Sonography as a Diagnostic Tool in Midurethral Sling Complications: A Narrative Review.

Despite the established safety and efficacy of midurethral slings (MUS), which are the current gold standard treatment for stress urinary incontinence (SUI), the potential for postoperative complications remains a significant concern for both healthcare professionals and patients. Meanwhile, sonography has emerged as a significant diagnostic tool in urogynecology, and one of the applications of this imaging modality may be the evaluation of complications arising from MUS procedures. This review, based on a comprehensive literature search, focuses on the use of pelvic floor ultrasound (US) in the context of MUS complications. It includes analyses of randomized controlled trials, prospective, and retrospective studies, covering preoperative and postoperative investigations, to assess complications such as persistent and recurrent SUI, urinary retention and obstructive voiding, de novo urgency/overactive bladder, vaginal exposure, sling erosion, pain, and hematoma. The review critically examines the existing literature, with a particular focus on recent publications. Despite the variability in findings, it appears that for each of the discussed complications, the application of pelvic floor US can significantly support the diagnostic and therapeutic process. The paper also identifies potential future directions for the development of US applications in diagnosing MUS complications.

Epidemiological Features of the Bladder Neck Rest Position and Mobility.

The data concerning epidemiological determinants of the bladder neck (BN) mobility are scarce. The aim of the study was to determine epidemiological features and identify factors influencing BN position at rest and BN mobility in patients without pelvic organ prolapse (POP). Seven hundred and ninety-six patients that attended two outpatient clinics were enrolled in the study. Position and mobility of the BN were measured with the use of pelvic floor ultrasound. Demographic and functional factors that were hypothesized to influence BN mobility were assessed. Vaginal deliveries (VDs) and age ≥65 were associated with lower BN position at rest. Higher BN mobility was observed in women with stress urinary incontinence (SUI). In obese women, higher BN position and lower BN mobility was observed compared to non-obese women, and it was correlated with longer urethras in this group of patients. VDs and their number were associated with increased BN mobility, independently of body mass index (BMI). To conclude, obesity, VDs, and age are factors associated with changes in bladder neck position at rest and its mobility. Higher BMI correlates with restricted BN mobility, and, therefore, the incidence of SUI in obese patients is probably not connected to BN hypermobility.

Impact of Midurethral Sling Implantation on Sexual Function in Women with Stress Urinary Incontinence.

Stress urinary incontinence (SUI) negatively influences sexual functions. However, the available data on sexual activity of patients who underwent midurethral sling (MUS) implantation are inconsistent. Our aim was to evaluate the impact of MUS implantation on sexual functions of women with SUI. We enrolled 171 patients undergoing the MUS procedure. Preoperative examination included the cough test, 1 h pad test and the Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA Revised (PISQ-IR). All patients had the retropubic sling implanted. Follow-up visits were performed 6-12 months after surgery. Objective cure rate was obtained in 90.98% of patients. Coital incontinence was reported by 56% of women before the surgery, and 8.6% afterwards. Among women who gained continence, significant improvement in sexual function was observed in the majority of the domains. In women who were not objectively cured (9.02%), we did not observe improvement in sexual life. All these patients indicated fear of leaking urine during sexual activity as the main cause of avoiding sex, similarly as before operation. To conclude, successful treatment of SUI with MUS significantly improves the quality of sexual life. On the other hand, persistent incontinence appears to be the most probable cause of lack of improvement in the quality of sexual life.

Does Previous Pelvic Organ Prolapse Surgery Influence the Effectiveness of the Sub-Urethral Sling Procedure?

Pelvic organ prolapse (POP) often co-occurs with stress urinary incontinence. There is no consensus on whether prolapse repair and anti-incontinence surgery should be performed concomitantly or separately, in a two-step manner. The present study evaluated the effects of the tension-free vaginal tape (TVT) procedure in patients who had previously undergone pelvic floor repair (study group), compared to women who underwent TVT insertion only (control group). The study group comprised 84 patients who underwent the TVT procedure but had previously also undergone surgical POP repair. The control group consisted of 250 women in whom the TVT was inserted. The primary objective was to compare the objective cure rate and the secondary objective was to compare the subjective cure rate in both groups. Negative pad test was achieved in over 91% in both groups. Objective and subjective cure rates were compared, as well as complication rates. Significant improvement was observed in the postoperative 1-h pad test in all patients. In all patients, we observed significant improvement in the quality of life, with no differences between the groups. No differences were found in the occurrence of postoperative urinary retention, urgency and frequency of daytime micturition, or vaginal erosion between the groups. The current results demonstrate that the two-step approach to pelvic reconstruction and anti-incontinence surgery is as safe and effective as primary TVT implantation.

