Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment.

Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.

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.

The PLART study: incidence of preterm labor and adverse pregnancy outcomes after assisted reproductive techniques-a retrospective cohort study.

KEY MESSAGE: Even though assisted reproductive techniques represent one of the greatest achievements in modern medicine, the risk of preterm birth related to these pregnancies is about twice as high. This must be highlighted and further investigated to optimize the management of both mothers and newborns. PURPOSE: The purpose of this study was to compare adverse pregnancy outcomes after assisted reproductive techniques (ART) and spontaneous conceptions, focusing on the incidence of preterm births (PTB) and distinguishing between iatrogenic and spontaneous events. METHODS: This retrospective cohort study analyzed single births of one Italian hospital. The incidence of PTBs in ART pregnancies, divided into iatrogenic procedures, spontaneous preterm labors and preterm premature ruptures of the membranes (pPROMs), was compared with the non-ART control group. The incidence of other adverse pregnancy outcomes and the types of delivery were also reported and compared. RESULTS: Of the 11,769 single births included, 2.39% were conceived by ART. The incidence of PTBs was 4.74% for spontaneous pregnancies and 12.8% for ART pregnancies (aOR 1.93; 95% CI 1.29-2.88). The percentage of iatrogenic procedures was 27.78% in the ART-PTBs' group and 30.88% in the non-ART-PTBs' controls. ART pregnancies showed an increased incidence of pPROMs (6.40% versus 2.41%), preterm labors (2.85% versus 0.93%), hypertensive disorders of the pregnancy (8.19% versus 2.32%), placenta previa (3.20% versus 0.59%), cesarean sections (28.47% versus 16.27%) and vacuum extractions (10.32% versus 5.19%). CONCLUSIONS: Singleton ART pregnancies have a higher risk of PTB which is mostly linked to a higher incidence of pPROMs and spontaneous preterm labor. The concurrency of a demonstrated higher risk of hypertensive gestational disorders and placenta previa suggests that placental development plays an important role in the pathogenesis of PTB.

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.

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.

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 uterosacral ligament hysteropexy: a video tutorial.

INTRODUCTION AND HYPOTHESIS: Uterine-sparing procedures could be attractive in patients concerned about fertility preservation and corporeal image changes. Transvaginal uterosacral ligaments (USLs) hysteropexy can provide a mesh-free technique for uterine suspension. This video is intended to serve as a tutorial for surgical steps. METHODS: A 38-year-old woman with symptomatic stage III POP desired preserving fertility. After proper counseling, the patient was admitted for vaginal hysteropexy through bilateral high USL suspension according to the featured technique. RESULTS: Prolapse repair was successfully achieved without complications. We had already published a series of 20 cases that confirmed that transvaginal USLs hysteropexy is a promising technique for correcting genital prolapse with uterus preservation. CONCLUSION: Transvaginal USLs hysteropexy provides a feasible technique for apical support without the use of prosthetic material. This procedure could be attractive to women who desire a uterine-sparing surgical option.

Transvaginal uterosacral ligament hysteropexy: a retrospective feasibility study.

INTRODUCTION AND HYPOTHESIS: Uterine-sparing procedures could be attractive in patients concerned about preservation of fertility and change in corporeal image and sexuality. Transvaginal uterosacral hysteropexy can provide an alternative mesh-free technique for uterine suspension. This study aimed to evaluate the feasibility of transvaginal uterine suspension to uterosacral ligaments in terms of operative data, complications, midterm efficacy, and patient satisfaction. MATERIALS AND METHODS: This retrospective study analyzed the first 20 cases of transvaginal hysteropexy through bilateral high uterosacral ligaments (modified Shull technique) performed in our Institution. RESULTS: Mean follow-up was 33.2 months. The procedure was performed in 84 ± 19 min ,and blood loss was 228 ± 139 ml. Three mild complications (15 %) were observed. Recurrence [Pelvic Organ Prolapse Quantification system (POP-Q) stage ≥ II was observed in five patients (25 %), and three of them (15 %) required reintervention. Mean Patient Global Impression of Improvement score was "much improved." Two woman (40 %) who had not fulfilled their childbearing desire obtained a pregnancy. Both underwent elective caesarean section at term. CONCLUSIONS: Transvaginal uterosacral hysteropexy appears a feasible mesh-free technique for apical support. This procedure can be indicated in women with the desire of preserving fertility or who prefer a uterine-sparing surgical option.

Transvaginal iliococcygeus fixation for posthysterectomy vaginal vault prolapse repair.

