Trends in Urogynecology-Transvaginal Mesh Surgery in Germany.

BACKGROUND: Pelvic organ prolapse constitutes a prevalent condition associated with a considerable impact on the quality of life. The utilization of transvaginal mesh surgery for managing POP has been a subject of extensive debate. Globally, trends in TVM surgery experienced significant shifts subsequent to warnings issued by the FDA. METHODS: This study aims to explore temporal patterns in transvaginal mesh surgery in the German healthcare system. A comprehensive analysis was conducted on in-patient data from the German Federal Statistical Office spanning 2006 to 2021. A total of 1,150,811 operations, each associated with specific codes, were incorporated into the study. Linear regression analysis was employed to delineate discernible trends. RESULTS: The trends in transvaginal mesh surgery within the anterior compartment exhibited relative stability (p = 0.147); however, a significant decline was noted in all other compartments (posterior: p < 0.001, enterocele surgery: p < 0.001). A subtle increasing trend was observed for uterine-preserving transvaginal mesh surgery (p = 0.045). CONCLUSION: Surgical trends over the specified timeframe demonstrate how POP management has evolved globally. Notably, despite observed fluctuations, transvaginal mesh surgery remains a viable option, particularly for specific cases with a high risk of relapse and contraindications to alternative surgical approaches.

Action competence in obstetric emergencies-can this be achieved via e-learning? Interprofessional blended learning module on diagnostics and emergency treatment of shoulder dystocia.

BACKGROUND: Due to the rarity of shoulder dystocia, an obstetric emergency, it is difficult even for experts to develop the appropriate routine in this emergency. Regular further training is therefore recommended for obstetricians and midwives. Evidence is lacking on the extent to which e-learning as a teaching method can be successfully used to acquire these skills and put them into practice. The purpose of this study is to demonstrate how the learning objectives for shoulder dystocia, listed in the National Competence Based Learning Objectives Catalog for Medicine (NKLM, Germany) can be successfully taught in medical studies using a blended learning concept (e-learning and practical application on a birth simulator). METHODS: After completing an e-learning course, final year medical students and midwife trainees demonstrated their action competence for shoulder dystocia procedure on a birth simulator. This transfer of the theoretical knowledge to the case study was assessed using an evaluation form oriented to the recommendations for action. RESULTS: One hundred sixty medical students and 14 midwifery trainees participated in the study from April to July 2019. Overall, 95.9% of the study participants met the required standards, i.e. achieved very good to adequate performance (Ø good) in simulation training. CONCLUSIONS: E-learning with annotated high-quality learning videos is an excellent way to transfer theoretical knowledge about shoulder dystocia procedures into medical practice on a birth simulator. The learning objectives required by the NKLM for shoulder dystocia can be successfully conveyed to students via the applied blended learning concept.

Three-dimensional vs two-dimensional endoscopic approach in urogynecology: A retrospective cohort study of laparoscopic sacrocolpopexy.

AIM: The gold standard to treat an apical pelvic organ prolapse is the abdominal route via a sacrocolpopexy, which is also reproduced by laparoscopic route. A laparoscopic sacrocolpopexy however, requires surgical expertise. Three-dimensional (3D) laparoscopy has been developed to overcome the lack of depth perception, that is a known disadvantage of conventional two-dimensional (2D) laparoscopy. This procedure can accelerate the learning curve and optimize the intra-, peri-, and postoperative outcomes. This study aims to compare 3D laparoscopy to traditional 2D laparoscopy for sacrocolpopexy. METHODS: Data from 132 patients who underwent a sacrocolpopexy with 2D or 3D laparoscopy in Department of Obstetrics and Gynecology, University Medical Center of the Johannes Gutenberg University, between June 2012 and September 2021, were collected retrospectively. Seventy-one laparoscopic sacrocolpopexy operations in 2D (n = 23) and 3D (n = 48) group were reviewed and compared regarding the duration of surgery, blood loss and the length of hospital admission as primary objectives. RESULTS: There were no differences in the baseline demographics between the two groups. The estimated blood loss (1.0 (±0.6) g/dL vs 1.7 (±1.0) g/dL, p = 0.010), and duration of surgery (115.4 (±34.7) min. vs 134.7 (±26.2) min., p = 0.012) was significantly better in favor of 3D laparoscopy. The length of hospital stay was comparable in both groups (p = 0.833). Furthermore, no differences were observed between the groups regarding other surgical outcomes. CONCLUSION: 3D laparoscopy shows a significant benefit in terms of estimated blood loss and surgery duration among complex urogynecological surgeries compared to traditional 2D laparoscopy.

