Perioperative Vaginal Estrogen as Adjunct to Native Tissue Vaginal Apical Prolapse Repair: A Randomized Clinical Trial.

Importance: Surgical repairs of apical/uterovaginal prolapse are commonly performed using native tissue pelvic ligaments as the point of attachment for the vaginal cuff after a hysterectomy. Clinicians may recommend vaginal estrogen in an effort to reduce prolapse recurrence, but the effects of intravaginal estrogen on surgical prolapse management are uncertain. Objective: To compare the efficacy of perioperative vaginal estrogen vs placebo cream on prolapse recurrence following native tissue surgical prolapse repair. Design, Setting, and Participants: This randomized superiority clinical trial was conducted at 3 tertiary US clinical sites (Texas, Alabama, Rhode Island). Postmenopausal women (N = 206) with bothersome anterior and apical vaginal prolapse interested in surgical repair were enrolled in urogynecology clinics between December 2016 and February 2020. Interventions: The intervention was 1 g of conjugated estrogen cream (0.625 mg/g) or placebo, inserted vaginally nightly for 2 weeks and then twice weekly to complete at least 5 weeks of application preoperatively; this continued twice weekly for 12 months postoperatively. Participants underwent a vaginal hysterectomy (if uterus present) and standardized apical fixation (either uterosacral or sacrospinous ligament fixation). Main Outcomes and Measures: The primary outcome was time to failure of prolapse repair by 12 months after surgery defined by at least 1 of the following 3 outcomes: anatomical/objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, subjective vaginal bulge symptoms, or repeated prolapse treatment. Secondary outcomes included measures of urinary and sexual function, symptoms and signs of urogenital atrophy, and adverse events. Results: Of 206 postmenopausal women, 199 were randomized and 186 underwent surgery. The mean (SD) age of participants was 65 (6.7) years. The primary outcome was not significantly different for women receiving vaginal estrogen vs placebo through 12 months: 12-month failure incidence of 19% (n = 20) for vaginal estrogen vs 9% (n = 10) for placebo (adjusted hazard ratio, 1.97 [95% CI, 0.92-4.22]), with the anatomic recurrence component being most common, rather than vaginal bulge symptoms or prolapse repeated treatment. Masked surgeon assessment of vaginal tissue quality and estrogenization was significantly better in the vaginal estrogen group at the time of the operation. In the subset of participants with at least moderately bothersome vaginal atrophy symptoms at baseline (n = 109), the vaginal atrophy score for most bothersome symptom was significantly better at 12 months with vaginal estrogen. Conclusions and Relevance: Adjunctive perioperative vaginal estrogen application did not improve surgical success rates after native tissue transvaginal prolapse repair. Trial Registration: ClinicalTrials.gov Identifier: NCT02431897.

Evaluation of acupuncture treatments of postpartum female pelvic floor dysfunction by four-dimensional transperineal pelvic floor ultrasound.

INTRODUCTION: In the present investigation, a systematic evaluation of the clinical treatment performance of diagnosed with pelvic floor dysfunction is explored. By comparing the 4Dtransperineal pelvic floor ultrasound images with the acupuncture treatment performance of the patients, an evaluation system with various parameters is established to provide critical information to guide the clinical treatment fpostpartum female pelvic floor dysfunction (FPFD). METHODS: Eighty patients diagnosed with FPFD are divided into 2 groups. After the designated treatment to the patients, they are carefully examined using transperineal pelvic floor ultrasound. The shape and activity of bladder neck, cervix and rectum anal canal under resting, anal sphincter and Valsalva movements are observed and recorded. The morphology and continuous shape of levator ani muscle in different states after 4D image reconstruction are obtained. RESULTS: After the acupuncture treatment, the bladder neck descent is decreased by 3.8 cm and the anal levator muscle area is decreased by 3.4 cm2 comparing with the control group. The anal levator muscle hole diameter is decreased by 0.3 cm, while the anterior and posterior diameter is reduced by 0.5 cm. Reduced possibility of cystocele and uterine prolapse is demonstrated by X2 test. These changes upon acupuncture therapy are in line with the improved conditions of the patients, indicating these parameters can help evaluate the therapy performance. CONCLUSION: 4D pelvic floor ultrasound imaging provides objective and quantified information for the clinical diagnosis and treatment of FPFD and the assessment of therapy efficacy, making it a promising novel method in practical applications.

Protease Inhibition Improves Healing of The Vaginal Wall after Obstetrical Injury: Results from a Preclinical Animal Model.

