Reviewing Patients Following Mesh Repair; The Benefits.

BACKGROUND/AIMS: The use of synthetic mesh implants for vaginal prolapse surgery is still a subject of debate due to safety concerns. We aimed to explore long-term complications of all women treated with mesh surgery for pelvic organ prolapse (POP) in our centre. METHODS: This is a cross-sectional study of 188 women who underwent vaginal mesh surgery in a Dutch University Hospital between 2007 and 2012. The prevalence of mesh exposure, pain symptoms and patient satisfaction has been documented. RESULTS: Vaginal mesh surgery was performed in 188 women - in 147 (78%) because of recurrent POP. After a median follow-up of 40 months (range 12-76 months), 11 women (6%) had a symptomatic exposure of whom 8 women underwent surgery. Nine women (5%) had de novo pain following mesh surgery and in 3 women, (2%) this symptom was persistent despite treatment. Eighty-six percent of the responders were satisfied about their treatment. CONCLUSION: With this study, we showed that performing a total mesh recall is feasible. The prevalence of persisting symptomatic exposure and persisting pain symptoms was low in our population. Most of the complications we found were treatable. This is also reflected in the high overall satisfaction rate.

Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for vaginal hysterectomy: a randomised controlled trial.

OBJECTIVE: To compare the effects of electrical bipolar vessel sealing and conventional suturing on postoperative pain, recovery, costs and micturition symptoms in women undergoing vaginal hysterectomy. DESIGN: Randomised controlled trial. SETTING: Eight teaching hospitals in the Netherlands. POPULATION: One hundred women scheduled to undergo vaginal hysterectomy for benign conditions excluding pelvic organ prolapse. METHODS: Women were randomised to vessel sealing or conventional surgery. The quality of life related to pelvic floor function was assessed using validated questionnaires before surgery and 6 months after surgery. Pain scores and recovery were assessed using a diary, including daily visual analogue scale scores, starting from the day before surgery until 6 weeks after surgery. MAIN OUTCOME MEASURES: Visual analogue scale pain scores, surgery time, blood loss, complications, quality of life related to pelvic floor function and costs. RESULTS: The evening after surgery, women in the vessel-sealing group reported significantly less pain (5.7 versus 4.5 on a scale of 0-10, P = 0.03), but after that pain scores were similar. Operation duration was shorter for vessel sealing (60 versus 71 minutes, P = 0.05). Blood loss and hospital stay did not differ. We observed no major difference in costs between the two interventions (2903 versus 3102 €, P = 0.26). Changes in micturition and defecation symptoms were not affected by the surgical technique used. CONCLUSION: Using vessel sealing during vaginal hysterectomy resulted in less pain on the first postoperative day, shorter operating time, similar morbidity and similar pelvic floor function. No major differences in costs were found between the two interventions.

Evaluation of the female pelvic floor in pelvic organ prolapse using 3.0-Tesla diffusion tensor imaging and fibre tractography.

OBJECTIVES: To prospectively explore the clinical application of diffusion tensor imaging (DTI) and fibre tractography in evaluating the pelvic floor. METHODS: Ten patients with pelvic organ prolapse, ten with pelvic floor symptoms and ten asymptomatic women were included. A two-dimensional (2D) spin-echo (SE) echo-planar imaging (EPI) sequence of the pelvic floor was acquired. Offline fibre tractography and morphological analysis of pelvic magnetic resonance imaging (MRI) were performed. Inter-rater agreement for quality assessment of fibre tracking results was evaluated using weighted kappa (κ). From agreed tracking results, eigen values (λ1, λ2, λ3), mean diffusivity (MD) and fractional anisotropy (FA) were calculated. MD and FA values were compared using ANOVA. Inter-rater reliability of DTI parameters was interpreted using the intra-class correlation coefficient (ICC). RESULTS: Substantial inter-rater agreement was found (κ = 0.71 [95% CI 0.63-0.78]). Four anatomical structures were reliably identified. Substantial inter-rater agreement was found for MD and FA (ICC 0.60-0.91). No significant differences between groups were observed for anal sphincter, perineal body and puboperineal muscle. A significant difference in FA was found for internal obturator muscle between the prolapse group and the asymptomatic group (0.27 ± 0.05 vs 0.22 ± 0.03; P = 0.015). CONCLUSION: DTI with fibre tractography permits identification of part of the clinically relevant pelvic structures. Overall, no significant differences in DTI parameters were found between groups. KEY POINTS: Diffusion tensor MRI offers new insights into female pelvic floor problems. DTI allows 3D visualisation and quantification of female pelvic floor anatomy. DTI parameters from pelvic floor structures can be reliably determined. No significant differences in DTI parameters between groups with/without prolapse.

