Antibiotic prophylaxis in invasive urodynamics, a Delphi consensus of the Italian Society of Urodynamics (SIUD).

INTRODUCTION: Although antibiotic prophylaxis (AB) demonstrated a statistically significant reduction in bacteriuria after invasive urodynamics (UDS), no significant decrease in the incidence of urinary tract infections (UTI) has been confirmed. No absolute recommendations on the use of AB in case of relevant potential risk of UTI have been reported, though some categories of patients at increased infective probability after UDS have been recognized. The aim of this study is to report the experts' consensus on the best practice for the use of AB before UDS in the main categories of patients at potential risk of developing UTI. MATERIALS AND METHODS: A systematic literature review was performed on AB before UDS in males and females. A panel of experts from the Italian Society of Urodynamics, Continence, Neuro-Urology, and Pelvic Floor (SIUD) assessed the review data and decided by a modified Delphi method on 16 statements proposed and discussed by the panel. The cut-off percentage for the consensus was a ≥70% of positive responses to the survey. The study was a Delphi consensus with experts' opinions, not a clinical trial involving directly patients. RESULTS: The panel group was composed of 57 experts in functional urology and UDS, mainly urologists, likewise gynaecologists, physiatrists, infectivologists, pediatric urologists, and nurses. A positive consensus was achieved on 9/16 (56.25%) of the statements, especially on the need for performing AB before UD in patients with neurogenic bladder and immunosuppression. Urine analysis and urine culture before UDS are mandatory, and in the event of their positivity, UDS should be postponed. A consensus was reached on avoiding AB in menopausal status, diabetes, age, gender, bladder outlet obstruction, high postvoid residual, chronic catheterization, previous urological surgery, lack of urological abnormalities, pelvic organ prolapse, and negative urine analysis. CONCLUSIONS: Antibiotic prophylaxis is not recommended for patients without notable risk factors and with a negative urine test due to the potential morbidities that may result from antibiotic administration. However, AB can be used for risk categories such as neurogenic bladder and immunosuppression. The evaluation of urine analysis and urine culture and postponing UDS in cases of positive tests were considered good practices, as well as performing AB in the neurogenic bladder and immunosuppression.

Prevalence and severity of lower urinary tract symptoms in the third trimester of pregnancy.

INTRODUCTION AND HYPOTHESIS: Pregnancy is a risk factor for urinary disorders, mainly in the third trimester. Lower urinary tract symptoms (LUTS) are often underreported by health care professionals and significantly impact the quality of life of pregnant women. Our objective is to analyse lower urinary tract function during the third trimester of pregnancy and assess the impact of traditional risk factors for pelvic floor dysfunctions on bladder health in pregnant women. METHODS: This is a secondary analysis of a multicentre cross-sectional study. Third-trimester pregnant women aged 18 years or older anonymously filled in the "Italian Pelvic Floor Questionnaire for pregnant and postpartum women" questionnaire, validated for pelvic floor disorders in pregnancy and postpartum. RESULTS: A total of 927 pregnant patients completed the questionnaire. Among them, 97.3% complained of at least one urinary disorder. Frequency was the symptom reported most often (77.3%), whereas nocturnal enuresis was the least reported (17%). Despite the high prevalence of LUTS in our sample, only 13.4% reported that they negatively impact their quality of life. Overweight and obesity, advanced maternal age, smoking, family history of pelvic floor disorders and poor pelvic floor contraction capacity were confirmed to be risk factors for the onset of LUTS, even in our population. CONCLUSIONS: Urinary symptoms are extremely common in the third trimester and significantly affect the quality of life of pregnant women. Since overweight, obesity, smoking and reduced pelvic floor contractility emerged as modifiable risk factors for the development of these symptoms, prevention and adequate counselling are cornerstones of pregnancy care.

Italian validation of the Pelvic Floor Distress Inventory (PFDI-20) questionnaire.