Vaginal delivery with obstetrical trauma is a risk factor for pelvic organ prolapse later in life. Loss of fibulin-5 (FBLN5), an elastogenesis-promoting cellular matrix protein, results in prolapse in mice. Here, we evaluated effects of pregnancy, parturition, and obstetrical injury on FBLN5 content, elastic fibers, biomechanics, and histomorphology of the vaginal wall in rats. Further, we analyzed the effects of actinonin, a protease inhibitor, on obstetrical injury of the vaginal wall. Vaginal FBLN5 decreased significantly in pregnancy, and injury resulted in further downregulation. Stiffness of the vaginal wall decreased 82% in pregnant rats and 74% (p = 0.019) with injury relative to uninjured vaginal delivery controls at 3d. Actinonin ameliorated loss of FBLN5, rescued injury-induced loss of elastic fibers and biomechanical properties after parturition, and reduced the area of injury 10-fold. We conclude that pregnancy and parturition have a profound impact on vaginal FBLN5 and biomechanics of the vaginal wall. Further, obstetrical injury has significant deleterious impact on recovery of the vaginal wall from pregnancy. Actinonin, a non-specific matrix metalloprotease inhibitor, improved recovery of the parturient vaginal wall after obstetrical injury.

Modified Extraperitoneal Uterosacral Ligament Suspension in Preventing Cuff Prolapse Risk after Vaginal Hysterectomy; 4 Clamp Method.

Objectives: The extraperitoneal uterosacral ligament suspension (ULS) can be performed during the removal of the uterus in vaginal hysterectomy to prevent cuff prolapse. In this study, we evaluated the modified extraperitoneal ULS technique in terms of preventing cuff prolapse. Methods/Technique: Forty patients with second and third-stage uterine prolapse who were operated were included in the study. During routine vaginal hysterectomy procedure performed on patients, after sacrouterine ligaments which are the first-bites and uteroovarian and round ligaments which are the last-bites have been sutured and knotted, these ligaments were marked with 4-distinct clamps to make the right and left, upper and lower separation. After vaginal cuff was closed the sutures hanged by the clamps were ligated together, and the cuff tissue was stretched to the apical line. Results: According to the POP-Q classification, 22 patients with stage-2 and 18 patients with stage-3 prolapse were operated. During the 2-year follow-up; 4 patients could not be reached and were excluded from follow-up. Five of the remaining 36 patients (13.8%) found to have stage-1 cuff prolapse and 31 (86.1%) of patients had no prolapse. There was no significant decrease in postoperative vaginal length (p [Formula: see text] 0.05). The PISQ-12 sexual function scores was found similar before and after surgery (p [Formula: see text] 0.05). Conclusions: The extraperitoneal ULS is a successful method to prevent cuff prolapse after hysterectomy. Although there are various modified forms of this method, the modified ULS, which we have described as the 4-clamp method, seems to be successful in terms of initial results.

Preliminary investigation of the effect of treating sheep during pregnancy with a vitamin A, D, E formulation on the incidence of vaginal prolapse.

Aim: To determine if vitamin D3 treatment reduced the incidence of vaginal prolapse in pregnant sheep on a North Canterbury sheep breeding property.Methods: Pregnant ewes from a single farm were allocated to three treatment groups in May 2018. At this time, the first group (EarlyVitADE; n = 512) received an I/M 1 mL dose of 500,000 IU/mL vitamin D3, 60,000 IU/mL vitamin A, and 25 mg/mL vitamin E. This was repeated in July 2018, when the second group (LateVitADE; n = 695) also received the same treatment. The third group (n = 737) were untreated controls. All cases of vaginal prolapse on the property were recorded from pregnancy diagnosis in June 2018 until ewes were set-stocked in August 2018. The planned start of lambing was 10 August 2018.Results: During the period of observation, vaginal prolapses were recorded in 3/699 (0.4%) 2-year-old ewes, and the odds of vaginal prolapse were not associated with treatment group in these ewes (p > 0.3). Amongst ewes aged ≥3 years, during the same period, there were 6/333 (1.8%), 6/443 (1.4%) and 25/469 (5.3%) cases in the EarlyVitADE, LateVitADE and control groups, respectively. Compared to control ewes, the odds of vaginal prolapse were reduced in both the EarlyVitADE (OR = 0.37; 95% CI = 0.15-0.92) and LateVitADE (OR = 0.25; 95% CI = 0.10-0.62) treatment groups.Conclusions and clinical relevance: In this preliminary study, administration of injectable vitamins A, D3, and E to pregnant ewes reduced the incidence of vaginal prolapse during the period from pregnancy diagnosis to set-stocking on one North Canterbury hill-country farm. Due to the restricted data collection period, this investigation should be replicated to better quantify the repeatability of the observed treatment effect over the complete lambing period.

