Polypropylene and polyvinylidene fluoride transobturator slings for the treatment of female stress urinary incontinence: 1-Year outcomes from a multicentre randomized trial.

AIMS: To compare the effectiveness and safety of polypropylene (PP) and polyvinylidene fluoride (PVDF) transobturator tapes (TOT) for the treatment of female stress urinary incontinence (SUI). METHODS: This is a multicentre randomized trial. Women with SUI or stress-predominant mixed urinary incontinence and scheduled for a TOT procedure were randomized to PP or PVDF slings. The primary outcome was 1-year cure or improvement rate using composite criteria. Complications were also compared. Relationships with outcomes were analyzed using multivariable logistic regressions models. RESULTS: From April 2016 to January 2018 285 participants were randomized. PP and PVDF slings showed similar high cure or improvement rate (91.0% vs. 95.6%, p = .138). Improvement in validated questionnaires was also similar. PVDF slings were associated with a lower rate of de novo urgency incontinence (adjusted odds ratio = 0.35; 95% confidence interval = 0.15-0.80). We found no statistical differences in complications rates, although a higher incidence of long-term pain events were observed in the PP group. The study is underpowered to find differences in specific complications owing to the low number of events. CONCLUSION: PP and PVDF TOTs are equally effective, although PVDF is associated with fewer cases of de novo urgency incontinence. Further studies are needed to give robust conclusions on safety profiles.

Long-term outcomes of retropubic tension-free vaginal tape for stress urinary incontinence after a transobturator tape failure: a retrospective study.

INTRODUCTION AND HYPOTHESIS: Management of stress urinary incontinence (SUI) after a transobturator tape (TOT) failure is a controversial issue. There are few long-term data on the different treatment options. The aim of this study is to evaluate the long-term effectiveness and safety of retropubic suburethral slings (RP-TVT) in this setting. METHODS: A descriptive retrospective study was performed among women with persistent/recurrent SUI treated at the Vall d'Hebron University Hospital between January 2006 and December 2014. All women were preoperatively evaluated to rule out complications of the first sling. Postoperative follow-up was performed at 1, 6 and 12 months and yearly thereafter. Outcomes were classified as cured, improved or failed. RESULTS: Forty-one women were operated on over the study period. The median follow-up time was 103.2 months. Likelihood to be cured or improved at 3, 5, 7 and 10 years was 78.0%, 75.4%, 71.9% and 67.4%, respectively. Absence of urethral hypermobility was the only variable related to RP-TVT failure. Complications during follow-up were observed in 39% of patients, although most of them were mild. However, two cases (4.9%) of vaginal exposure and three (7.3%) of lower urinary tract extrusion were observed. De novo urgency occurred 17.1% of women. CONCLUSIONS: RP-TVT showed reasonable long-term effectiveness but had a high overall complication rate in the treatment of persistent/recurrent SUI after TOT. Expected outcomes and possible side effects should be discussed in detail during counseling before opting for a treatment option.

External validation of de novo stress urinary incontinence prediction model after vaginal prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Stress urinary incontinence (SUI) may appear after the correction of pelvic organ prolapse (POP). The aim of this study was to externally validate a described predictive model for de novo SUI and to assess its clinical performance when used as a diagnostic test. METHODS: This was a retrospective descriptive study on a cohort of consecutive women treated in our institution. The main outcome used to validate the model was the presence of objective or subjective SUI 1 year after surgery. A receiver operating characteristic curve was generated from our population to evaluate the predictive accuracy and to compare it with the original model. A cutoff point of ≥50% was used to evaluate its clinical performance as a diagnostic test. RESULTS: Of the full cohort, 169 women were suitable for analysis. The rate of de novo SUI was 11.8%. The predictive accuracy of the model in our population was similar to the original [area under the curve (AUC) = 0.69; 95% confidence interval (CI) = 0.58-0.80). However, its performance measures when evaluated as a diagnostic test were low: positive likelihood ratio = 2.71 and negative likelihood ratio = 0.86. Only 15 women presented a positive test result. CONCLUSIONS: External validation of the model found a global predictive accuracy similar to that of the original model. Despite the study being underpowered to give firm conclusions, the test did not show a good clinical performance when applied to our population with low de novo SUI prevalence. A larger sample size is needed to validate the model conclusively.

Prolapse assessment supine and standing: do we need different cutoffs for "significant prolapse"?