Demographic risk factors for mid-urethral sling failure. Do they really matter?

Age, obesity and vaginal deliveries (VD) are recognized risk factors for stress urinary incontinence (SUI). According to many authors, the abovementioned risk factors for incontinence also increase the risk of mid-urethral sling (MUS) failure. Our aim was to evaluate the objective and subjective effectiveness of retropubic MUS in 12 months observation, relative to the three potential risk factors of failure: obesity, age and VDs. A prospective observational study including 238 women who underwent retropubic MUS implantation was performed. Patients were divided into subgroups: obese vs non-obese, <65 vs ≥65 years old and no history of VD vs ≥1 VD. Follow-up took place between 6 and 12 months post-surgery. Cough test, 1-hour pad test, pelvic floor ultrasound examination, and Incontinence Impact Questionnaire 7 (IIQ-7) results were assessed pre- and post-operatively. Of the 238 patients, 208 (86.3%) completed a minimum follow-up period of 12 months. Significant improvement in the pad test was observed in all patients (83.2 ± 78.6 g vs 0.7 ± 3.3 g). Negative cough test results were obtained in over 94% of patients. Significant improvement in the IIQ7 results was observed in all patients (74.2 ± 17.7 vs 5.5 ± 13.4). No significant differences in all the analyzed parameters with regard to BMI, age and parity were observed. No combination of risk factors influenced the objective and subjective cure rates. Our study demonstrated that older age, obesity and history of VDs have no impact on objective and subjective sling effectiveness in a short term observation. There is no influence of combined demographic features on the failure risk.

Demographic features of female urethra length.

AIMS: To determine cohort urethral length, identify epidemiological factors influencing the parameter and to establish the percentage of cases with clinically relevant outsized urethras. METHODS: Prospective cohort study conducted in two tertiary clinical centers between 2013 and 2017. Nine hundred and twenty seven consecutive adult, Caucasian females attending outpatients' clinics were included. The urethral length has been measured in pelvic floor ultrasound examination. The exclusion criteria were inadequate bladder filling (<200 mL; >400 mL), previous history of pelvic floor surgery, and no consent. RESULTS: Urethral length varied from 19 to 45 mm. The distribution of the examined parameter was normal. Obese patients had significantly longer urethras as compared to non-obese subjects. Number of vaginal deliveries was connected with shorter urethral length. The limitations of the study are: analysis only of Caucasian patients and subjects without previous pelvic floor surgeries. CONCLUSIONS: Differences in urethral length in the female population were demonstrated. Thirty percent of patients have atypical urethras that may be a risk factor for sling surgery failure. We therefore postulate introduction of urethral measurement before the procedure.

Is Bariatric Surgery a Prophylaxis for Pelvic Floor Disorders?

INTRODUCTION: Obesity is one of the well-documented risk factors of pelvic floor disorders (PFDs). The PFDs include urinary and fecal incontinence (UI, FI) and pelvic organ prolapse (POP). Surgery-induced weight loss improves different kinds of incontinence as well as POP symptoms. However, there is a lack of evidence how bariatric surgery influences pelvic floor anatomy and function in women without previous PFDs and whether it may be concerned as PFD prophylaxis tool. MATERIALS AND METHODS: The present analysis is a prospective, non-randomized case-control study from January 2014 to September 2017. Participants underwent pelvic floor ultrasound examination with bladder neck position estimation at rest, during levator ani tension, and at Valsalva maneuver before surgery and 12-18 months after. Pelvic organ prolapse quantification (POPQ) > 2 stage and PFD complaints were the exclusion criteria. RESULTS: Fifty-nine patients underwent bariatric surgery (57 sleeve gastrectomy and 2 gastric bypass). Mean BMI decreased from 43.8 ± 5.9 to 29 ± 4.6 kg/m2 after surgery (p < 0.001). Statistically significant higher position of the bladder neck at rest, during tension, and at Valsalva maneuver (p < 0.05) was shown after surgery. We did not demonstrate differences in bladder neck mobility and bladder neck elevation at tension after weight loss. CONCLUSIONS: Bariatric surgery is associated with a betterment of bladder neck position at rest, tension, and Valsalva maneuver in women without PFDs. We postulate that bariatric surgery may be a tool for PFD prevention. It does not improve levator ani function and does not limit bladder neck mobility, which implicates that it has no influence on preexisting pelvic dysfunction.

