Hysteropexy in the treatment of uterine prolapse stage 2 or higher: laparoscopic sacrohysteropexy versus sacrospinous hysteropexy-a multicentre randomised controlled trial (LAVA trial).

OBJECTIVE: To investigate whether laparoscopic sacrohysteropexy (LSH) is non-inferior to vaginal sacrospinous hysteropexy (SSHP) in the surgical treatment of uterine prolapse. DESIGN: Multicentre randomised controlled, non-blinded non-inferiority trial. SETTING: Five non-university teaching hospitals in the Netherlands, one university hospital in Belgium. POPULATION: 126 women with uterine prolapse stage 2 or higher undergoing surgery without previous pelvic floor surgery. METHODS: Randomisation in a 1:1 ratio to LSH or SSHP, stratified per centre and severity of the uterine prolapse. The predefined inferiority margin was an increase in surgical failure rate of 10%. MAIN OUTCOME MEASURES: Primary outcome was surgical failure, defined as recurrence of uterine prolapse (POP-Q ≥ 2) with bothersome bulging/protrusion symptoms and/or repeat surgery or pessary at 12 months postoperatively. Secondary outcomes were anatomical recurrence (any compartment), functional outcome and quality of life. RESULTS: Laparoscopic sacrohysteropexy was non-inferior for surgical failure (n = 1, 1.6%) compared with SSHP (n = 2, 3.3%, difference -1.7%, 95% CI: -7.1 to 3.7) 12 months postoperatively. Overall, anatomical recurrences and quality of life did not differ. More bothersome symptoms of overactive bladder (OAB) and faecal incontinence were reported after LSH. Dyspareunia was more frequently reported after SSHP. CONCLUSION: Laparoscopic sacrohysteropexy was non-inferior to SSHP for surgical failure of the apical compartment at 12 months' follow up. Following LSH, bothersome OAB and faecal incontinence were more frequent, but dyspareunia was less frequent. TWEETABLE ABSTRACT: Laparoscopic sacrohysteropexy and vaginal sacrospinous hysteropexy have equally good short-term outcomes.

Follow-up of mesh complications using the IUGA/ICS category-time-site coding classification.

INTRODUCTION: The International Urogynecological Association (IUGA) and the International Continence Society (ICS) developed a complication classification to facilitate international comparison and to improve our understanding of complications. This code was applied to surgical cases for the analysis of complications after mesh insertion. METHODS: The study included patients who had undergone vaginal prolapse repair with a trocar-guided polypropylene mesh between 2006 and 2010 in a Dutch peripheral hospital. Complications were assessed at secondary follow-up and classified using category (C), timing (T), and site (S) components (CTS). RESULTS: Of the 107 women included, 84 returned for secondary follow-up (response rate 80 %, median time after surgery 36 months, range 12-64). In 45 patients no complications occurred. In the remaining 39 patients, 43 complication codes were established. Six of the seven categories of complications were found at all different time codes. Concerning the site of the complication codes S1, S2, and S3 were applicable. Perioperative complications (6 %) included hemorrhage and bladder perforation. Six patients were reoperated for symptomatic mesh exposure or local pain. At secondary follow-up exposure was diagnosed in another 4 patients (12 %). In 36 % mesh wrinkling or shrinkage was discovered, although without complaints in most. Eight women had daily complaints or dyspareunia. Eighty-two percent of patients indicated strong improvement after surgery. Several limitations of the classification are discussed. CONCLUSIONS: Despite limitations, the IUGA/ICS code is demonstrated to be useful in describing mesh complications. We advise the use of the CTS code at follow-up consultations after a minimum of 2 years for improved insight into and knowledge on the occurrence of complications.

Arthrodesis of the knee following failed arthroplasty.

PURPOSE: Primary stability in arthrodesis of the knee can be achieved by external fixation, intramedullary nailing or plate fixation. Each method has different features and results. We present a practical algorithm for arthrodesis of the knee following a failed (infected) arthroplasty, based on our own results and a literature review. METHODS: Between 2004 and 2010, patients were included with an indication for arthrodesis after failed (revision) arthroplasty of the knee. Patients were analyzed with respect to indication, fusion method and bone contact. End-point was solid fusion. RESULTS: Twenty-six arthrodeses were performed. Eighteen patients were treated because of an infected arthroplasty. In total, ten external fixators, ten intramedullary nails and six plate fixations were applied; solid fusion was achieved in 3/10, 8/10 and 3/6, respectively. CONCLUSIONS: There is no definite answer as to which method is superior in performing an arthrodesis of the knee. Intramedullary nailing achieved the best fusion rates, but was used most in cases without--or cured--infection. Our data and the contemporary literature suggest that external fixation can be abandoned as standard fusion method, but can be of use following persisting infection. The Ilizarov circular external fixator, however, seems to render high fusion rates. Good patient selection and appropriate individual treatment are the key to a successful arthrodesis. Based upon these findings, a practical algorithm was developed.

