Natural orifice vaginal sacrocolpopexy (NOVaS): a cadaver feasibility study.

INTRODUCTION AND HYPOTHESIS: The primary objective was to determine the feasibility of a vaginal approach to sacrocolpopexy using a cadaver model. Secondary objectives were to measure the distance from the vaginal introitus to the sacrum and distances of the sacral fixation elements to other vital structures. METHODS: Fourteen fresh-frozen cadavers were used. Specialized instruments were developed to optimize visualization and facilitate performance of the procedure. RESULTS: Five cadavers had a transperineal approach (an approach found unfeasible), and eight of the remaining nine had complete or partial completion of the transvaginal approach. The mean distance from the introitus to the promontory was 14.6 cm (12-16.5 cm). The mean distance from the sacral fixation elements to the aorta was 5.2 cm; common iliac artery, 3.5 cm; internal iliac artery, 3.25 cm; middle sacral artery, 1.75 cm, and ureters, 3.5 cm. The position of the sacral fixation elements was consistently at the level of S1-2. CONCLUSION: Vaginal sacrocolpopexy is feasible in a cadaver model.

Anterior repair with or without collagen matrix reinforcement: a randomized controlled trial.

OBJECTIVE: To compare outcomes of anterior colporrhaphy alone to that reinforced with bovine pericardium graft. METHODS: Women with anterior vaginal wall prolapse were enrolled in a randomized fashion in this grafted compared with nongrafted repair study. Outcome measures included pelvic organ prolapse quantification data, quality-of-life assessment, healing abnormalities, and complications. RESULTS: Ninety-four patients were enrolled. Seventy-two (77%) provided 1-year data, and 59 (63%) supplied 2-year data. Demographics and stage of prolapse were similar between groups at baseline. Postoperative complications consisted basically of low urinary tract infection and were low in both groups (10 in bovine pericardium graft and 16 in anterior colporrhaphy alone). One year after surgery, successful anterior vaginal wall support was obtained in 85.7% of the bovine pericardium graft group and 78.4% of anterior colporrhaphy-alone group (P=.544). For the cohort that comprised 2-year analyses, the success rate was 76.5% for the bovine pericardium graft group and 63% for anterior colporrhaphy-alone group (P=.509). Postoperative Urogenital Distress Inventory-6 and Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire-12 scores were uniformly improved over baseline in both groups. CONCLUSION: The use of bovine pericardium graft for anterior vaginal prolapse does not have higher complication rates or healing difficulties. At 1- and 2-year follow-up, anterior colporrhaphy with bovine pericardium reinforcement did not show a statistically significant improvement over colporrhaphy alone. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00860912 LEVEL OF EVIDENCE: I.

Review and clinical experience exploring evidence, clinical efficacy, and safety regarding nonsurgical treatment of feminine rejuvenation.

INTRODUCTION: The use of energy-based devices for the treatment of vaginal laxity, orgasmic dysfunction, and stress incontinence, such as minimally ablative fractional laser and radiofrequency, is gaining momentum. This review aims to answer clinical questions on the application of energy-based devices for feminine genital rejuvenation. METHODS: The target group includes physicians involved in esthetic medicine and feminine genital rejuvenation. A literature review was conducted on technologies in use for feminine rejuvenation to explore their safety, efficacy, tolerability, patient satisfaction, and clinical usability. A panel of physicians with clinical experience conducting these types of treatment reviewed and discussed the results of the literature search and gave clinical evidence-based recommendations. RESULTS: Energy-based devices may induce wound healing, stimulating new collagen, and elastin fiber formation. Radiofrequency treatment may also increase small nerve fiber density in the papillary dermis, improving nerve sensitivity, sexual function, including arousal and orgasmic dysfunction. Both minimally ablative fractional laser and radiofrequency has been shown to be effective when treating mild to moderate primary or secondary vulvovaginal laxity and associated secondary conditions. These treatments are reported to be safe, effective, and well tolerated with a rapid return to activities of daily living. CONCLUSIONS: As this is an evolving medical field, clinical evidence often lacks robustness. Studies and clinical experience suggest that feminine genital rejuvenation using energy-based devices seems an attractive option for patients with mild-to-moderate medical conditions. The treatment can be safely and effectively delivered by trained staff as part of the comprehensive care, that is, currently available to women.