Does the suburethral sling change its location?

OBJECTIVES: To ascertain whether a phenomenon of sling migration exists after suburethral sling placement, whether this might be responsible for suboptimal sling location and persistent incontinence, and whether a link exists between sling dislocation or migration and risk factors, such as obesity or age. METHODS: The present prospective cohort study was carried out in a group of 244 patients who underwent retropubic sling implantation. Sling location was determined by means of pelvic floor ultrasound, and calculated relative to the individual patient's urethral length measured before the procedure. The sling location was visualized on 1 day, and 1 and 6 months post-surgery. Overweight/obese and elderly patients were analyzed separately to assess the possible influence of those factors on sling location. RESULTS: The mean urethral length in the studied cohort was 28.76 ± 3.67 mm. The mean tape position 1 day post-surgery was 66.18 ± 8.43% of the urethral length, and it did not change 1 and 6 months post-surgery in the whole group. Similar results were obtained in elderly and overweight/obese patients. CONCLUSIONS: Suboptimal sling location appears to result from incorrect surgical technique, and should be diagnosed and treated early after the primary surgery. Sling location does not change after mid-term follow up.

The Outcome of Repeated Mid Urethral Sling in SUI Treatment after Vaginal Excisions of Primary Failed Sling: Preliminary Study.

Mid urethral sling is the standard in SUI treatment. Nevertheless, the risk of reoperation reaches 9%. There is no consensus as to the best treatment option for complications. A question is raised: what is the optimal way to achieve the best result in patients after primary failure? The aim of the study was to evaluate the outcomes of repeat MUS surgery in patients after excision of the sling with recurrent SUI. We compared its effectiveness with uncomplicated cases treated with TVT. 27 patients who underwent the repeated MUS and 50 consecutive patients after primary TVT were enrolled in the study. After 6 months, we have found that 24 (88.46%) patients from repeat sling group and 48 (96%) patients after primary sling were dry (1-hour pad test, 2 g or less). The difference between groups was not significant. We showed statistically significant improvement of quality of life in both groups. In conclusion, we showed that repeated sling after MUS excision is almost as effective as primary MUS. We postulate that sling excision and repeated MUS may be the best option for persistent SUI and/or complications after MUS procedures. Further multicenter observations are ongoing as to provide results on bigger group of cases.

Posture and low back pain during pregnancy - 3D study.

OBJECTIVES: Back pain is a common complaint of pregnant women. The posture, curvatures of the spine and the center of gravity changes are considered as the mechanisms leading to pain. The study aimed to assess spinal curvatures and static postural characteristics with three-dimensional surface topography and search for relationships with the occurrence of back pain complaints among pregnant women. MATERIAL AND METHODS: The study was conducted from December 2012 to February 2014. Patients referred from University Clinic of Gynecology and Obstetrics were examined outpatient at the Posture Study Unit of Department of Orthopaedics and Traumatology. Sixty-five women at 4-39 weeks of pregnancy were assessed and surveyed with Oswestry Disability Index; posture was evaluated using surface topography. RESULTS: The study confirmed that difficulties in sitting and standing are significant in the third trimester of the pregnancy. The overall tendency for significant lumbar curvature changes in pregnant women was not confirmed. Major changes in sagittal trunk inclination in relation to the plumb line were not observed in the study group. CONCLUSIONS: The issue regarding how the pregnancy causes changes in spinal curvature and posture remains open for further studies. Presented method of 3D surface topography can reveal postural changes, but that requires several exams of each subject and strict follow-up of the series of cases.

Quality of life assessment in women after cervicosacropexy with polypropylene mesh for pelvic organ prolapse: a preliminary study.

