Long-term Outcomes of Self-Management Gellhorn Pessary for Symptomatic Pelvic Organ Prolapse.

OBJECTIVE: The aim of this study is to estimate the long-term survival and to identify adverse events associated with the use of Gellhorn pessaries over a 9-year period. METHODS: This was a retrospective case series study at a tertiary urogynecology unit in Taiwan. Between January 2009 and June 2017, 93 patients who opted for self-management Gellhorn pessaries to treat symptomatic pelvic organ prolapse (POP) and who were continuously followed-up were enrolled. Long-term use was defined as use for longer than 1 year. Length of use, factors that predicted discontinuation, and adverse events were analyzed and reviewed by chart or telephone inquiry. RESULTS: The cumulative probabilities of continued pessary use at 1 and 5 years were 62.4% and 47.2%, respectively. Of those who discontinued use, 34 (70.8%) participants discontinued use within 1 year, and the mean duration of use was 13.7 months (range, 0-75 months; median, 5 months). Most of the participants stopped using the pessary because of bothersome adverse events such as pessary expulsion, vaginal pain, de novo urinary incontinence, and erosion/infection. CONCLUSIONS: Self-management Gellhorn pessary was safe and relatively effective and increased patients' autonomy and ability to manage their POP. One third of the patients discontinued use by 1 year, and half of the patients discontinued use at 5 years.

Use of a pessary in treatment of pelvic organ prolapse: quality of life, compliance, and failure at 1-year follow-up.

STUDY OBJECTIVES: To estimate the effect of pessary use on symptom improvement and quality of life in women with pelvic organ prolapse, to examine factors that influence patient choice and continued use of a pessary, and to determine reasons associated with discontinuation of pessary use. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Outpatient urogynecologic clinic of a university hospital. PATIENTS: Seventy-two patients with symptomatic pelvic organ prolapse were evaluated for pessary insertion between March 2006 and August 2008. INTERVENTIONS: Insertion of a Gellhorn pessary. MEASUREMENTS AND MAIN RESULTS: Urinary symptoms and quality of life were assessed using the Urinary Distress Inventory incontinence questionnaire (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) at baseline and postinsertionally at 2 months and at 1 year. Frequency of choosing pessary use or surgery and rate of continuous use of a pessary was compared between groups. Compared with baseline findings, at 1 year, UDI-6 and IIQ-7 demonstrated significant improvement in frequency of micturition, stress incontinence, voiding function, and bowel evacuation. Substantially more older or menopausal women opted for a pessary rather than surgery, and significantly more sexually active women preferred surgery. Women with diabetes mellitus or occult stress urinary incontinence and those without family support are more likely to discontinue pessary use. CONCLUSIONS: Use of a pessary in treatment of pelvic organ prolapse is associated with good compliance, and results in significant improvement in quality of life and urinary and bowel symptoms. Women with diabetes or occult stress urinary incontinence and those without family support should receive intensive counseling before placement of a pessary.

Simple sling resection and a second, intermediate polypropylene mesh for treatment of vaginal tape protrusion concurrent with recurrent urinary stress incontinence after TVT procedure.

The tension-free vaginal tape (TVT) procedure is a simple, effective and minimally invasive method for the surgical treatment of urodynamic stress incontinence (USI). Yet, complications such as mesh protrusion and recurrent urinary leakages after TVT have been reported. A case of recurrent USI complicated with vaginal mesh protrusion following a TVT procedure was referred. Video-urodynamics and introital ultrasonography confirmed that the recurrence of USI was secondary to mal-position of the protruded TVT. A simple salvaging procedure was carried out. The mal-positioned distal protruded TVT was resected and a second intermediate piece of polypropylene (Prolene) mesh was replaced at mid-urethra. The operation time was short and blood loss was minimal. The patient was objectively continent at 6 months follow-up with no defect of healing. Considering the cost-effectiveness and invasiveness of the surgeries, the method of inserting an intermediate mesh is clinically useful.

Treatment for unsuccessful tension-free vaginal tape operation by shortening pre-implanted tape.

PURPOSE: We studied the efficacy of shortening the pre-implanted suburethral tape in patients with recurrent urodynamic stress incontinence after a TVT operation. MATERIALS AND METHODS: A total of 14 women, including 6 with ISD, were treated for recurrent urodynamic stress incontinence after the initial TVT operation by performing the shortening procedure under local anesthesia. Urodynamics, a 1-hour pad test, introital ultrasonography of the urethra and a cotton swab test were done before the procedure and 1 year postoperatively. RESULTS: All 14 patients completed the shortening procedure. Mean patient age was 47.2 years (range 43 to 66). Mean time between initial TVT and the shortening procedure was 4 months (range 3 to 14). Ten patients (71.4%) were objectively cured and treatment failed in 4 (2 with ISD and 2 with a fixed urethra). Mean operative time was 17 minutes (range 10 to 25). No intraoperative surgical complications were observed. The 1-hour pad test showed a decrease from a median of 9.0 gm to 1.0. Median postoperative hospital stay was 1 day (range 1 to 4). Spontaneous voiding with adequate post-void residual urine was noted in all patients before discharge home. CONCLUSIONS: Shortening a pre-implanted TVT tape for the treatment of recurrent urodynamic stress incontinence is a safe, effective and minimally invasive option requiring only a short hospital stay. However, ISD and an immobile urethra seem to be risk factors for failure. Long-term followup is needed to determine if this surgery achieves long-lasting results.

The prevalence of urinary incontinence and associated risk factors in Taiwanese women with lower urinary tract symptoms.