INTRODUCTION AND HYPOTHESIS: Posthysterectomy vaginal vault prolapse repair is a surgical challenge. Successful surgical management using native tissue can be achieved via the vaginal approach by iliococcygeus fascia fixation. However, although iliococcygeus fascia fixation is technically simple and has a low morbidity, it is not commonly performed. The aim of the video is to provide anatomic views and the surgical steps necessary to achieve successful transvaginal iliococcygeus fascia fixation for vaginal vault prolapse repair. METHODS: A 60-year-old woman with symptomatic stage III vaginal vault prolapse was admitted for transvaginal iliococcygeus fascia fixation according to the described technique. RESULTS: Surgery was successful without complications. The final examination showed good apical support and preservation of vaginal length. This step-by-step video tutorial may be an important tool to improve practical surgical knowledge. In particular, proper suture positioning requires adequate pararectal space preparation and levator ani exposure, as shown in the video. CONCLUSIONS: Transvaginal iliococcygeus fascia fixation is an alternative technique for apical support without the use of synthetic prosthetic materials. This technique may be indicated when an abdominal approach or a synthetic device is not recommended.

Transvaginal uterosacral ligament suspension for posthysterectomy vaginal vault prolapse repair.

INTRODUCTION AND HYPOTHESIS: Posthysterectomy vaginal vault prolapse repair represents a challenge for urogynecologists. Surgical management can be successfully achieved with native tissue using a vaginal approach with uterosacral ligament (USL) suspension. However, severe complications have been described, mainly related to ureteral injury. METHODS: A 57-year-old woman with symptomatic stage 2 vaginal vault prolapse underwent transvaginal USL suspension according to the described technique. RESULTS: Surgical procedure was successfully achieved without complications. Final examination revealed excellent apical support and preservation of vaginal length. However, ureteral damage represents the major pitfall of USL suspension. This step-by-step video tutorial may represent an important tool to improve surgical know how and minimize the risk of ureteral injury. CONCLUSION: Transvaginal USL suspension provides an effective technique for apical support without the use of prosthetic materials. Intimate understanding of pelvic anatomy, direct visualization of ureter, and proper suture positioning are the key points to minimize the risk of complications.

Modified McCall culdoplasty versus Shull suspension in pelvic prolapse primary repair: a retrospective study.

INTRODUCTION AND HYPOTHESIS: Uterosacral ligament suspension at the time of primary prolapse repair represents a well-established surgical option. Our aim was to compare the effectiveness, complications rate, and functional results of modified McCall culdoplasty and Shull suspension. METHODS: Patients who underwent vaginal hysterectomy and cuff suspension for pelvic organ prolapse were retrospectively analyzed. McCall culdoplasty (group A) or Shull suspension (group B) were performed according to surgeon choice based on age and sexual activity. Perioperative data, objective, and subjective cure rate were noted. RESULTS: A total of 339 patients (215 in group A and 124 in group B) completed follow-up. Operating time and blood loss were slightly higher in group B. The complications rate was similar in the two groups. Anatomical outcomes in terms of recurrence and reoperation rate did not show any statistically significant differences. POP-Q items analysis revealed only a different total vaginal length between groups (8 mm longer in group B). Functional outcomes were similar in the two groups as was patient satisfaction. CONCLUSION: Both uterosacral ligament suspension procedures were shown to be safe and effective. There were no clinically significant differences with regard to surgical data, complications, anatomical, functional, and subjective outcomes between modified McCall culdoplasty and Shull suspension.

Repair of a traumatic cloaca after obstetric anal sphincter injury.

INTRODUCTION AND HYPOTHESIS: Unsuccessful primary repair of fourth-degree obstetric trauma can lead to permanent communication between the rectum and the vagina, which, in association with full-thickness anal sphincter defects, is characterized by complete fecal incontinence and severe impairment of quality of life. The aim of this video is to serve as a tutorial for repair. METHODS: A 27-year-old woman who developed a full-thickness recto-vaginal defect extended from the perineum to the upper third of the vagina has been managed through layered surgical repair without flaps. RESULTS: Anatomy and fecal continence have been completely restored by a follow-up of 24 months. CONCLUSION: The procedure described in this video has been shown to be effective and safe.

Transvaginal primary repair of a suprasphincteric rectovaginal fistula.

INTRODUCTION AND HYPOTHESIS: Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair. METHODS: An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps. RESULTS: Anatomy restoration was completed without complications. CONCLUSION: The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.

Stem cell augmented mesh materials: an in vitro and in vivo study.

INTRODUCTION AND HYPOTHESIS: To test in vitro and in vivo the capability of mesh materials to act as scaffolds for rat-derived mesenchymal stem cells (rMSCs) and to compare inflammatory response and collagen characteristics of implant materials, either seeded or not with rMSCs. METHODS: rMSCs isolated from rat bone marrow were seeded and cultured in vitro on four different implant materials. Implants showing the best rMSC proliferation rate were selected for the in vivo experiment. Forty-eight adult female Sprague-Dawley rats were randomly divided into two treatment groups. The implant of interest-either seeded or not with rMSCs-was laid and fixed over the muscular abdominal wall. Main outcome measures were: in vitro, proliferation of rMSCs on selected materials; in vivo, the occurrence of topical complications, the evaluation of systemic and local inflammatory response and examination of the biomechanical properties of explants. RESULTS: Surgisis and Pelvitex displayed the best cell growth in vitro. At 90 days in the rat model, rMSCs were related to a lower count of neutrophil cells for Pelvitex and a greater organisation and collagen amount for Surgisis. At 7 days Surgisis samples seeded with rMSCs displayed higher breaking force and stiffness. CONCLUSIONS: The presence of rMSCs reduced the systemic inflammatory response on synthetic implants and improved collagen characteristics at the interface between biological grafts and native tissues. rMSCs enhanced the stripping force on biological explants.

