacy of intravesical DMSO/heparin/hydrocortisone/bupivacaine therapy in patients with IC/BPS. METHODS: Patients with IC/BPS from our institutions who underwent this therapy with >2 years follow-up were surveyed with O'Leary-Sant interstitial cystitis symptom and problem index questionnaires before and after therapy. Chart reviews and telephone surveys were then conducted to determine their posttherapy course. RESULTS: Of 68 eligible women, 55 (80.0%) with a median follow-up of 60 months (range 24-142) were surveyed. Their mean age at therapy onset was 44.8 years and their mean body mass index was 26.2 kg/m2. There were statistically significant improvements in O'Leary-Sant and pain scores of 23-47% at both 6 weeks and the end of the follow-up period. At the end of the follow-up period, 19 of the 55 women (34.5%) were cured (requiring no further treatment) and 12 (21.8%) were significantly improved (requiring only ongoing oral medication). Univariate and multivariate analyses showed that DMSO treatment failure was more likely in patients with pretreatment day-time urinary frequency more than 15 episodes per day (OR 1.41), nocturia more than two episodes per night (OR 2.47), maximum bladder diary voided volume <200 ml (OR 1.39) and bladder capacity under anaesthesia <500 ml (OR 1.6). CONCLUSIONS: At a median follow-up of 60 months, intravesical DMSO cocktail therapy appeared moderately effective for the treatment of IC/BPS. Treatment failure was more frequent in patients with pretreatment symptoms of reduced bladder capacity.

Failure of Expectations in Vaginal Surgery: Lack of Appropriate Consent, Goals and Expectations of Surgery.

INTRODUCTION AND BACKGROUND: Vaginal surgery for the treatment of urinary stress incontinence (USI) and pelvic organ prolapse (POP) using a synthetic polypropylene mesh is going through a time of unprecedented turmoil and debate. This review focuses on vaginal surgery for vaginal prolapse and looks at the current scientific literature on issues surrounding surgery including consent and expectations. SAFETY AND EFFECTIVENESS OF SURGICAL OPTIONS: Synthetic mesh has been used both abdominally and vaginally to improve the effectiveness of POP surgery. The relatively high incidence of mesh complications particularly with vaginal surgery has lead to repeat surgery, disappointment and litigation in some women. The benefits and risks of the various POP procedures are reviewed including native tissue repair, uterine conservation and obliterative vaginal surgery. CONCLUSION: Women with symptomatic pelvic organ prolapse and their doctors have many treatment options. The benefits and risks should be discussed as part of shared decision making.