Birth experience from the perspective of the fathers.

PURPOSE: As men nowadays often attend the delivery of their own child, they also have to go through the labor period. In this study, the condition of the expectant fathers attending labor was evaluated. METHODS: In 2016, fathers who went through labor with their partners in the University medical center of Mainz were interviewed within the first days after delivery and 6 months later. They received a "Fathers questionnaire" concerning their motivation, the valuation of their attendance, their emotions during labor, and concerning the service in the labor ward. Six months later, they also received the validated Impact of Event Scale questionnaire (IES-R). In total, 318 participants answered the "Fathers' Questionnaire", 226 the IES-R. RESULTS: Father's attendance during labor was considered to be beneficial for fathers themselves (254, 79.8%), for the mother (272, 85.5%), for the newborn child (187, 58.8%), for the relationship (234, 73.6%). Only four could not see a purpose in their attendance. 73 men (23%) felt helpless, 47 (14.8%) were overwhelmed by the situation, 116 (36.5%) felt fear, 299 (94%) were happy to be present at birth, 27 (8.5%) felt traumatized by experiencing their partners in labor. According to the IES-R, none of the 226 men surveyed showed all symptoms of post-traumatic stress disorder. CONCLUSION: Childbirth is related to positive and negative emotions. Positive emotions are predominant, but come along with negative feelings. In this survey, posttraumatic stress disorder did not occur among men after delivery. Nevertheless, fathers' needs should be kept in view.

Fertility After Ovarian Cystectomy: How Does Surgery Affect IVF/ICSI Outcomes?

Introduction For patients considering undergoing assisted reproductive techniques (ART), many concerns arise when persistent ovarian cysts are found. This large study aimed to determine how ovarian cyst removal affects success rates of IVF/ICSI therapies. Methods 550 patients who underwent an IVF/ICSI treatment between 2002 and 2011 with a persistent ovarian cyst ≤ 5 cm before treatment were analyzed retrospectively. 328 patients' preference was to undergo a laparoscopic cystectomy and 222 patients opted for a conservative management. Control subjects included 13 552 patients undergoing IVF/ICSI at the same period of time without an ovarian cyst. Results After adjusting for age, patients with ovarian cysts without surgery needed a significant higher stimulation dose than the control group (2576.4 vs. 2207.5 IU, p < 0.001). However, on average, they had 1.13 (- 0.25 - 2.01) higher oocyte number retrieved compared to the operated patients (9.0 ± 5.5 vs. 8.2 ± 5.0) (p = 0.012). Patients after surgical cyst removal had a significant lower number of oocytes retrieved (MNOR) in comparison to the control group (8.2 ± 5.0 vs. 9.5 ± 5.4) (p = 0.00). Compared to controls, operated patients had similar clinical pregnancy rate (CPR) (34.2 vs. 33.5%) OR 1.031 (95% CI 0.817 - 1.302) (p = 0.815). Compared to controls, patients without surgery showed significant lower pregnancy rate (34.2 vs. 25,7%) OR 1.428 (95% CI 1.054 - 1.936) (p = 0.002) and lower live birth rate (LBR) (21.9 vs. 13.5%) OR 1.685 (95% CI 1.143 - 2.485) (p = 0.008). Conclusions Ovarian cystectomy did not negatively impact the pregnancy rate or the live birth rate compared to controls.

Assessment of pelvic floor muscle contractility: digital palpation versus 2D and 3D perineal ultrasound.