Iliococcygeus fixation or abdominal sacral colpopexy for the treatment of vaginal vault prolapse: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: To compare the efficacy and safety of iliococcygeus fixation (ICG) and abdominal sacral colpopexy (SCP) in the treatment of vaginal vault prolapse. METHODS: Patients with symptomatic vaginal vault prolapse after hysterectomy were considered in this analysis. Surgical outcomes, i.e., the capacity to restore the anatomy of the vaginal cuff and improvement in the prolapse-related symptoms were compared. Continuous variables were compared using the Student's t test, while non-continuous variables using a Chi-squared test or Fisher's exact test. RESULTS: Sacrocolpopexy was performed in 41 patients, while ICG fixation was carried out in 36 patients. Operative time was significantly shorter (78 vs 140 min, p < 0.001) and median blood loss higher in the ICG group (150 ml vs 100 ml, p=0.01). The rates of postoperative complications of the two groups were not statistically different. Relapse rate was similar in the two groups (15 % in the SCP and 22 % in the ICG group respectively, p=0.36). Considering the POP-Q score, both SCP and ICG achieved a significant and comparable correction of vaginal prolapse. The evaluation of postoperative subjective symptoms revealed a significant improvement in voiding and vaginal bulging related to pelvic organ prolapse in both groups. CONCLUSIONS: Both ICG fixation and SCP are effective in restoring normal anatomy in patients with vaginal vault prolapse and in relieving associated symptoms. Owing to its lower morbidity and to the advantage of not using a synthetic device, ICG might be an excellent option for the treatment of recurrent vaginal vault prolapse following hysterectomy.

Three-dimensional ultrasound assessment and middle term efficacy of a single-incision sling.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the functional outcome of a single-incision sling procedure for the treatment of female stress urinary incontinence (SUI) and to correlate the cure rate with a pelvic floor ultrasound examination METHODS: Fifty-seven patients treated with a single-incision sling procedure between January 2009 and September 2010 were included in the study. Functional outcome was evaluated as objective cure rate assessed with stress test and subjective cure rate determined by the International Consultation on Incontinence-Short Form and Patient Global Impression of Improvement scores. Women underwent perineal ultrasound examination by a combined 2D translabial and 3D transvaginal approach to assess bladder neck and tape mobility, tape position along the urethral axis, and tape anchorage. According to the position of self-fixating tips, we divided patients into group A (both tips crossed the obturator membrane), group B (only one tip crossed the obturator membrane) and group C (none of the tips crossed the obturator membrane). Objective cure rate and type of anchorage were compared with all ultrasound parameters. RESULTS: At an average follow-up of 13 months objective cure rate was 87.7 % with a significant subjective improvement. A significant difference in tape mobility was noted between group A and group C. Bladder neck mobility significantly increased in failures. Sling was significantly closer to mid-urethra in cured than in failures. CONCLUSIONS: In 77 % of patients MA didn't reach the obturator membrane on both sides. This feature conditioned significantly bladder neck mobility but not the efficacy of the procedure. Tape position seems to be the most important factor for success.

Coexisting overactive-underactive bladder and detrusor overactivity-underactivity in pelvic organ prolapse.

OBJECTIVE: The coexisting overactive-underactive bladder (COUB) syndrome could be related to the increased urethral resistance caused by severe pelvic organ prolapse (POP). We aimed to evaluate the clinical and urodynamic findings of patients with COUB and/or detrusor overactivity-underactivity (DOU) in a cohort of patients scheduled for POP surgery and the possible risk factors of COUB after surgery. METHODS: This retrospective study analyzed all patients who underwent POP repair between 2008 and 2013, excluding women with a history of pelvic floor surgery. Patients were divided into COUB and non-COUB according to baseline symptoms and into DOU and non-DOU based on urodynamic findings. A multivariate model was performed to identify risk factors for COUB symptoms after surgery. RESULTS: A total of 533 women underwent POP surgery. Preoperatively, patients with COUB had more severe anterior compartment prolapse (Pelvic Organ Prolapse Quantification staging system Aa point, P = 0.008) and more frequently had overactive bladder compared with controls (P = 0.023). The rate of COUB decreased significantly after surgery. Preoperative opening detrusor pressure resulted as the only independent predictor of postoperative COUB symptoms (P = 0.034). CONCLUSION: POP is a valid pathogenetic model for COUB development. POP repair induced a significant decrease in COUB symptoms with low opening detrusor pressure resulting as the only independent predictor of postoperative COUB.