INTRODUCTION AND HYPOTHESIS: The use of validated Quality of Life (QoL) questionnaires is useful in the standardization and interpretation process of pelvic floor patient symptoms, due to their functional nature and high prevalence. The Pelvic Floor Distress Inventory QoL questionnaire (PFDI-20) serves both as a symptom inventory and a measure of the degree of bother and distress caused by pelvic floor symptoms. It includes items related to pelvic organ prolapse and lower gastrointestinal and bladder dysfunction. METHODS: After consensus translation and a comprehension test, the Italian version of the questionnaire was submitted to patients reporting bowel, bladder, or pelvic disorders (cases) and to asymptomatic women (controls). Cases received the questionnaire once again 2 weeks later by email. RESULTS: A total of 254 patients answered the questionnaire. Construct validity was demonstrated by discriminating between cases and controls. Convergent validity was demonstrated for each domain (F < 0.001). In-ernal consistency reliability showed a satisfactory range (0.816-0.860). CONCLUSIONS: The PFDI-20 allows a comprehensive assessment of the effect of pelvic floor disorders on the quality of life of women. Moreover, the PFDI-20 represents a very solid QoL tool, since it has been extensively used in literature, and its use is highly recommended by the International Consultation on Incontinence. The present study demonstrated good features for the Italian version of the PFDI-20 questionnaire.

Detrusor underactivity prevalence and risk factors according to different definitions in women attending urogynecology clinic.

INTRODUCTION AND HYPOTHESIS: There is still no consensus on definitions of detrusor underactivity; therefore, it is difficult to estimate the prevalence. The primary objective of the study was to evaluate the prevalence of detrusor underactivity in a cohort of patients with pelvic floor disorders according to different proposed urodynamics definitions. The secondary objectives were to estimate the association between detrusor underactivity and symptoms, anatomy and urodynamic findings and to build predictive models. METHODS: Patients who performed urodynamic evaluation for pelvic floor disorders between 2008 and 2016 were retrospectively analyzed. Detrusor underactivity was evaluated according to Schafer's detrusor factor, Abrams' bladder contractility index and Jeong cut-offs. The degree of concordance between each method was measured with Cohen's kappa, and differences were tested using Student's t test, Wilcoxon test and Pearson's chi-squared test. RESULTS: The prevalence of detrusor underactivity among a cohort of 2092 women, concerning the three urodynamic definitions, was 33.7%, 37.0% and 4.1%, respectively. Age, menopausal status, voiding/bulging symptoms, anterior and central prolapse, first desire to void and positive postvoid residual were directly related to detrusor underactivity. Conversely, stress urinary incontinence, detrusor pressures during voiding and maximum flow were inversely associated. Final models for detrusor underactivity resulted in poor accuracy for all considered definitions. CONCLUSIONS: The prevalence of detrusor underactivity varies depending on the definition considered. Although several clinical variables resulted as independent predictors of detrusor underactivity, instrumental evaluation still plays a key role in the diagnosis.

Inability to walk and persistent thigh pain after transobturator tape procedure for stress urinary incontinence: surgical management.

INTRODUCTION AND HYPOTHESIS: Groin pain after transobturator tape is often a self-limiting situation, but can occasionally persist and be associated with serious neurological sequelae. The video is aimed at presenting the surgical management of persistent groin pain and inability to walk after transobturator sling placement and subsequent partial removal. METHODS: The featured patient is a 31-year-old woman unable to walk after transobturator sling implantation 2 years before. She reported left thigh pain immediately after surgery that was not responsive to postoperative medication. Six months later, suburethral portion excision was performed but no pain relief was obtained. She was unable to walk, and needed a wheelchair. Electromyography showed axonal injury of the left obturator nerve. After providing proper informed consent, the patient was admitted for combined transvaginal and transcutaneous transobturator tape arm removal. RESULTS: The featured procedure was completed in 120 min and blood loss was <100 ml. No surgical complications were observed. The patient is currently doing left leg rehabilitation, has regained the ability to walk with the aid of a crutch, and the need for chronic pain control medication is greatly reduced. CONCLUSION: This represents a valid surgical approach for the late management of this mesh-related complication.