Anterior colporrhaphy does not induce bladder outlet obstruction.

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate if anterior colporrhaphy causes incomplete voiding due to bladder outlet obstruction. METHODS: Women scheduled for anterior colporrhaphy were asked to undergo multichannel urodynamic investigation before surgery and the first postoperative day. Bladder outlet obstruction was assessed using the Blaivas­Groutz voiding nomogram. Maximum flow rate, detrusor pressure and residual volume were compared between pre- and postoperative measurements and between women with and without an abnormal post-void residual volume (PVR; volume exceeding 150 ml). RESULTS: Seventeen women participated. One woman who was unobstructed before surgery was obstructed after surgery. Overall, detrusor pressure and maximum flow rate before and after surgery did not differ. After surgery, six women had an abnormal PVR, one was unable to void, four were mildly obstructed and one moderately obstructed. CONCLUSION: Urodynamic investigation the first day after anterior colporrhaphy did not show that anterior colporrhaphy induces bladder outlet obstruction. The explanation for postoperative urinary retention can therefore also lie in nonanatomical causes such as postoperative pain and psychological factors.

A long-term prospective study to compare the effects of vaginal and abdominal hysterectomy on micturition and defecation.

OBJECTIVE: We compared micturition and defecation symptoms with the route of hysterectomy over a period of 10 years. DESIGN: Prospective multicentre observational study. SETTING: Thirteen teaching hospitals in the Netherlands. POPULATION: A total of 430 women who underwent vaginal or abdominal hysterectomy for benign conditions (pelvic organ prolapse excluded). METHODS: The presence and discomfort experienced as a result of micturition and defecation symptoms were assessed using validated questionnaires before surgery, and at 6 weeks, 6 months, 1 year, 3 years and 10 years after surgery. Statistically significant differences in symptoms between vaginal and abdominal hysterectomy were adjusted for pre-operative differences in uterine descent, uterine size, parity and indication for hysterectomy. MAIN OUTCOME MEASURE: Presence of bothersome micturition and defecation symptoms, as assessed by the Urogenital Distress Inventory (UDI) and Defecation Distress Inventory (DDI). RESULTS: Ten years after hysterectomy the response rate was 73%. Preoperatively, no differences were observed in the prevalence of micturition symptoms between patients who underwent vaginal and abdominal hysterectomy. However, 10 years after vaginal hysterectomy, significantly more women had been treated for micturition symptoms (18 versus 8%; P = 0.02; adjusted OR 3.8, 95% CI 1.2-11.6). Defecation symptoms also seemed more common after vaginal hysterectomy (58 versus 46%; P = 0.08). After adjustment, no statistically significant differences in defecation symptoms were found. CONCLUSIONS: Despite the same incidence of micturition symptoms before surgery, patients undergoing vaginal hysterectomy are more likely to seek medical help for micturition symptoms. Defecation symptoms were also more common after vaginal hysterectomy; however, this difference was not statistically significant.

Feasibility of diffusion tensor imaging (DTI) with fibre tractography of the normal female pelvic floor.

OBJECTIVES: To prospectively determine the feasibility of diffusion tensor imaging (DTI) with fibre tractography as a tool for the three-dimensional (3D) visualisation of normal pelvic floor anatomy. METHODS: Five young female nulliparous subjects (mean age 28 ± 3 years) underwent DTI at 3.0T. Two-dimensional diffusion-weighted axial spin-echo echo-planar (SP-EPI) pulse sequence of the pelvic floor was performed, with additional T2-TSE multiplanar sequences for anatomical reference. Fibre tractography for visualisation of predefined pelvic floor and pelvic wall muscles was performed offline by two observers, applying a consensus method. Three eigenvalues (λ1, λ2, λ3), fractional anisotropy (FA) and mean diffusivity (MD) were calculated from the fibre trajectories. RESULTS: In all subjects fibre tractography resulted in a satisfactory anatomical representation of the pubovisceral muscle, perineal body, anal - and urethral sphincter complex and internal obturator muscle. Mean FA values ranged from 0.23 ± 0.02 to 0.30 ± 0.04, MD values from 1.30 ± 0.08 to 1.73 ± 0.12 × 10(-)³ mm²/s. Muscular structures in the superficial layer of the pelvic floor could not be satisfactorily identified. CONCLUSIONS: This study demonstrates the feasibility of visualising the complex three-dimensional pelvic floor architecture using 3T-DTI with fibre tractography. DTI of the deep female pelvic floor may provide new insights into pelvic floor disorders.