Modified extraperitoneal uterosacral ligament suspension for prevention of vault prolapse after vaginal hysterectomy.

INTRODUCTION AND HYPOTHESIS: During vaginal hysterectomy, extraperitoneal uterosacral ligament suspension (ULS) bites can be taken before removing the uterus. We evaluated this modified extraperitoneal ULS for vault prolapse prevention. METHODS: Study period was 3.5 years. Fifty-one women with third- and fourth-degree prolapse were enrolled. An inverted V incision was made on the anterior vaginal wall and continued as a semicircular incision on the posterior vaginal wall. Lateral vaginal mucosa was pushed up to expose the cardinal-uterosacral ligament complex. The first ULS suture, using polypropylene no. 1, was taken in the upper-most exposed area of the uterosacral ligament. The second suture, using polyglactin no. 1 or 0, was taken 0.5-1 cm below the first suture. During placement of both sutures, traction on the cervix was maintained. The cardinal-uterosacral ligament complex was clamped, dissected, and ligated 1 cm below the second suture. Vaginal hysterectomy was completed. Ends of the ULS suture were fastened to the vault via vesicovaginal and rectovaginal septum using polypropylene within and polyglactin outside vaginal mucosa. RESULTS: Prolapse stage was 3 in 42 cases and 4 in nine. Duration of operation ranged from 60 to 120 min. Blood loss was 100-300 ml. During follow-up (average 2.3 years) four (8.3%), cases had stage 1 pelvic organ prolapse (POP), three were lost to follow-up, and 44 (91.6%) had no POP. CONCLUSIONS: Using the cervix as a traction device is a good option when performing extraperitoneal ULS during vaginal hysterectomy to prevent vault prolapse.

Does Home Birth Reduce the Risk of Pelvic Organ Prolapse?

OBJECTIVES: To determine the relationship between vaginal birth and the development of POP among women who deliv-ered in non-hospital settings (home birth). MATERIAL AND METHODS: Data were collected retrospectively from the files of patients who presented to a hospital outpatient clinic between April 1, 2011 and April 1, 2012 with complaints of urinary incontinence, uterine sagging, vaginal mass, or vaginal pain. The patients' age, height, weight, body mass index, menopause age, number of deliveries, and presence of hypertension and diabetes mellitus were noted. Patients whose urogynecologic evaluation included POP Quantification (POP-Q) scoring were included in the study. The patients were separated into a group of women who had never given birth and another group of women with one or more deliveries. RESULTS: Of the 179 patients in the study, 28 had never given birth and 151 had given birth at least once. The nulliparous patients had no cystocele, rectocele, or uterine prolapse. The prevalence rates of cystocele, rectocele, and uterine prolapse were significantly higher in the multiparous group. Cystocele, rectocele, and uterine prolapse development were significantly correlated with number of deliveries, but there was no statistical association with age, body mass index, menopausal age, diabetes mellitus, or hypertension. univariate analysis reveals that the only factor effective in the development of cytocele, rectocele and prolapse is the number of births. CONCLUSIONS: Our study suggests that only number of deliveries is associated with development of cystocele, rectocele, and uterine prolapse in women who gave birth by vaginal route in residential settings.

Laparoscopic management of severe ureteral obstruction after vaginal hysterectomy and colposuspension.

INTRODUCTION AND HYPOTHESIS: After vaginal hysterectomy, uterosacral ligaments are commonly used to suspend the vaginal vault in order to prevent and to treat recurrence of central prolapse. Shull et al. proposed a technique to fix endopelvic fascia and vagina to the higher portion of the uterosacral ligaments using a vaginal approach [1]. This technique is associated with a risk of ureteral obstruction (0-11%) [2, 3]. Although intraoperative cystoscopy is recommended to check ureteral patency at the end of colposuspension, this secondary prevention technique could be false negative due to partial stenosis [4]. METHODS: A 60-year-old woman with stage 3 uterine and anterior compartment descensus assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system underwent vaginal hysterectomy, bilateral adnexectomy, and vaginal vault suspension to the uterosacral ligaments using the Shull technique. Intraoperative cystoscopy with indigo carmine was negative. On postoperative day 0, the patient complained left flank pain. Transabdominal ultrasound showed a left hydroureteronephrosis without ureteral stones, which was confirmed by uro-computed tomography scan. The attempts of ureteral stent positioning and opening the vaginal vault failed to resolve the ureteral obstruction, which was corrected, and a new vault suspension performed using the laparoscopic approach. Prophylactic ureteral stent positioning was performed. Informed consent was obtained from the patient for publication of this case report. RESULTS: The patient was discharged on postoperative day 5 with normal renal function. The ureteral stent was removed after 1 month, and renal ultrasound at 3 and 6 months' follow-up showed normal renal pelvis caliber. No recurrence of genital prolapse was observed at gynecological examination. CONCLUSIONS: Laparoscopy can be a wise alternative option to manage ureteral obstruction secondary to vaginal colposuspension for genital organ prolapse.