The biodrying concept: an innovative technology creating energy from sewage sludge.

A full-scale biodrying installation was treating 150 kton (wet weight) of dewatered waste activated sludge per year. The waste was treated at thermophilic conditions (65-75 °C) in a 2-step forced aeration process reducing the total wet sludge weight by 73%. The final product had a high caloric value (7700-10,400 (kJ/kg)), allowing a combustion for energy generation in external facilities. The resulting product met the European microbial and heavy metal quality standards needed for an application as organic fertilizer. The facility used <0.5 MW of electricity and recovered 9.3 MW from biologically produced heat, which was internally used for the heating of office buildings. Produced ammonia, originating from the microbial conversion of organic matter, was recovered from the ventilated air in an acid gas scrubber as an ammonium sulphate solution 40% (w/w) (7.3 kton/year) and was sold as substitute for artificial fertilizers. The sustainability of this process is discussed relative to other sludge handling processes.

Microbiological cultures of allografts of the femoral head just before transplantation.

Allografts of bone from the femoral head are often used in orthopaedic procedures. Although the donated heads are thoroughly tested microscopically before release by the bone bank, some surgeons take additional cultures in the operating theatre before implantation. There is no consensus about the need to take these cultures. We retrospectively assessed the clinical significance of the implantation of positive-cultured bone allografts. The contamination rate at retrieval of the allografts was 6.4% in our bone bank. Intra-operative cultures were taken from 426 femoral head allografts before implantation; 48 (11.3%) had a positive culture. The most frequently encountered micro-organism was coagulase-negative staphylococcus. Deep infection occurred in two of the 48 patients (4.2%). In only one was it likely that the same micro-organism caused the contamination and the subsequent infection. In our study, the rate of infection in patients receiving positive-cultured allografts at implantation was not higher than the overall rate of infection in allograft surgery suggesting that the positive cultures at implantation probably represent contamination and that the taking of additional cultures is not useful.

Is there an association between depressive and urinary symptoms during and after pregnancy?

Depressive symptoms and urinary symptoms are both highly prevalent in pregnancy. In the general population, an association is reported between urinary symptoms and depressive symptoms. The association of depressive and urinary symptoms has not yet been assessed in pregnancy. In this study, we assessed (1) the prevalence of depressive symptoms, over-active bladder (OAB) syndrome, urge urinary incontinence (UUI) and stress urinary incontinence (SUI) during and after pregnancy using the Center for Epidemiologic Studies Depression Scale (CES-D) and the Urogenital Distress Inventory (UDI) and (2) the association of depressive symptoms with urinary incontinence and over-active bladder syndrome during and after pregnancy, controlling for confounding socioeconomic, psychosocial, behavioural and biomedical factors in a cohort of healthy nulliparous women. Our data show a significant increase in prevalence of depressive symptoms, UUI, SUI and OAB during pregnancy and a significant reduction in prevalence of depressive symptoms, SUI and OAB after childbirth. UUI prevalence did not significantly decrease after childbirth. In univariate analysis, urinary incontinence and the OAB syndrome were significantly associated with a CES-D score indicative of a possible clinical depression at 36 weeks gestation. However, after adjusting for possible confounding factors, only the OAB syndrome remained significantly associated (OR 4.4 [1.8-10.5]). No association was found between depressive and urinary symptoms at 1 year post-partum. Only OAB was independently associated with depressive symptoms during pregnancy. Possible explanations for this association are discussed.

Which factors determine the sexual function 1 year after childbirth?