PURPOSE: The aim of our study was to investigate 2D and 3D ultrasound assessment of pelvic floor muscle contractility as an objective non-invasive diagnostic tool in urogynecologic patients. METHODS: Patients from our urogynecological outpatient clinic were examined clinically by a single investigator including digital palpation as well as 2D and 3D perineal ultrasound. Muscle contractility was graded according to the modified Oxford Score and ultrasound images were saved for later analysis. Stored images were evaluated offline by another investigator blinded to all clinical data at a later stage. Bladder neck distance from pubic symphysis and symphysis-levator distance were measured in 2D at rest and during maximal pelvic floor muscle contraction. Hiatal area at the level of minimal hiatal dimensions as a 3D ultrasound parameter was measured at rest and during maximal pelvic floor muscle contraction, too. Spearman's rho was used to calculate statistical correlation between ultrasound parameters and digital assessment. RESULTS: A total of 114 patients were examined in our study. We found a significant correlation between modified Oxford Score and 2D ultrasound parameters of elongation of bladder neck length (Spearman's rho 0.292, p = 0.002) and reduction of symphysis-levator distance (Spearman's rho 0.0.301, p = 0.001), respectively. In addition, we detected a statistical significant correlation of modified Oxford Score and reduction of hiatal area in 3D ultrasound (Spearman's rho 0.458, p < 0.001), too. CONCLUSIONS: In this study, we found a significant correlation of subjective digital assessment of pelvic floor muscle strength with 2D and 3D ultrasound parameters as an objective diagnostic tool.

The effect of ovarian stimulation on the outcome of intrauterine insemination.

PURPOSE: Although intrauterine insemination is one of the oldest techniques in reproductive medicine, its significance is still controversially discussed. Many factors have been reported as influencing pregnancy rates after IUI. The aim of this retrospective analysis is to evaluate the success rate of repeated inseminations depending on the type of ovarian stimulation. METHODS: Patients who underwent intrauterine insemination in Wiesbaden Kinderwunschzentrum between 1998 and 2010, not older than 45 years of age, with male subfertility were included in this study. On the whole, 5,346 inseminations on 2,180 patients were analyzed retrospectively. RESULTS: Females' mean age was 34.1, ranging from 19-45 years. In 433 cycles an insemination was performed during a natural cycle. 4,020 cycles were stimulated with recombinant FSH, 596 cycles with clomiphene, 194 with urinary FSH, 103 with HMG. The pregnancy rates range from 7.4% in the clomiphene group to 14.4% in the urinary FSH group. Clomiphene stimulation seems to offer the significantly lowest pregnancy rate (p = 0.03). The other types of stimulation do not differ significantly from each other concerning the pregnancy rate. Patients under 39 years of age do not profit from any ovarian stimulation. In 40 and more years of old patients, pregnancy rates are higher, if any stimulation was performed. CONCLUSION: To sum up, clomiphene stimulation showed to offer significantly lower pregnancy rates in comparison to the natural cycle, FSH stimulation and HMG stimulation in IUI treatment. While women younger than 40 seem not to profit from any ovarian stimulation, women over 40 do profit.

Changes in sexual function and quality of life after single-incision mid-urethral sling for treatment of female stress urinary incontinence.

OBJECTIVES: To evaluate the effectiveness and assess the changes in sexual function and quality of life after placement of a single-incision sling for the treatment of female stress urinary incontinence. STUDY DESIGN: A prospective study of women diagnosed with stress urinary incontinence. The single-incision sling was implanted and patients were followed postoperatively for 6 months. The postoperative rate of continence, complications, changes in sexual function, and patient-reported quality of life were evaluated. Female Sexual Function in sexually active patients was evaluated before and after the single-incision sling procedure using the Female Sexual Function Index. From January 2009 to November 2011, 73 patients were enrolled and underwent the procedure to implant the MiniArc® or Ajust® single-incision sling. RESULTS: Overall, 93.2% of the patients who successfully received a single-incision sling demonstrated total restoration of continence (83.6%) or improved continence (9.6%) at the 6-month postoperative visit. Improvements were seen in the quality of life scores related to global bladder feeling (87.7%) and the Female Sexual Function Index (preoperative score 23.86±5.67 vs postoperative score 27.25±4.66 [P<0.0001]). CONCLUSION: Single-incision sling treatment for stress urinary incontinence led to improvements in continence and sexual function at 6 months of postoperative follow-up.