No evidence of association between native tissue vault suspension and risk of pelvic pain or sexual dysfunction.

OBJECTIVE: Hysterectomy is suspected of increasing risk of subsequent pelvic organ prolapse (POP). In attempt to prevent this, several suspension methods during hysterectomy on benign indication are used as a prophylactic procedure. However, possible complications to the use of prophylactic vaginal vault suspension to prevent POP are not fully investigated. We aimed to elucidate prophylactic vaginal vault suspension as a possible cause for pelvic pain and sexual dysfunction. STUDY DESIGN: We included all women registered with a total hysterectomy on benign indication and registered with a suspension method or specifically no suspension in the nationwide Danish Hysterectomy and Hysteroscopy Database (DHHD) between 10 May 2012 and 4 September 2013 (N = 3999). A postal questionnaire on pelvic pain and sexual dysfunction was sent to women 25.8 (range 23.8-28.4) months after hysterectomy. Questions were selected from a previous study as well as from the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). We used independent samples t-tests and χ2-tests for univariate analyses. In multivariable analyses, we used log-binomial - and linear regression models adjusted for risk factors of pelvic pain and sexual dysfunction, respectively. RESULTS: The response rate was 60.3% (N = 2412). Of the respondents, 88.8% (N = 2143) were registered with a suspension method and 11.2% (N = 269) were registered with specifically no suspension. Overall, pelvic pain of any kind was reported in 24.3% (N = 576) of the respondents. In adjusted log-binomial regression, suspension did not increase risk of pelvic pain compared to no suspension (RR 0.92; 95% CI 0.75 to 1.14; p-value 0.45). In adjusted linear regression, suspension was significantly associated with less degree of sexual dysfunction (regression coefficient -0.92; 95% CI -1.70 to -0.14; p-value 0.02). CONCLUSIONS: In women undergoing prophylactic vaginal vault suspension during hysterectomy, we found less sexual dysfunction and no evidence of increased risk of pelvic pain compared to women with no vaginal vault suspension.

Clinical outcomes in women undergoing laparoscopic hysteropexy: A systematic review.

OBJECTIVES: To systematically review the current evidence on the anatomic and functional outcomes in women undergoing laparoscopic hysteropexy. STUDY DESIGN: An electronic database search was undertaken (2000-2016). Keywords were: "laparoscopy", "hysteropexy", "cervicopexy", "uterine suspension", "uterosacral plication". References of identified studies as well as abstracts from conferences were considered. We restricted the search to humans, female patients and currently used surgical procedures. Studies with ≥5 cases in English language and published in 2000 or later, were included. After the initial yield, studies were selected following title screening, abstract and full text scrutiny. RESULTS: A total of 17 studies were deemed suitable for inclusion in the review. A total of 770 patients in 17 studies received the intervention being studied (laparoscopic hysteropexy) and were assessed post-operatively with pooled success rates of 85.32% (95%CI: ±2.5). Laparoscopic suture hysteropexy has pooled success of 70.5% (95%CI:±5.33) whereas the pooled success of the suspension to the sacral promontory using mesh or tape is 92% (95%CI: ±2.53). One small study on suspension to the anterior abdominal wall (28 cases) and one to the pectineal ligament (18 cases) have shown 96.4% (95%CI:±6.9) and 94.5% (95%CI:±10.53) objective success rates respectively. CONCLUSION: Laparoscopic hysteropexy was associated with good anatomic cure rates of greater than 90% in majority of the studies. There was an improvement in symptoms, and good subjective cure rates in 73%-100% of the patients. Reoperation rates were low in most studies ranging from around 0%-28%. Complications rates were generally low. Laparoscopic hysteropexy is a feasible alternative for women needing surgical correction of uterovaginal prolapse and who desire conservation of the uterus.

Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse.

BACKGROUND: A wide variety of grafts have been introduced with the aim of improving the outcomes of traditional native tissue repair (colporrhaphy) for vaginal prolapse. OBJECTIVES: To determine the safety and effectiveness of transvaginal mesh or biological grafts compared to native tissue repair for vaginal prolapse. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ongoing trials registers, and handsearching of journals and conference proceedings (6 July 2015). We also contacted researchers in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing different types of vaginal repair (mesh, biological graft, or native tissue). DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed risk of bias, and extracted data. The primary outcomes were awareness of prolapse, repeat surgery, and recurrent prolapse on examination. MAIN RESULTS: We included 37 RCTs (4023 women). The quality of the evidence ranged from very low to moderate. The main limitations were poor reporting of study methods, inconsistency, and imprecision. Permanent mesh versus native tissue repairAwareness of prolapse at one to three years was less likely after mesh repair (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.54 to 0.81, 12 RCTs, n = 1614, I(2) = 3%, moderate-quality evidence). This suggests that if 19% of women are aware of prolapse after native tissue repair, between 10% and 15% will be aware of prolapse after permanent mesh repair.Rates of repeat surgery for prolapse were lower in the mesh group (RR 0.53, 95% CI 0.31 to 0.88, 12 RCTs, n = 1675, I(2) = 0%, moderate-quality evidence). There was no evidence of a difference between the groups in rates of repeat surgery for continence (RR 1.07, 95% CI 0.62 to 1.83, 9 RCTs, n = 1284, I(2) = 21%, low-quality evidence). More women in the mesh group required repeat surgery for the combined outcome of prolapse, stress incontinence, or mesh exposure (RR 2.40, 95% CI 1.51 to 3.81, 7 RCTs, n = 867, I(2) = 0%, moderate-quality evidence). This suggests that if 5% of women require repeat surgery after native tissue repair, between 7% and 18% in the permanent mesh group will do so. Eight per cent of women in the mesh group required repeat surgery for mesh exposure.Recurrent prolapse on examination was less likely after mesh repair (RR 0.40, 95% CI 0.30 to 0.53, 21 RCTs, n = 2494, I(2) = 73%, low-quality evidence). This suggests that if 38% of women have recurrent prolapse after native tissue repair, between 11% and 20% will do so after mesh repair.Permanent mesh was associated with higher rates of de novo stress incontinence (RR 1.39, 95% CI 1.06 to 1.82, 12 RCTs, 1512 women, I(2) = 0%, low-quality evidence) and bladder injury (RR 3.92, 95% CI 1.62 to 9.50, 11 RCTs, n = 1514, I(2) = 0%, moderate-quality evidence). There was no evidence of a difference between the groups in rates of de novo dyspareunia (RR 0.92, 95% CI 0.58 to 1.47, 11 RCTs, n = 764, I(2) = 21%, low-quality evidence). Effects on quality of life were uncertain due to the very low-quality evidence. Absorbable mesh versus native tissue repairThere was very low-quality evidence for the effectiveness of either form of repair at two years on the rate of awareness of prolapse (RR 1.05, 95% CI 0.77 to 1.44, 1 RCT, n = 54).There was very low-quality evidence for the effectiveness of either form of repair on the rate of repeat surgery for prolapse (RR 0.47, 95% CI 0.09 to 2.40, 1 RCT, n = 66).Recurrent prolapse on examination was less likely in the mesh group (RR 0.71, 95% CI 0.52 to 0.96, 3 RCTs, n = 292, I(2) = 21%, low-quality evidence)The effect of either form of repair was uncertain for urinary outcomes, dyspareunia, and quality of life. Biological graft versus native tissue repairThere was no evidence of a difference between the groups at one to three years for the outcome awareness of prolapse (RR 0.97, 95% CI 0.65 to 1.43, 7 RCTs, n = 777, low-quality evidence).There was no evidence of a difference between the groups for the outcome repeat surgery for prolapse (RR 1.22, 95% CI 0.61 to 2.44, 5 RCTs, n = 306, I(2) = 8%, low-quality evidence).The effect of either approach was very uncertain for recurrent prolapse (RR 0.94, 95% CI 0.60 to 1.47, 7 RCTs, n = 587, I(2) = 59%, very low-quality evidence).There was no evidence of a difference between the groups for dyspareunia or quality of life outcomes (very low-quality evidence). AUTHORS' CONCLUSIONS: While transvaginal permanent mesh is associated with lower rates of awareness of prolapse, reoperation for prolapse, and prolapse on examination than native tissue repair, it is also associated with higher rates of reoperation for prolapse, stress urinary incontinence, or mesh exposure and higher rates of bladder injury at surgery and de novo stress urinary incontinence. The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. While it is possible that in women with higher risk of recurrence the benefits may outweigh the risks, there is currently no evidence to support this position.Limited evidence suggests that absorbable mesh may reduce rates of recurrent prolapse on examination compared to native tissue repair, but there was insufficient evidence on absorbable mesh for us to draw any conclusions for other outcomes. There was also insufficient evidence for us to draw any conclusions regarding biological grafts compared to native tissue repair.In 2011, many transvaginal permanent meshes were voluntarily withdrawn from the market, and the newer, lightweight transvaginal permanent meshes still available have not been evaluated within a RCT. In the meantime, these newer transvaginal meshes should be utilised under the discretion of the ethics committee.