Single-incision slings for the treatment of stress urinary incontinence: efficacy and adverse effects at 10-year follow-up.

INTRODUCTION AND HYPOTHESIS: Single-incision slings are not considered a first-choice surgical treatment owing to a lack of data about long-term outcomes. We aimed to assess the long-term results of urinary incontinence treatment after single-incision sling implantation at 10 years' follow-up and to investigate possible deterioration over time. METHODS: This retrospective study analyzed women with subjective and urodynamically proven stress urinary incontinence who underwent single-incision sling procedure. The objective cure rate was assessed with a 300-ml stress test. The subjective cure rate was determined by the Patient Global Impression of Improvement (PGI-I) questionnaire. International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire scores and self-answered patient-satisfaction scales were collected to assess symptom severity. Findings were compared with short-term outcomes in the same patients, available through our previous database, in order to detect possible outcome deterioration over time. RESULTS: The records of 60 patients were analyzed. Nine patients (15%) were lost to follow-up. A total of 51 patients completed the evaluation, with a mean follow-up of 10.3 ± 0.7 years. Objective and subjective cure resulted 86.3% and 88.2% respectively. Mean PGI-I scores and ICIQ-SF were 1.5 ± 1.0 and 3.2 ± 4.8 respectively. Patients' satisfaction scored 8.6 ± 2.6 out of 10. No long-term complications occurred. Comparison of short-term (2.6 ± 1.4 years after surgery) and long-term follow-up did not show a significant deterioration of outcome over time. CONCLUSIONS: Single-incision slings were shown to be a procedure with a great efficacy and safety profile at very long-term follow-up. Cure rates and functional outcomes did not show any deterioration over time compared with short-term results.

Update in fertility-sparing native-tissue procedures for pelvic organ prolapse.

Uterine-sparing prolapse surgery has been gaining back popularity with clinicians and patients. Although both prosthetic and native-tissue surgery procedures are described, the latter is progressively regaining a central role in pelvic reconstructive surgery, owing to a lack of mesh-related complications. Available native-tissue procedures have different advantages and pitfalls, as well as different evidence profiles. Most of them offer anatomical and subjective outcomes comparable with those of hysterectomy-based procedures. Moreover, native-tissue procedures in young women desiring childbearing allow to avoid synthetic material implantation, which may lead to potentially serious complications during pregnancy. As a consequence, we do think that offering a reconstructive native-tissue procedure for uterine preservation (with the exception of the Manchester procedure) is the safest option in women wishing for pregnancy. Sacrospinous ligament hysteropexy and high uterosacral ligament hysteropexy may be considered first-line options in consideration of the higher level of evidence and lack of adverse obstetrical outcomes.

Surgical management of bladder erosion and pelvic pain after laparoscopic lateral suspension for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Mesh-augmented lateral suspension for prolapse repair seems to be associated with few complications. However, mesh-related complications can negatively affect the quality of life and may be challenging to manage. This video is aimed at presenting the surgical management of a case of severe pelvic pain and dyspareunia after lateral laparoscopic suspension associated with mesh erosion in the bladder. METHODS: A 46-year-old woman was referred to our Unit for severe pelvic pain and inability to have sexual intercourses since undergoing a uterus-sparing laparoscopic lateral suspension procedure for genital prolapse 2 years before in another hospital. Moreover, she reported bladder pain and recurrent urinary tract infections. Cystoscopy showed mesh erosion in the bladder. She was admitted to laparoscopic hysterectomy plus subtotal mesh excision and bladder reconstruction (video). RESULTS: No surgical complications were observed. The postoperative course was uneventful. At the current follow-up, the patient reported complete resolution of her symptoms. CONCLUSION: The featured video shows laparoscopic subtotal mesh excision, concomitant hysterectomy and bladder repair for pelvic pain, dyspareunia and bladder erosion after lateral suspension. This video may be useful in providing anatomical views and surgical steps necessary for achieving successful surgical management of this mesh-related complication.