Long-term outcomes of the Ajust Adjustable Single-Incision Sling for the treatment of stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the effectiveness and overall safety of the Ajust Adjustable Single-Incision Sling in the treatment of female stress urinary incontinence. METHODS: This was a prospective, multicenter study conducted in women diagnosed with stress urinary incontinence. The Ajust Sling was implanted and patients were followed postoperatively for up to 29 months. Evaluations were performed to assess postoperative rate of continence, complications, and patient quality of life (QOL). RESULTS: From November 2008 through May 2009, 52 patients were enrolled and underwent a procedure to implant the Ajust Sling. Overall, 86.3 % of the patients who successfully received the Ajust Sling demonstrated total restoration or improvement of continence at the last study visit. QOL scores related to global bladder feeling and lifestyle improved. Only one patient reported the occurrence of mild pain which resolved without treatment or sequelae. CONCLUSIONS: In long-term follow-up, the Ajust Sling was safe and effective, restoring or improving continence in 86.3 % of patients.

Sexual function and quality of life following retropubic TVT and single-incision sling in women with stress urinary incontinence: results of a prospective study.

PURPOSE: The objective of this prospective cohort study was to compare effectiveness, morbidity, quality of life (QoL) and sexual function in women treated with tension-free vaginal tape (TVT) versus single-incision sling (SIS) in the treatment of female stress urinary incontinence (SUI). METHODS: Retropubic TVT sling or SIS was implanted in local anesthesia and patients were followed post-operatively for 6 months. Evaluation was performed to assess post-operative rate of continence, complications, changes in sexual function and patient reported quality of life. Female sexual function was evaluated before and after sling procedure using Female Sexual Function Index (FSFI) in sexually active patients. RESULTS: From January 2009 to December 2011, 150 patients were enrolled and underwent a procedure to implant the retropubic TVT (n = 75) or the MiniArc(®) and Ajust(®) SIS (n = 75). Overall, 93.3 % of the patients who successfully received SIS demonstrated total restoration (84 %) or improvement of continence (9.3 %) at the 6 month post-operative study visit. In TVT group we found 88 % total continence and 6.7 % improvement, respectively. Improvements were seen in the QoL scores related to global bladder feeling (89.3 %) in SIS group and 96 % for TVT. Post-operative FSFI score improves significantly and were comparable in both groups (SIS pre-operative 24.30 ± 4.56 to 27.22 ± 4.66 (P < 0.001) post-operative; TVT 24.63 ± 6.62 to 28.47 ± 4.41, respectively). CONCLUSIONS: The SIS procedure appears to be as effective in improving incontinence-related quality of life and sexual function as the TVT through 6 months of post-operative follow-up. No differences in complications and sexual function were demonstrated between the groups.

Mesh complications following prolapse surgery: management and outcome.

OBJECTIVE: This is a description of complications following prolapse surgery with the use of alloplastic materials, the management and outcome. STUDY DESIGN: 54 women have been referred to Mainz, urogynecology referral center due to complications following mesh-augmented prolapse surgery. RESULTS: The complaints who lead to the admission are expressed by the new terminology and standardized classification for complications arising directly from the insertion of prostheses and grafts in female pelvic floor surgery [1]. Pain (66.7%), mesh erosion (55.6%) and vaginal discharge (48.1%) were the most frequent complaints. Revision was performed after a median time of 27.2 months post mesh implantation. Nine patients underwent limited excision of the mesh, 49 had a vaginal revision with wide mesh removal and 10 had a laparotomy with wide mesh removal. After 3 months 48 patients had a follow-up, 25 could have been relieved from their complaints. CONCLUSION: Although the incidence is low, complications after prolapse repair with mesh use are difficult to prevent, affect quality of life and often require a new surgical intervention, which should be performed by an experienced and competent surgeon.