Knowledge and acceptance of Thai women toward the pelvic floor muscle training.

BACKGROUND: Pelvic floor muscle training (PFMT) is considered as an effective management for relieving pelvic organ prolapse (POP) and urinary incontinence (UI). Although the benefits of PFMT are known among the health care professionals, the benefits from PFMT among the Thai women are not known. OBJECTIVE: To evaluate the basic knowledge and acceptance of PFMT in women who visited the gynecologic out-patient clinic. MATERIAL AND METHOD: A cross-sectional survey was conducted by administering a brief anonymous 2-part questionnaire to 415 women who visited the gynecologic out-patient clinic at King Chulalongkorn Memorial Hospital between November 2010 and January 2011. A questionnaire, consisting of 24 questions, was divided into two parts where part one, made up of 10 questions, collected demographic data and the remaining 14 questions in part 2 gathered more information about the knowledge and acceptance towards PFMT. These questionnaires required approximately five minutes for completion. RESULTS: Mean age of all women was 42.9 years. The percentage of patients having stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence (MUI) were 21.9%, 5.3%, and 15.2%, respectively. Overactive bladder (OAB) and pelvic organ prolapse (POP) were found in 19.5% and 9.9%, respectively. Half of the respondents were unaware of PFMT efficacy. Most of them (80.2%) never received instruction from their health care providers. However 52.8% of women expressed interest for requesting PFMT instruction while 84.6% were willing to practice if they were made aware of benefits. CONCLUSION: A limited understanding and acceptance of PFMT exists among Thai women. However if informed, most women express interest in practicing PFMT after clinic visit.

A randomized trial of prophylactic uterosacral ligament suspension at the time of hysterectomy for Prevention of Vaginal Vault Prolapse (PULS): design and methods.

The primary aim of this randomized trial is to evaluate whether a standardized uterosacral ligament suspension colpopexy (USLSC), added to a planned hysterectomy for an indication other than pelvic organ prolapse (POP), decreases the rate of subsequent vaginal vault prolapse in women without preoperative symptomatic POP. Secondary aims include comparison of perioperative complications, urinary, bowel and sexual functions between subjects with and without concomitant USLSC. If shown to be beneficial, the cost-effectiveness of prophylactic USLSC at the time of hysterectomy will be evaluated. This trial will be performed at 4 centers across the United States. The data will be analyzed by the data-coordinating center of the Southern California Kaiser Permanente. Standardized questionnaires and objective measurements will be obtained. The patients and providers performing assessments are masked to treatment assignment. The primary outcome, defined as absence of POP at/distal to the hymen on Pelvic Organ Prolapse Quantitative examination, will be determined 12 months post-operatively. Secondary outcomes include: no prolapse symptoms by questionnaires, and no treatment for POP besides the prophylactic study intervention. Additional follow-up occurs annually for a total of 5 years. Accrual is projected to take 3 years. Given cost and morbidity of surgical repair of post-hysterectomy prolapse, preventive strategies are of outmost importance. The risks and benefits of prophylactic USLSC have never been studied prospectively. This trial is designed to determine if USLSC is an appropriate clinical adjunct at the time of hysterectomy, with subsequent reduction of symptomatic POP.

Effect of uterine preservation on outcome of laparoscopic uterosacral suspension.