INTRODUCTION AND HYPOTHESIS: Translabial ultrasound (TLUS) has shown good correlations between clinical examination and imaging findings in the supine position, and limits of normality have been described. This is not the case for imaging in the standing position. This study was designed to test the hypothesis that different cutoff values are required for imaging in the standing position. METHODS: This was a retrospective study carried out in a tertiary urogynecological unit in women presenting with symptoms of lower urinary tract and pelvic floor dysfunction between August 2013 and December 2015. All women underwent a standardized interview, 4D TLUS and a POP-Q assessment. Organ descent on ultrasound was measured relative to the postero-inferior margin of the symphysis pubis (SP) on maximal Valsalva in the supine and standing positions. Receiver operator characteristic (ROC) statistics were used to determine optimal cutoffs for "normal" pelvic organ support. RESULTS: We assessed 243 data sets. Mean patient age was 57 years. Prolapse symptoms were reported by 59.2%, and POP of stage ≥ 2 was found in 82.3%. On analysing imaging data sets obtained in the standing position, we obtained similar cutoff values to those established previously for supine imaging, using ROC statistics. The levator hiatus distended significantly more on Valsalva in the standing position compared with supine, and on ROC analysis we identified a new optimal cutoff of 29 cm2. CONCLUSIONS: Established cutoffs for supine imaging of organ descent are suitable for imaging in the standing position. Hiatal distensibility may require a higher cutoff of 29 cm2.

Current situation: lower genital tract pathology and colposcopy training in spanish gynecology and obstetrics residents.

OBJECTIVE: This study aimed to evaluate the impact of an educational intervention in lower genital tract pathology (LGTP) on the knowledge and skills acquired by the Spanish specialist residents. This didactic change was carried out under the auspices of the Asociación Española de Patología Cervical y Colposcopia and the Sociedad Española Ginecología y Obstetricia and its Resident Section. STUDY DESIGN: This is an observational, descriptive, and cross-sectional study. The survey was composed of 15 questions voluntarily answered by Spanish gynecology and obstetrics trainees. RESULTS: Compared with a previous survey, a substantial increase in the proportion of Spanish teaching hospitals with an LGTP unit (9/42 vs 47/59) has been detected while doubling the percentage of residents who acknowledge medium to high knowledge on this pathology. The same cannot be said about the handling capacity of vulvodynia registering a great improvement. CONCLUSIONS: Spanish scientific societies, concerned in the quality of LGTP training gained by their residents, have focused on the necessity of LGTP units. Our study confirms the usefulness of this performance in the new continued LGTP education.

Can the microcystic, elongated and fragmented pattern of invasion influence the evaluation of the depth of myometrial invasion in low-grade endometrioid endometrial cancer using imaging techniques?

Objectives: The microcystic, elongated and fragmented pattern of invasion can be associated with an underestimation of the depth of myometrial invasion by imaging techniques. We aimed to evaluate the influence of microcystic, elongated and fragmented pattern of invasion in the diagnostic performance of transvaginal ultrasound scan and magnetic resonance imaging for the prediction of the depth of myometrial invasion in low-grade endometrioid endometrial carcinomas. Methods: Prospective and consecutive study including all low-grade (G1-G2) endometrioid endometrial carcinomas diagnosed between October 2013 and July 2018 in a tertiary hospital. Preoperative staging was performed with transvaginal ultrasound scan and/or magnetic resonance imaging followed by surgical staging. Final histology was considered as the reference standard. Sensitivity, specificity and diagnostic accuracy for the prediction of depth of myometrial invasion was calculated for both imaging techniques. The STARD 2015 guidelines were used. Results: A total of 136 patients were consecutively included. Transvaginal ultrasound scan was performed in 132 patients and magnetic resonance imaging in 119 patients. The diagnostic accuracy of transvaginal ultrasound scan for the prediction of depth of myometrial invasion in the microcystic, elongated and fragmented negative group (82% (95% confidence interval = 73-88)) was higher compared to the microcystic, elongated and fragmented positive group (61% (95% confidence interval = 36-83)). The diagnostic accuracy of magnetic resonance imaging was also higher in the microcystic, elongated and fragmented negative group (80% (95% confidence interval = 71-87)) compared to the microcystic, elongated and fragmented positive (47% (95% confidence interval = 21-73)). Conclusions: In low-grade endometrioid endometrial carcinomas with a positive microcystic, elongated and fragmented pattern of invasion, the evaluation of the depth of myometrial invasion using transvaginal ultrasound scan and magnetic resonance imaging may be underestimated.