Surgical treatment of complete uterovaginal prolapse and concomitant vaginal cancer: a video case report.

INTRODUCTION AND HYPOTHESIS: The concurrence of vaginal cancer with irreducible uterine prolapse is rare. Reports about the management of vaginal cancer and concomitant irreducible prolapse are scanty in the literature, and there is no consensus on optimal treatment. In this video case report, we show surgical management of vaginal cancer and concomitant stage IV uterovaginal prolapse. METHODS: The featured video shows surgical management of vaginal cancer and concomitant stage IV uterovaginal prolapse through anterior colpectomy and retrograde hysterectomy en bloc plus transvaginal levator ani plication as a non-obliterative native-tissue technique for apical support. RESULTS: Final examination revealed good apical support and vaginal "habitability" preservation. The patient underwent five sessions of intracavity brachytherapy for a total of 20 Gy as adjuvant therapy. CONCLUSION: Surgical management of vaginal cancer and concomitant stage IV uterovaginal prolapse was successfully achieved without complications. Transvaginal levator ani plication can provide a versatile non-obliterative native-tissue technique for apical support, allowing subsequent adjuvant brachytherapy.

Transvaginal uterosacral ligament hysteropexy versus hysterectomy plus uterosacral ligament suspension: a matched cohort study.

INTRODUCTION AND HYPOTHESIS: Uterine-sparing procedures are associated with shorter operative time, less blood loss and faster return to activities. Moreover, they are attractive for patients seeking to preserve fertility or concerned about the change of their corporeal image and sexuality after hysterectomy. This study aimed to compare outcomes of transvaginal uterosacral hysteropexy with transvaginal hysterectomy plus uterosacral suspension. METHODS: This retrospective study compared all patients who underwent uterosacral hysteropexy for symptomatic prolapse at our institute to matched control patients who underwent hysterectomy plus uterosacral ligament suspension. Anatomic recurrence was defined as postoperative prolapse stage ≥ II or reoperation for prolapse. Subjective recurrence was defined as the presence of bulging symptoms. PGI-I score was used to evaluate the patients' satisfaction. RESULTS: One hundred four patients (52 for each group) were analyzed. Mean follow-up was 35 months. Hysteropexy was associated with shorter operative time and less bleeding compared with hysterectomy (p < 0.0001), without differences in complication rates. Moreover, overall anatomic and subjective cure rate and patient satisfaction were similar between groups. However, hysteropexy was found to be associated with a significantly higher central recurrence rate (21.2% versus 1.9%, p = 0.002), mostly related to cervical elongation, and subsequently a higher reoperation rate (13.5% versus 1.9%, p = 0.04). A 42.9% pregnancy rate in patients still desiring childbirth was found. CONCLUSIONS: Transvaginal uterosacral hysteropexy resulted in similar objective and subjective cure rates, and patient satisfaction, without differences in complication rates, compared with vaginal hysterectomy. However, postoperative cervical elongation may lead to higher central recurrence rates and need for reoperation.

COVID-19 does not stop obstetrics: what we need to change to go on safely birthing. The experience of a University Obstetrics and Gynecology Department in Milan.

Since SARS-COV-2 appeared in Wuhan City, China and rapidly spread throughout Europe, a real revolution occurred in the daily routine and in the organization of the entire health system. While non-urgent clinical services have been reduced as far as possible, all kind of specialists turned into COVID-19 specialists. Obstetric assistance cannot be suspended and, at the same time, safety must be guaranteed. In addition, as COVID-19 positive pregnant patients require additional care, some of the clinical habits need to be changed to face emerging needs for a vulnerable but unstoppable kind of patients. We report the management set up in an Obstetrics and Gynecology Unit during the COVID-19 era in a University Hospital in Milan, Italy.