STUDY OBJECTIVE: To compare the objective outcome of laparoscopic uterosacral hysteropexy with that of hysterectomy combined with laparoscopic uterosacral colpopexy. DESIGN: Retrospective cohort study, 1999-2010 (Canadian Task Force classification II-2). SETTING: University hospital in South Australia. PATIENTS: Women with uterovaginal prolapse who had undergone laparoscopic uterosacral hysteropexy (n = 104) or laparovaginal hysterectomy with uterosacral colpopexy (n = 160). Apical suspension procedures were subdivided into prophylactic (Pelvic Organ Prolapse Quantification System [POP-Q] stage 1 apical descent, with stage ≥2 prolapse in an adjacent compartment) and therapeutic (POP-Q stage ≥2 apical descent, with or without adjacent compartment prolapse). INTERVENTIONS: All patients were assessed via POP-Q scoring preoperatively and postoperatively at 6 weeks, 6 months, annually, and then biannually. Recurrence of bulge symptoms and need for repeat treatment were recorded. MEASUREMENTS AND MAIN RESULTS: Demographic data, preoperative degree of prolapse, and percentages of prophylactic and therapeutic procedures were similar in both groups. With a median follow-up of 2.5 years, objective success rates (POP-Q stage <2 in all compartments) for uterosacral hysteropexy were 53% for prophylactic procedures and 41% for therapeutic procedures, and for hysterectomy with uterosacral colpopexy were 66% for prophylactic procedures and 59% for therapeutic procedures. Repeat operation rates overall were 28% for hysteropexy and 21% for hysterectomy with colpopexy. Failures at the apex specifically were 27% for hysteropexy and 11% for hysterectomy with colpopexy (p < .02). CONCLUSION: Hysterectomy with laparoscopic uterosacral colpopexy produced better objective success rates than did laparoscopic uterosacral hysteropexy; however, repeat operation rates were not significantly different.

A review of the technique and complications from 2,012 cases of laparoscopically assisted vaginal hysterectomy at a single institution.

AIMS: To present our experience of modified laparoscopically assisted vaginal hysterectomy (LAVH) and to evaluate the surgical outcomes and complications. METHODS: Women with benign gynaecologic tumours that underwent a modified LAVH at the Samsung Medical Centre were analysed retrospectively. The technique is primarily a vaginal hysterectomy with a minor component of the laparoscopic procedures (stage 2 laparoscopic hysterectomy (LH)) and had two modifications (vaginal anterior colpotomy and McCall culdoplasty) from the standard technique. RESULTS: A total of 2012 LAVH procedures were performed from January 2000 to May 2008. The mean duration of the operations and the uterine weight were 102±32 min and 305±168 g, respectively. In 196 (9.7%) cases, the uterine weight was more than 500 g. Conversion to laparotomy was needed in 97 cases. Major intraoperative complications occurred in 45 cases (2.2%): bladder injury, 26 (1.29%); bowel injury, nine (0.45%); haemorrhage of major vessels, nine (0.45%); and ureteral injury, one (0.05%). Major long-term complications occurred in three cases: one fistula and two trocar site herniations. CONCLUSIONS: Stage 2 LH combined with modified vaginal anterior colpotomy and modified McCall culdoplasty is safe and effective for benign gynaecologic tumours and the prevention of post-LAVH vaginal prolapse.

Prevención del prolapso genital en histerectomía abdominal utilizando los ligamentos redondos: experiencia personal / Prevention of genital prolapse in abdominal hysterectomy using the round ligaments: personal experience

Prevenir el prolapso de la cúpula vaginal, empleando una técnica peroperatoria que consiste en fijar la cúpula vaginal a los ligamentos redondos, en el momento de realizar la intervención. Realizada la histerectomía, se procedió al cierre de la cúpula vaginal con puntos separados en número de 6 a 8 con material no absorbible, dependiendo de la amplitud de la vagina. Los cabos distales son utilizados para anudar horizontalmente los ligamentos redondos. La fijación de las dos paredes del extremo superior de la vagina, garantiza mayor estabilidad de la vagina y menor posibilidad de producir el prolapso de la cúpula y/o de las paredes anterior y posterior de la vagina. Servicio de Ginecología, Hospital Universitario de Caracas. Las 124 pacientes histerectomizadas y controladas anualmente en un lapso entre 2 y 27 años, con un promedio de 7 años, ninguna de ellas presentó prolapso de cúpula vaginal. Las histerectomías se realizaron en el ejercicio privado. En centros asistenciales públicos, es muy difícil hacer seguimiento y evaluar las pacientes, por razones múltiples. La histerectomía ocupa el primer lugar de las intervenciones ginecológicas, esto obliga a realizar la suspensión y fijación de la cúpula vaginal y simultáneamente corregir la patología asociada del aparato genital. El procedimiento que hemos empleado tuvo resultados muy favorables. La calidad de vida de las mujeres intervenidas quirúrgicamente no se desmejoró, como suele suceder cuando se produce el prolapso de la cúpula vaginal