Surgical treatment of vaginal prolapse with Prolift® mesh in patients with risk of recurrence.

OBJECTIVE: The aim of this paper is to analyze the results obtained in pelvic floor surgery using a non-absorbable mesh in selected patients with risk factors of recurrent prolapse. METHODS: Case series including a total of 76 patients who were surgically treated for severe genital prolapse from July 2005 to December 2009, with risk factors for recurrence of genital prolapse. RESULTS: We detected 3 cases (6.8%) of symptomatic prolapse recurrence and 6 cases (13.6%) of prolapse of another compartment in the anterior Prolift® group. In the posterior Prolift® group there were no recurrences but there were 2 cases (10.52%) of prolapse of another compartment. In the total Prolift® group, there were 2 cases (16.6%) of symptomatic prolapse recurrence. As for de novo urgency, there were a total of 4 cases (5.33%), 3 in the anterior Prolift® group and 1 in the total Prolift® group. We did not detect any case of severe pain in the pelvis or mesh insertion points that required reoperation due to persistence. CONCLUSIONS: The use of mesh in pelvic floor reconstructive surgery in selected patients with risk factors for recurrence is a good treatment option to prevent or attempt to reduce the recurrence or reoperation rates currently described.

Hysteroscopic myomectomy without anesthesia.

OBJECTIVE: Scarce literature about myoma removal without anesthesia has been published. The aim of this paper is to evaluate the feasibility of a new alternative for a hysteroscopic myomectomy in a conventional office setting, without need for anesthesia. METHODS: Step-by-step description of the surgical technique has been provided, based on video images. An office hysteroscopy was performed in a Gynecological Endoscopy Department of a tertiary European hospital. RESULTS: A 49-year-old woman was referred for management of severe hypermenorrhea. Consent and approval were received from the patient and the institutional review board, respectively. The introduction of a Truclear® hysteroscopic polyp morcellator of 5.5 mm with optic of 0 degrees into the uterine cavity did not require any kind of anesthesia or cervical dilatation. The use of saline flow helped distend the cavity and identify a submucosal myoma. Under direct vision, a full myomectomy was performed via mechanical energy with continuous cutting movements, without any complication. After the procedure was completed, the excised material was aspirated through the device into a collecting pouch. A successful complete morcellation of a Type-0 submucosal leiomyoma with a polyp morcellator device was performed in an outpatient setting. Good medical results, good tolerance by the patient besides lower surgical risks due to mechanical instead of electrical energy are shown. CONCLUSION: In conclusion, this video demonstrates that a hysteroscopic myomectomy can be performed successfully in office with lower risk of complications from the procedure and without use of general anesthesia besides good tolerance by the patient.

Pelvic organ prolapse and stress urinary incontinence, do they share the same risk factors?

OBJECTIVE: To determine whether there are differences in the etiologies of two of the most common pelvic floor disorders (PFD), pelvic organ prolapse (POP) and stress urinary incontinence (SUI). STUDY DESIGN: This cross-sectional descriptive study included 1042 women, referred to a pelvic floor unit in a tertiary Spanish hospital, between 2008 and 2012. Subjects at their fist visit were interviewed and examined generally and specifically (medical and urogynecological history). Collected parameters included: age, weight, height, medical and surgical background (including in-depth obstetrical and gynecological characteristics). The participants were classified into 3 different groups (POP, SUI, and mixed pathology). Descriptive analyses of each variable and multinomial logistic regression were performed to determine factors associated with POP and SUI. RESULTS: Patients with POP were older, thinner, with greater parity and their newborns tended to be heavier. Furthermore, forceps, vaginal tears and vaginal surgeries were more common in the POP group. In contrast, family history was an important factor for the development of SUI, with a 6.45-fold increase (95% CI: 3.69-11.24). Two protective factors were identified for POP, cesarean section reduces the risk by 3 fold (OR=0.33) (95% CI: 0.13-0.85) whereas pelvic floor rehabilitation produces a 2 fold reduction (OR=0.49) (95% CI: 0.31-0.76). CONCLUSIONS: Our data study demonstrates differences in potential triggers and risk factors for POP and SUI. Cesarean section and pelvic floor rehabilitation have a protective effect on preventing the development of POP. Bringing up that a personal medical care and a specific urogynecological follow-up should be developed for those who are more susceptible or at risk of PFD.