Complications following the use of alloplastic materials in urogynecological surgery.

STUDY DESIGN: 118 patients, who were admitted from 2005 to 2008 to our department due to complications following mesh implantation, were included in a retrospective survey. We investigated patient symptoms, findings and subsequent patient management. There was a re-evaluation of symptoms in a follow-up eight weeks after the revision procedure. Data from our urogynecological file archive were used. RESULTS: The main complaints were de novo urgency, pain and recurrent urinary tract infections. The main findings were mesh erosion and infections including abscess formations and osteomyelitis. Before being admitted to our department, 42 patients (35.6%) had already undergone at least one intervention. Surgery to overcome complications was performed in our unit after an average time of 27 months. In most cases, mesh removal was necessary. CONCLUSIONS: Surgeons need to be aware of potential mesh complications, which should be managed in referral centres as soon as symptoms arise and should be documented in registers. There is a need for more prospective randomised studies on complications arising from surgery.

The effect of genital and lower urinary tract symptoms on steroid receptor expression in women with genital prolapse.

INTRODUCTION AND HYPOTHESIS: This study evaluates the expression of estrogen receptor (ER) isoforms alpha (α) and beta (ß) and progesterone receptor (PR) in vaginal and periurethral tissue in women with genital prolapse in relation to genital and lower urinary tract symptoms (LUTS). METHODS: Forty-seven postmenopausal women without systemic estrogen therapy underwent pelvic organ prolapse quantification and urodynamic assessment. LUTS were evaluated by CATI questionnaire. Biopsies from vaginal and periurethral tissue were obtained during prolapse surgery. The steroid receptor gene expression was measured by RT-PCR. RESULTS: The expression of PR in periurethral and ER ß in vaginal tissue varied with prolapse extent. Nulliparous women showed a significantly higher expression of PR in periurethral tissue. Women with a positive stress test and those with overactive bladder symptoms showed a significantly lower amount of PR in vaginal tissue. CONCLUSION: Changes in PR expression in vaginal or periurethral tissue might be a marker of structural and endocrine changes.

The effect of hormonal status on the expression of estrogen and progesterone receptor in vaginal wall and periurethral tissue in urogynecological patients.

OBJECTIVE: Our objective was to study the expression of estrogen receptor (ER) isoforms ER alpha (α) and ER beta (ß) and of progesterone receptor (PR) in the vaginal wall and in periurethral tissue of women who underwent urogynecological surgical treatment with reference to estrogen status. STUDY DESIGN: The study included 89 patients undergoing vaginal surgery for urogynecological conditions. Patients' history and clinical data including estrogen status and body mass index (BMI) were evaluated. Biopsies from the vaginal wall and from periurethral tissue were obtained during surgery. The expression of ER α and ß and of PR in vaginal wall and periurethral tissue was measured by RT-PCR. RESULTS: Nine patients were premenopausal. Eighty women were menopausal, of whom 21 were taking estrogen/progestin replacement therapy (HRT), 20 used local estrogen, and 39 had no endocrine treatment. Neither BMI nor age had any influence on the expression of ER and PR. Menopausal women showed a higher amount of PR expression in vaginal tissue than premenopausal women. Women with no endocrine treatment showed a lower amount of ER ß expression in vaginal tissue. CONCLUSION: Steroid receptors are expressed in periurethral and vaginal tissue. The receptor expression varies with hormonal changes only in vaginal tissue. Vaginal tissue seems to be more sensitive to estrogen than periurethral tissue.

Unbalanced translocation 6p/16q (partial monosomy 6p and trisomy 16q): prenatal diagnosis and cytogenetics.