To prevent vaginal vault prolapse, using a preoperative technique to fix the vaginal vault to the round ligaments in total abdominal hysterectomy, and identify associated pathology in the genital area. After hysterectomy, we proceed to the closure of the vaginal vault with interrupted sutures with non-absorbable material, in number of 6-8, depending of the amplitude of the vagina, the distal ends are used to tie horizontally bilateral round ligaments. The setting of the two upper walls of the vagina, ensures greater stability of the vagina and lower possibility of occurrence of prolapse of the dome and/or the anterior and posterior vaginal walls. Servicio de Ginecologia, Hospital Universitario de Caracas The 124 patients undergoing hysterectomy, checked annually over a period of time between 2 and 27 years, with an average of 7 years, neither had vaginal prolapse. Histerectomy is the firstone gynecological operation. It requires making the suspension and fixation of the vaginal vault and simultaneously correct the genital tract associated pathology. The procedure we used had very favorable results. We can not compare our results with other techniques, do to scarse national an international references. The quality of life of women surgically intervened did not deteriorated, as usually happens when there is prolapse of the vaginal vault

Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up.

OBJECTIVE: The objective of the study was to compare anterior colporrhaphy with and without a mesh. STUDY DESIGN: Two hundred two women with anterior prolapse were assigned to undergo colporrhaphy alone or reinforced with a tailored polypropylene mesh. Before and 2, 12, 24, and 36 months after surgery, the outcome was assessed by examination and standard questions. The primary endpoint was anatomic recurrence of anterior vaginal prolapse. Secondary outcomes were symptom resolution, reoperation, and mesh exposure. RESULTS: Recurrences of anterior vaginal prolapse were noted in 40 of the 97 (41%) in the colporrhaphy group and 14 of 105 (13%) in the mesh group (P < .0001). The number needed to treat was thus 4. The proportion of symptomatic patients, including those with dyspareunia, did not differ between the groups. The mesh erosion rate was 19%. CONCLUSION: At 3 year follow-up, anterior colporrhaphy with mesh reinforcement significantly reduced anatomic recurrences of anterior vaginal prolapse, but no difference in symptomatic recurrence were noted and the mesh erosion rate was high. The use of mesh was not associated with an increase in dyspareunia.

Transvaginal mesh repair of anterior and posterior vaginal wall prolapse: a clinical and ultrasonographic study.

OBJECTIVES: To investigate whether ultrasonography coupled with clinical examination can help in understanding the mechanism of recurrence after transvaginal mesh repair of anterior and posterior vaginal wall prolapse. METHODS: Ninety-one patients who had undergone surgery for anterior and/or posterior vaginal wall prolapse with the Prolift system had a clinical examination and introital/endovaginal two-dimensional ultrasonography a minimum of 1 year later. The retraction of anterior and posterior meshes was estimated relative to the original length of the mesh by transvaginal palpation. Patients with no, moderate (< 50%) or severe (> or = 50%) mesh retraction were compared. Anterior recurrence of prolapse was defined according to the International Continence Society by a Ba value > or = -1 and posterior recurrence by a Bp value > or = -1 (where Ba represents the most distal position of the anterior vaginal wall and Bp the most distal position of the posterior vaginal wall). On ultrasonography, two distances were measured in the midsagittal plane: Distance 1, from the distal margin of the anterior mesh to the bladder neck, and Distance 2, from the distal margin of the posterior mesh to the rectoanal junction. RESULTS: Seventy-five anterior and 62 posterior meshes were studied at a mean follow-up of 17.9 months. Patients with anterior recurrence presented significantly more often with severe anterior mesh retraction compared with patients without anterior recurrence (5/8 vs. 2/67, P < 0.001) and also had an increased Distance 1 (P < 0.001). Patients with posterior recurrence presented significantly more often with severe posterior mesh retraction compared with patients without posterior recurrence (3/4 vs. 3/58, P < 0.01) and also had an increased Distance 2 (P < 0.01). CONCLUSIONS: Recurrence of prolapse after transvaginal mesh repair appears to be associated with severe mesh retraction and loss of mesh support on the distal part of the vaginal walls.