Long-term effects of episiotomy on urinary incontinence and pelvic organ prolapse: a systematic review.

PURPOSE: To focus attention on the long-term effects of episiotomy on urinary incontinence and pelvic organ prolapse. METHODS: A systematic review was conducted including only studies with mean follow-up ≥ 5 years. We searched using combinations of the following keywords and text words: "episiotomy", "perineal laceration", "perineal tear", "perineal damage" and "long term", "long term outcomes", "prolapse", "pelvic organ prolapse", "pelvic floor", "pelvic floor dysfunction", "urinary incontinence", "hysterocele", "cystocele" and "rectocele". RESULTS: The electronic database search provided a total of 6154 results. After exclusions, 24 studies were included yielding the following results: (1) episiotomy might be detrimental with respect to urinary incontinence symptoms; (2) the relationship between episiotomy and anti-incontinence surgery is not clear; (3) episiotomy does not seem to negatively influence genital prolapse development and might even be protective with respect to prolapse severity and prevalence; (4) episiotomy does not seem to affect genital prolapse surgery rate. CONCLUSIONS: We did not find evidence for a long-term beneficial effect of episiotomy in the prevention of urinary incontinence symptoms and anti-incontinence surgery. Episiotomy does not seem to negatively influence genital prolapse development and might even be protective with respect to prolapse severity and prevalence without affecting surgery rates.

Risk factors for stress urinary incontinence recurrence after single-incision sling.

AIMS: The aim of the study was to identify in a pure stress urinary incontinence (SUI) population risk factors for recurrence after single-incision slings (SIS). METHODS: This retrospective study analyzed women with complaints of SUI symptoms and urodynamically proven SUI. Exclusion criteria were recurrent SUI, overactive bladder syndrome/detrusor overactivity, preoperative postvoid residual >100 mL, reduced urethral mobility (<10° at the Q-tip test), concomitant anterior prolapse >I stage and previous history of radical pelvic surgery. Objective cure rate was assessed with stress test. RESULTS: A total of 192 patients were analyzed. Objective cure rate was obtained in 86.5% of patients. According to univariate analysis, recurrences had higher prevalence of severe ICIQ-SF score (≥18 points), higher prevalence of reduced urethral mobility (Qtip ≤30°), higher prevalence of low detrusor pressures during voiding phase (opening pressure <15 cmH2 O, pressure at maximum flow <20 cmH2 O, closing pressure <15 cmH2 O), and higher prevalence of postoperative complications According to multivariate analysis ICIQ-SF score ≥18 points (P = 0.02; OR = 2.7) and detrusor pressure at maximum flow <20 cmH2 O (P < 0.01; OR = 3.6) resulted as independent risk factors for SUI recurrence (Table 3). A trend was found for urethral mobility ≤30° (P = 0.07; OR = 2.2). CONCLUSIONS: Our study identifies SUI severity expressed with ICIQ-SF scores and low detrusor pressure at maximum flow as independent risk factors for SUI recurrence after SIS implantation while only a trend was found for reduced urethral mobility. Therefore, preoperative assessment of symptoms and urodynamics evaluation may play a key role in improving preoperative counseling and tailoring surgical treatment.

Risk factors for recurrence after hysterectomy plus native-tissue repair as primary treatment for genital prolapse.