UNLABELLED: Unbalanced translocation 6p/16q in one fetus is a very rare event and the prenatal sonographic findings have never been published before. We will give a short overview of the literature along with a case report focussing on prenatal ultrasound features and molecular cytogenetic analysis. CASE DESCRIPTION: A 21-year-old primigravid woman presented with a singleton pregnancy at 19 weeks' gestation. The fetus revealed a mild hydrocephalus, a ventricular septal defect (VSD), a Dandy-Walker malformation as well as an intrauterine growth retardation (IUGR) and limb anomalities. MLPA analysis from amniotic fluid cells showed an unbalanced translocation from the subtelomeric region of chromosome 6p to the subtelomeric region of chromosome 16q. Karyotype of the fetus was 46, XX.ishder(6)t(6;16)(p2?5;q?13)(pVYS246A+, pVYS228B-, pVYS229A+). Despite the karyotype the mother decided not to interrupt pregnancy. The fetus died in utero within the 39th week of gestation and was delivered vaginally after labour induction, with a birth weight of 1815g. Prenatal FISH and MLPA studies can be very important to help outline the chromosomal area of deletion and duplication and the sonographic findings forebode the cytogenetic region of interest. Subsequent to the processing of the case, a complete Medline search was conducted to review previous cases with similar genetic alterations.

Isolation of fibroblasts for coating of meshes for reconstructive surgery: differences between mesh types.

AIMS: An extensive colonization of surgical meshes with autologous fibroblasts may reduce complications. Therefore, we aimed to establish a technique that allows isolation and propagation of fibroblasts from vaginal biopsies. Using these cells we tested the applicability of several clinically applied meshes for fibroblast coating. MATERIALS & METHODS: Fibroblasts were isolated from vaginal tissue after digestion with collagenase. Characterization was performed by immunostaining for cytokeratin 5, 6 and 14, smooth muscle actin and vimentin. A semiquantitative technique was applied to determine the degree of mesh coating 5 h and 5 weeks after seeding of fibroblasts. Seven meshes of different mesh types have been tested. RESULTS: Cells with a fibroblast-like morphology have been isolated from vaginal tissue and could be propagated for at least 12 passages, resulting in a total number of 1.2 x 10(7) cells. Immunostaining showed that cells were positive for the mesenchymal cell marker vimentin and negative for smooth muscle actin, as well as the epithelial cell markers cytokeratin 5, 6 and 14, supporting their classification as fibroblasts. Clear differences in fibroblast colonization between the seven tested mesh types have been observed. Polypropylene mesh Obtape showed an acceptable covering with fibroblasts. The best coating was obtained for xenograft-based meshes, but under cell-culture conditions the mesh showed signs of decomposition. CONCLUSION: We have established a technique that allows isolation and propagation of vaginal fibroblasts. The result of vaginal fibroblast colonization of allograft-based meshes strongly depends on the mesh type, whereby the best coating could be achieved for a polypropylene mesh.

Postoperative funneling after anti-incontinence surgery--a prognostic indicator?--Part 1: colposuspension.

AIMS: How does funneling of the bladder neck after open colposuspension affect the postoperative cure rate? METHODS: In a retrospective study, 310 patients who underwent primary colposuspension for urodynamically proven genuine stress urinary incontinence were assessed by introital ultrasound before and immediately after surgery as well as at 6, 12, 24, 36, and 48 months. A total of 152 women completed 48-month follow-up. Objective cure rates at the different follow-up times were calculated and correlated with the presence of postoperative bladder neck funneling. RESULTS: The objective cure rate up to 6 months after colposuspension was 90.0 versus 76.8% up to 48-month follow-up. Urge symptoms occurred in 11.6% (36/310) of the women and de novo urge incontinence in 1.6% (5/310). Bladder neck funneling was significantly reduced after anti-incontinence surgery, from 55.2% before surgery to 12.3% (38/310) at 6-month follow-up (P < 0.0001). Postoperative funneling was associated with a higher recurrence rate. In the funneling group, 58.8 and 40.6% of the patients were continent up to 6 and 48 months, respectively, as opposed to 93.8 and 81.3% in the group without funneling (P < 0.0001). Urgency and de novo urge incontinence were more common in the funneling group (23.5 and 28.3% up to 6 and 48 months, respectively, vs. 12.7 and 13.5%; P < 0.05). CONCLUSIONS: Patients in whom funneling of the bladder neck diagnosed before surgery persists after colposuspension have a higher risk of recurrence and are more likely to develop postoperative complications.