AIM OF THE STUDY: Aim of the study was to assess the changes in the subjective perception of quality of life in patients who underwent abdominal cervicosacropexy for pelvic organ prolapse. MATERIAL AND METHODS: Forty patients with diagnosed pelvic organ prolapse (Pelvic Organ Prolapse - Quantification [POPQ] stage IV or IIIC) underwent abdominal supracervical hysterectomy and cervicosacropexy. The questionnaire concerning the quality of life was filled in before and 6 months after the surgery. RESULTS: In all patients, an accurate prolapse correction was achieved. In 42% of patients, stress urinary incontinence (SUI) was diagnosed prior to surgery, while after the surgery in 38.24% (p > 0.05). In 50% of women, symptoms of overactive bladder (OAB) occurred pre-surgery. These symptoms were reported by 17.65% of patients postoperatively (p < 0.05). Urinary retention was observed in 32.36% before and in 2.5% after the surgery (p < 0.05). The average score of the quality of sexual life was 5.75 (SD 2.52, 95% CI: 4.41-7.1) before and increased to 7.93 (SD 1.77, 95% CI: 6.9-8.95) after the procedure (p < 0.05). The mean score of the overall quality of life in relation to POP before and after the procedure was 2.77 (SD 2.39, 95% CI: 1.87-8.64) and 9.03 (SD 1.08, 95% CI: 8.66-9.43), respectively (p < 0.001). CONCLUSIONS: These results show a highly significant improvement of the quality of life in patients who underwent abdominal cervicosacropexy for POP. The change in quality of their sexual life, reduced OAB and urinary retention rates, as well as improvement of the esthetic self-perception may have contributed to this positive effect.

Assessment of patient acceptability of medical treatment in case of non-viable first trimester pregnancy.

OBJECTIVES: The aim of the present study was to assess patient acceptability and satisfaction with medical treatment (vaginal misoprostol) of non-viable first trimester pregnancy. MATERIAL AND METHODS: A total of 64 women, treated with vaginal misoprostol for non-viable first trimester pregnancy between October 2012 and December 2012 at the First Department of Obstetrics and Gynecology Medical University of Warsaw, were included in this questionnaire-based study. Questions pertaining to advantages and disadvantages of misoprostol treatment as compared to potential surgical intervention were used. The respondents also determined whether they would choose medical treatment if they were to decide again. The Visual Analogue Scale (VAS) was used to assess pain and bleeding intensity. RESULTS: Medical treatment was successful in 57 and surgical treatment was needed in 7 women. Average pain and bleeding intensity were 5.8 and 5.3, respectively. The most common side effects included diarrhea (27%), dizziness (22.2%), nausea (15.9%), and chills (15.6%). The most important advantages of misoprostol therapy were avoidance of the risk of uterine perforation (96.4%) and formation of intrauterine adhesions (74.6%), whereas the most significant disadvantages were prolonged bleeding (21.4%), pain (21.4%), and longer treatment duration (42.9%). Overall, 95.6% of the patients with successful treatment outcome declared they would choose this procedure if they were to decide again, as compared to 85.6% of women with treatment failure (p > 0.05). CONCLUSIONS: Medical treatment with vaginal misoprostol is acceptable and well-tolerated by the vast majority of women with non-viable first trimester pregnancy. Satisfaction is expressed by both, respondents with successful as well as unsuccessful treatment outcome.

Evaluation of uterine myomas during pregnancy using magnetic resonance imaging.

Patients with infertility commonly undergo various diagnostic and therapeutic procedures that may affect the future course of the pregnancy. In this presented case a female patient with infertility has been subjected to laparoscopic myomectomy and chromoscopy of the fallopian tubes, as it turned out later, 4 days after spontaneous conception. Due to severe pain in the 19th week of pregnancy the uterus area with the scar resulted from the removed myoma was visualised by magnetic resonance imaging (MRI). The MRI showed an active red degeneration in one of the myomas. At the same time the thickness of the uterus wall in previous myomectomy area was normal. The control MRI performed in the 36th week of pregnancy showed a hyaline degeneration of the myoma, underlying its dynamic refraction. The MRI approach enabled a non-invasive treatment and delivery in term.