Hysterectomy and lower urinary tract symptoms: a nonrandomized comparison of vaginal and abdominal hysterectomy.

BACKGROUND/AIMS: It has been reported that lower urinary tract symptoms (LUTS) are more prevalent in patients who have undergone hysterectomy. However, the effects of surgical approach of hysterectomy on micturition have not been well documented. The aim of this study is to compare LUTS between patients who underwent vaginal and abdominal hysterectomy. METHODS: Prospective observational study among 430 patients undergoing vaginal or abdominal hysterectomy for benign disease other than genital prolapse. Participating patients completed a validated disease-specific questionnaire before surgery, 6 months and 3 years after surgery. RESULTS: 112 women underwent vaginal hysterectomy and 318 abdominal hysterectomy. After correction for differences in uterine size, descent of the uterus and other differences, LUTS were more common at 3 years after surgery following vaginal than following abdominal hysterectomy (OR 2.2, 95% CI 1.3-4.0). After adjustment for descent of the uterus, uteral size, parity and indication for hysterectomy, this difference was still statistical significant (adjusted OR 3.0, 95% CI 1.4-6.2). CONCLUSION: As compared to abdominal hysterectomy, LUTS appear to be more common following vaginal hysterectomy.

A new method to measure vaginal sensibility.

INTRODUCTION: Vaginal surgery may affect sexual function both positively and negatively. Possibly, negative consequences of surgical interventions on sexuality may be caused by reduced sensibility of the vaginal wall. AIMS: To develop a new method to measure vaginal sensibility. METHODS: We developed a technique to measure the sensibility of the vaginal wall consisting of a St Marks electrode on a gloved index finger, with a stimulating electrode mounted at the tip. Measurements were performed in four different target areas (caudal and cranial, posterior and anterior) by two independent female researchers in a random order. Subjects were 12 healthy women. RESULTS: The intra-observer reproducibility of both researchers was almost perfect (Pearsons-Rho correlation coefficient 0.77-0.96 < 0.001). The inter-observer reproducibility was moderate (Pearsons-Rho correlation coefficient 0.39-0.49). Both researchers measured increased sensibility in the cranial posterior vaginal wall relative to the cranial anterior vaginal wall, but for all measurements, researcher 2 obtained higher sensibility ratings than researcher 1. In addition, researcher 2 found a decreased sensibility in the cranial anterior vaginal wall for women not using oral contraceptives. Phase of the menstrual cycle did not influence vaginal sensibility. CONCLUSION: We developed a new instrument to measure vaginal sensibility. The instrument has excellent intra-observer reproducibility. This method is sufficiently sensitive so as to differentiate between anterior and posterior cranial vaginal wall sensibility, but outcome differs as a function of researcher. Further evaluation of the clinical use of this method is needed, provided that measurements are performed by the same researcher.

Effects of genital prolapse surgery and hysterectomy on pelvic floor function.

This study was aimed to evaluate the effects of hysterectomy on pelvic floor function. We conducted a prospective observational multicenter study with three-year follow-up in thirteen teaching and nonteaching hospitals in the Netherlands. Four-hundred-thirty females who underwent hysterectomy for benign disease other than symptomatic uterine prolapse were included. Validated disease-specific quality-of-life questionnaire were completed before surgery and at 6 months, 12 months and three years after surgery to assess the presence of micturition symptoms, defecation symptoms and sexual problems. Micturition symptoms at three year after surgery were more common following vaginal hysterectomy than following abdominal hysterectomy (OR 2.2, 95% CI 1.3-4.0). Micturition symptoms that more often disappeared following -abdominal hysterectomy included urgency (OR 2.4, 95% CI 1.0-5.5) and obstructive micturition (OR 2.9, 95% CI 1.0-8.2). Constipation had developed in 2% of the patients without constipation before surgery and persisted in 46% of the -patients with constipation before surgery. Sexual pleasure statistically significantly improved in all patients, independently of the performed technique of -hysterectomy. At six months after vaginal, subtotal abdominal hysterectomy and total abdominal hysterectomy, the prevalence of one or more bothersome sexual problems was 43%, 41% and 39% respectively (Chi-square test: p = 0.88). From our prospective study it can be concluded that removal of the cervix during hysterectomy does not worsen pelvic floor function. Abdominal hysterectomy might have benefits over vaginal hysterectomy with respect to micturition. Hysterectomy does not cause constipation. Sexual function following hysterectomy does not depend on the performed technique and is on average better than before surgery.