OBJECTIVE: To evaluate which factors determine sexual activity and satisfaction with the sexual relationship 1 year after the first delivery. DESIGN: Prospective longitudinal cohort study. SETTING: Ten midwifery practices. POPULATION: Three hundred and seventy-seven nulliparous women were included. METHODS: The Maudsley Marital Questionnaire is a standardised and validated questionnaire with 15 items relating to marital and sexual adjustment, with a nine-point (0-8) scale appended to each question. Scores on the sexual scale (MMQ-S) range from 0 to 40. Higher scores are indicative of greater dissatisfaction. Sexual intercourse was dichotomised into having sexual intercourse or not having sexual intercourse. Several obstetric and maternal factors were analysed. MAIN OUTCOME MEASUREMENTS: Sexual intercourse at 1 year postpartum and dissatisfaction with the sexual relationship as assessed by the MMQ-S scale. RESULTS: In multiple logistic regression analysis, the main predictive factor for no sexual intercourse 1 year postpartum was no sexual intercourse at 12 weeks of gestation (beta 11.0 [4.01-30.4]). Women were five times less likely to be sexually active after a third/fourth degree anal sphincter tear as compared with women with an intact perineum (beta 0.2 [0.04-0.93]). Dissatisfaction with the sexual relationship 1 year after childbirth, assessed with the MMQ-S scale, is associated with not being sexually active at 12 weeks of gestation (beta- 0.208, P= 0.004) and with an older maternal age at delivery (beta 0.405, P= 0.032). CONCLUSION: An important prognostic factor for dissatisfaction with the sexual relationship 1 year postpartum was not being sexually active in early pregnancy. Satisfaction with the sexual relationship seems not to depend on pregnancy- and parturition-associated factors.

The Pregnancy Mobility Index: a mobility scale during and after pregnancy.

BACKGROUND: During pregnancy, every second woman will experience some degree of back or pelvic pain. While several validated instruments to assess back pain exist for the general population, these are not suitable for application in a pregnant population and have not been validated for this purpose. A pregnant population not only differs from the general population regarding the type of back pain--frequently a pelvic girdle component is added--but pregnant women also have different mobility patterns and expectations. We therefore present in this study a self-report mobility scale specifically designed for a pregnant population: the Pregnancy Mobility Index. METHODS: Longitudinal cohort study including 672 nulliparous women with a singleton low-risk pregnancy. The Pregnancy Mobility Index consists of items concerning day-to-day activities selected through literature research and clinical experience. Participating women completed the questionnaire at 12 and 36 weeks' gestation and one year after delivery. Reliability, construct and criterion validity were tested. RESULTS: The internal consistency (Cronbach's alpha) was 0.8 or higher. The Pregnancy Mobility Index scales correlated best with the physical and pain scale of the RAND-36, indicating a good construct validity. The assumptions that the Pregnancy Mobility Index scores increase during pregnancy and decrease after delivery and that women with back or pelvic problems scored higher on the Pregnancy Mobility Index domains than women without back or pelvic pain were confirmed, indicating a good criterion validation. CONCLUSION: The Pregnancy Mobility Index has been shown to be a reliable and valid questionnaire well suited for use during and after pregnancy.

Psychosocial factors and mode of delivery.

Childbirth is a substantial physical and emotional endeavor. Because emergency Cesarean and instrumental vaginal delivery impose a greater mortality and physical and emotional morbidity on both the mother and the infant than normal vaginal delivery, it is important to identify factors that are associated with the risk of operative delivery. In previous investigations, some associations have been found, but the effect of psychosocial factors is not clear. In this study we examined several factors which could be associated with the risk for instrumental and surgical delivery. In addition to biomedical factors we included psychosocial factors such as depressive symptoms, quality of the relationship of the woman with her partner, personality, lifestyle and educational level. We assessed 354 healthy nulliparous pregnant women with a child in vertex presentation and spontaneous onset of term labor using validated questionnaires. We found that social support from the woman's partner in pregnancy, lack of depressive symptoms and specific personality traits are not protective against instrumentally assisted vaginal delivery or emergency Cesarean section. Predictive factors for operative delivery after spontaneous onset of labor are higher fetal weight, non-occiput anterior presentation and advanced gestational age, and foremost fetal distress during parturition.

Sacrospinous hysteropexy compared to vaginal hysterectomy as primary surgical treatment for a descensus uteri: effects on urinary symptoms.

One hundred and three women underwent sacrospinous hysteropexy (n=54) or vaginal hysterectomy with a vaginal vault suspension (n=49) for the management of descensus uteri. They were sent a postal questionnaire. Logistic regression analysis was used to obtain crude and adjusted odds ratios. Seventy-four (72%) women responded. The adjusted odds ratios for urge incontinence is 3.4 (1.0-12.3) and for overactive bladder 2.9 (0.5-16.9) greater after vaginal hysterectomy. The women recovered significantly more quickly after sacrospinous hysteropexy. There were no differences in anatomical outcome or recurrence rate. When performed to correct a descensus uteri of grade 2 or more we found that vaginal hysterectomy is associated with a three times higher risk for urge incontinence and overactive bladder symptoms. In addition, the women who underwent sacrospinous hysteropexy also reported a quicker recovery from surgery. Sacrospinous hysteropexy, therefore, appears to be promising for the correction of descensus uteri.