INTRODUCTION AND HYPOTHESIS: Identification of risk factors for pelvic organ prolapse (POP) recurrence is crucial to provide adequate preoperative counselling and tailor surgical treatment. The aim of this retrospective study was to identify risk factors for recurrence in a large series of patients with POP treated with primary transvaginal native-tissue repair involving high uterosacral ligament suspension. METHODS: Postoperative descent of POP-Q stage 2 or higher in any compartment was considered as recurrence. Global recurrence (GR) was defined as any recurrence in any compartment irrespective of the surgical procedures performed during primary prolapse surgery. True recurrence (TR) was defined as recurrence in a compartment repaired during primary prolapse surgery. RESULTS: Of a total of 533 eligible women, 519 were available for follow-up. Univariate analysis showed that age ≤50 years, premenopausal status, obesity (BMI >30 kg/m2), history of severe macrosomia (>4,500 g), preoperative POP stage 3 or higher and absence of anterior repair at the time of POP surgery were risk factors for GR. Multivariate analysis confirmed lack of posterior repair (odds ratio, OR, 1.8), severe macrosomia (OR 2.7), premenopausal status (OR 3.9), obesity (OR 2.2) and preoperative stage 3 or higher (OR  2.6) as risk factors for GR. Univariate analysis showed that premenopausal status and preoperative POP stage 3 or higher were risk factors for TR. Multivariate analysis confirmed premenopausal status (OR 4.0) and preoperative stage 3 or higher (OR 4.5) as risk factors for TR. CONCLUSIONS: This study confirmed preoperative stage 3 or higher as a risk factor for prolapse recurrence. The study also identified additional risk factors for surgical failure including lack of posterior repair, severe macrosomia, premenopausal status and obesity.

Transvaginal levator myorrhaphy for posthysterectomy vaginal vault prolapse repair.

INTRODUCTION AND HYPOTHESIS: Posthysterectomy vaginal vault prolapse repair represents a surgical challenge. Surgical management can be successfully achieved with native-tissue repair through levator myorrhaphy. Despite low morbidity, levator myorrhaphy is not a common procedure. The aim of the video is to provide anatomic views and surgical steps necessary to achieve a successful transvaginal levator myorrhaphy for vaginal vault prolapse repair. METHODS: A 72-year-old woman with symptomatic stage IV vaginal vault prolapse was admitted for transvaginal levator myorrhaphy according to the described technique. RESULTS: Surgical repair was successfully achieved without complications. The final examination revealed good apical support and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know how. CONCLUSIONS: Transvaginal levator myorrhaphy provides an alternative technique for apical support without using prosthetic materials. This technique can be indicated when abdominal approach or synthetic device are not recommended or when peritoneum opening may be challenging. However, due to its possible constricting effect, it should be reserved to sexually inactive patients.

Tips and tricks for uterosacral ligament suspension: how to avoid ureteral injury.

INTRODUCTION AND HYPOTHESIS: Uterosacral ligament (USL) suspension is an effective and versatile surgical technique for repairing pelvic organ prolapse. However, ureteral injury is a feared complication that may act as a significant deterrent to the use of USL suspension. The aim of the video is to provide key steps to minimize the risk of ureteral injury while achieving successful transvaginal USL suspension. METHODS: The featured video provides a series of surgical tips and tricks that can be applied to protect the ureters while achieving USL suspension whether the procedure contemplated is vaginal hysterectomy, vaginal vault repair after hysterectomy, or hysteropexy. RESULTS: The tips and tricks are classified into four categories: identification of the USLs, identification of the ureters, passage of the sutures, and final measures. CONCLUSIONS: The USL suspension technique requires adequate surgical training and an understanding of pelvic anatomy. This tips and tricks video tutorial may be an important tool for improving surgical know-how, and thus for reducing the risk of ureteral injury. In particular, identification of the USLs and ureters, proper suture positioning and final cystoscopy are key points to minimize ureteral damage.

Repair of a vesicouterine fistula following cesarean section.