Current treatment options for female urinary incontinence--a review.

Urinary incontinence is a prevalent condition that impacts many women's lives. Stress urinary incontinence (SUI), urine loss associated with exertion, typically has its onset during the reproductive years, whereas urge incontinence, urine loss associated with urgency, more frequently affects postmenopausal women. Mixed incontinence, a combination of stress and urge incontinence, affects up to 30% of incontinent women. Simple modifications such as dietary and fluid management, timed voiding, and adjustment of medications can lessen symptom severity and should be attempted prior to instituting other treatments. Physiotherapy, including pelvic floor exercises, biofeedback, and functional electrical stimulation, center on improving pelvic floor neuromuscular function, thus improving bladder and urethral function. Current pharmacologic treatments focus primarily on urge incontinence, anticholinergics being the mainstays of therapy. Local estrogen therapy may improve urethral and bladder function if a woman's incontinence is associated with urogenital atrophy. Surgery is primarily reserved for management of severe SUI. Minimally invasive sling procedures have replaced the Burch colposuspension as the most common surgeries performed for SUI, and appear to have similar success rates. Surgical therapies for refractory urge incontinence have been attempted with limited success. Many new, potentially more effective, treatments are being developed.

Novel approach for correction of urethral prolapse using a retropubic sling with urethral fixation.

We describe the novel management of a 68-year-old postmenopausal woman with urethral mucosal prolapse, stress urinary incontinence, and significant pelvic organ prolapse. Successful surgical management of her urethral prolapse was achieved using a retropubic suburethral sling with urethral fixation at the time of anti-incontinence and pelvic reconstructive surgery.

A prospective, randomized controlled trial of the use of an anal purse-string suture to decrease contamination during pelvic reconstructive surgery.

The objective of this study was to evaluate the clinical utility of an anal purse-string suture to prevent contamination of the operative field during vaginal surgery. Patients undergoing vaginal surgery involving the posterior compartment were enrolled to receive a purse-string suture closing the anus (group 1) or to not receive the suture (group 2). Perineal/perianal cultures were performed after sterile preparation and at conclusion of surgery. The primary outcome measure was gross fecal contamination. Secondary outcomes were results of perineal cultures. Continuous and ordinal variables were compared between groups using Wilcoxon rank sum tests, while comparisons of binary variables were performed using exact unconditional tests. Forty (40) patients were randomized. There were no significant differences in the two groups including age (P = 0.95), parity (P = 0.40), operative time (P = 0.75), and estimated blood loss (P = 0.81). Gross contamination rates were 0/40 (0%) for group 1 and 5/19 (26.3%) for group 2 (P = 0.015). Contamination by fecal flora occurred in 2/20 (10%) for group 1 and in 5/20 (25%) for group 2 (P = 0.27). No wound infections, graft erosions, or healing abnormalities were noted in either group. An anal purse-string suture is an effective way of reducing fecal contamination of the sterile field when performing vaginal pelvic reconstructive surgery.

Initial experience with a new method for the dynamic assessment of pelvic floor function in women: the Kolpexin Pull Test.

The aim of this study was to evaluate a newly developed, simple test for assessing pelvic floor muscular function in women. Pelvic floor strength in women with symptomatic pelvic floor dysfunction was evaluated with a newly developed assessment tool, the Kolpexin Pull Test, and compared to a clinically validated digital pelvic floor strength assessment scale (DPA). A 36-mm Kolpexin sphere was inserted into the vagina above the levator plate and connected to a digital tensiometer/force gauge. The force required to remove the sphere was recorded for three resting trials and three maximum pelvic floor contractions. Results of the DPA and Kolpexin Pull Test were analyzed using ANOVAs of contrast variables, intraclass correlations, and regression analyses. Twenty-one women participated in the study. Age range was 36-85 years, parity range was 2-5. All six trials required less than 5 min to perform in each patient. Intraperson maximum contraction data were correlated at 0.96 (95% CI: 0.91, 0.98), and were greater at higher DPA scores ( p=0.016). There were positive correlations between the maximum contraction and DPA data (adjusted R(2)=0.52; p <0.001), and the maximum contraction minus resting vs DPA data (adjusted R(2)=0.54; p< 0.001). The Kolpexin Pull Test is reproducible, rapid, and correlates with digital clinical assessment of pelvic floor strength during maximal contractions.