INTRODUCTION AND HYPOTHESIS: Vesicouterine fistula is a rare complication of cesarean section. The aim of this video is to present a case report and to provide a tutorial on the surgical technique of delayed transvaginal repair of a high vesicouterine fistula that developed after cesarean section with manual removal of a morbidly adherent placenta. METHODS: A 43-year-old woman was referred to our unit for continuous urinary leakage 3 months after undergoing a cesarean section with manual removal of a morbidly adherent placenta. A vesicouterine fistula starting from the posterior bladder wall was identified. The surgical repair consisted of a transvaginal layered repair as shown in the video. RESULTS: No surgical complications were observed postoperatively. Two months after surgery the fistula had not recurred and the patient reported no urinary leakage. CONCLUSIONS: Transvaginal layered primary repair of vesicouterine fistula was shown to be a safe and effective procedure for restoring continence. The vaginal route can be particularly attractive for urogynecological surgeons.

Detrusor underactivity in pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The association between pelvic organ prolapse (POP) and detrusor underactivity (DU) is not well defined. The primary outcome of this study was to evaluate the prevalence of DU in a cohort of patients with POP and its association with symptoms, anatomy. and urodynamic findings. The secondary outcome was to evaluate the evolution of lower urinary tract symptoms after POP repair between DU and non-DU patients. METHODS: Consecutive patients who underwent preoperative urodynamic tests were retrospectively analyzed. Detrusor underactivity was evaluated by the Bladder Contractility Index (BCI = pDetQmax + Qmax × 5) proposed by Abrams. A BCI < 100 was considered indicative of an underactive bladder. Patients with underactive bladder were considered group A, whereas the remaining patients were classified as group B. RESULTS: A total of 518 patients were studied. According to BCI, detrusor underactivity was identified in 212 (40.9%) patients (group A). Group A showed higher rates of voiding symptoms (59.4% vs 36.3%, p < 0.0001) and positive (>100 ml) postvoid residual (29.7% vs 9.8%, p < 0.0001). Conversely, they displayed lower rates of urge incontinence (15.1% vs 23.2%, p = 0.02) and detrusor overactivity (15.6% vs 23.9%, p = 0.02). Preoperative Pelvic Organ Prolapse Quantification (POP-Q) demonstrated greater Aa (+1.1 ± 1.5 vs +0.9 ± 1.5, p = 0.03) and Ba (+1.4 ± 1.7 vs +1.2 ± 1.7, p = 0.04) points values in patients in group A. After POP surgery, postoperative voiding symptoms were similar in the two groups (16% vs 15.7%, p = 0.91). CONCLUSIONS: Our study showed a 40.9% prevalence of DU in POP patients. DU was associated with the presence of voiding symptoms and positive PVR. Moreover, cystocele showed to be more severe in DU group. After surgical repair of POP, voiding symptoms of DU patients became equal to non-DU ones, suggesting that obstruction removal might recover DU in these patients.

Transvaginal native-tissue repair of enterocele.

INTRODUCTION AND HYPOTHESIS: Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS). METHODS: A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique. RESULTS: Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how. CONCLUSIONS: Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.

Transvaginal sacrospinous ligament fixation for posthysterectomy vaginal vault prolapse repair.

INTRODUCTION AND HYPOTHESIS: Posthysterectomy vaginal vault prolapse repair is a challenge for urogynecologists. Surgical management can be successful with native tissue by the vaginal approach with sacrospinous ligament fixation. However, severe complications have been described, including nerve injury and life-threatening hemorrhage. METHODS: A 68-year-old woman with symptomatic stage III vaginal vault prolapse was admitted for transvaginal sacrospinous ligament fixation according to the described technique. RESULTS: The surgical procedure was successful without complications. The final examination revealed excellent apical support and preservation of vaginal length. This step-by-step video tutorial may be an important tool for improving surgical knowledge, thus leading to a reduction in the risk of complications. In particular proper suture positioning requires adequate preparation of the pararectal space and exposure of the sacrospinous ligament, as shown in the video. CONCLUSIONS: Transvaginal sacrospinous ligament fixation is a safe and effective technique for apical support without the use of prosthetic materials. Adequate preparation of the pararectal space, direct visualization of the sacrospinous ligament and proper suture positioning are the key points in minimizing the risk of complications.