BACKGROUND: To analyze the urodynamic-defined prevalence of urinary incontinence and the associated risk factors in Taiwanese women with lower urinary tract symptoms (LUTS). METHODS: We reviewed the medical records of 4,470 women who were referred to our urodynamic center between January 1999 and May 2003. Their records including a comprehensive medical history, physical examination, bladder diary and results of multi-channel urodynamic testing were analyzed. RESULTS: 3,161 of 4,470 women recruited were eligible for the analyses. The distribution of urodynamic prevalence in 3,161 women revealed that urodynamic stress incontinence (USI) was 1,755/3,161 (55.5%), detrusor overactivity (DO) 231/3,161 (7.3%), mixed incontinence (MI) 142/3,161 (4.5%), voiding dysfunction (VD) 793/3,161 (25.1%) and normal result (N) 240/3,161 (7.6%). The highest prevalence of USI was observed in women aged 40-49 (40.3%) and the prevalence of DO and MI seemed to be lower as compared with the literature reports. Linear regression analysis showed parity (p < 0.001) and three urodynamic study (UDS) variables [maximum free flow rate (p = 0.003), maximum urethral closure pressure (p = 0.003) and functional profile length (p = 0.014)] were significantly related to the urinary incontinence in women with LUTS. Menopause (p = 0.865) had no impact on the urinary incontinence. CONCLUSION: Risk factors contributing to Taiwanese women with LUTS to develop urinary incontinence included multiparity and three specific parameters observed during UDS. Of interest, our data also indicated 25% of patients were diagnosed as voiding dysfunction deserved future study.

Ultrasound and urodynamic comparison between caudocranial and craniocaudal tension-free vaginal tape for stress urinary incontinence.

OBJECTIVES: To compare the efficacy and safety of the conventional caudocranial tension-free vaginal tape (TVT) procedure and craniocaudal TVT procedure for the treatment of primary stress urinary incontinence. METHODS: Ninety patients with urodynamic stress incontinence and without prolapse underwent a caudocranial TVT (45 women) or craniocaudal TVT (45 women) procedure. The two patient groups were comparable in terms of age, parity, body weight, previous pelvic surgery, and menopausal status. Both methods were performed under local anesthesia with adequate sedation. Introital ultrasound evaluation on the mid-urethra TVT tapes and urodynamic evaluation was performed before and after surgery. RESULTS: The average follow-up period for caudocranial TVT and craniocaudal TVT was 1.9 years and 1.4 years, respectively. Objective evaluations were performed at similar times at 1 year postoperatively. No significant differences were found in the cure rate at 88.9% (40 of 45 women) after caudocranial TVT and 91.1% (41 of 45 women) after craniocaudal TVT (P = 1.000). The intraoperative complications were minor. No patient had long-term voiding difficulty or required long-term catheterization. Both groups had the vaginal tape implanted at the mid-urethra, with a urethral knee angle observed during maximal straining. A more proximal tape position, less elasticity of the tape, and more obstruction by the sling were found using the craniocaudal approach. Postoperative dysfunctional voiding was minor. CONCLUSIONS: The caudocranial and craniocaudal TVT procedures are highly effective, minimally invasive, and safe procedures in the treatment of urinary stress incontinence. The variations in implanted tape position and postoperative sling obstruction were most likely caused by the mode of insertion.

Repair of recurrent vaginal vault prolapse using sacrospinous ligament fixation with mesh interposition and reinforcement.

OBJECTIVE: Our goal was to study the efficacy of performing the repeated sacrospinous ligament fixation with mesh interposition and reinforcement in women with recurrent vaginal vault prolapse. MATERIALS AND METHODS: Fifteen consecutive patients with symptomatic severe vaginal vault or uterus prolapse after previous sacrospinous ligament fixation were enrolled. The sacrospinous ligament fixation was performed with a mesh interposition between sacrospinous ligament complex and vaginal apex. The mesh was extended to anterior and posterior vaginal wall for the repair of concurrent cystocele and rectocele, if indicated. The surgical results and complications were evaluated. The prolapse evaluation was performed according to International Continence Society (ICS) ordinal stages of pelvic organ prolapse. RESULTS: The mean age was 55 years. The mean follow-up was 2.9 years (range 1.0-5.5 years). Repeated sacrospinous ligament fixation was performed for all patients. Eleven were performed unilaterally to the right and four to the left. The average time for sacrospinous fixation was 20 min. The average blood loss for sacrospinous fixation was 75 ml. No major complication except one accidental rectotomy was observed. It was repaired intraoperatively without sequel. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies, and tension-free vaginal tape procedures. No recurrence of apical prolapse was observed. However, two patients developed stage I prolapse on anterior vaginal wall (cystocele) and required no further repair. Minor postoperative complications were observed. CONCLUSION: Repeated sacrospinous ligament fixation with mesh interposition and reinforcement is a safe and effective procedure for the correction of recurrent vault prolapse. The extended implanted mesh can be used for the repair of concurrent cystorectocele effectively. A long-term follow-up is necessary to detect any late complication.

Ultrasound assessment of mid-urethra tape at three-year follow-up after tension-free vaginal tape procedure.

OBJECTIVES: To evaluate the anatomic changes in the polypropylene mesh sling after a tension-free vaginal tape (TVT) procedure using introital ultrasonography in a prospective study. METHODS: Eighty women with genuine stress incontinence but without pelvic relaxation syndrome underwent surgery. Introital ultrasound evaluation of the mid-urethra TVTs was performed after surgery. RESULTS: Of the 70 women available for evaluation at postoperative year 3, 62 (88.5%) were objectively cured and 6 had improvement; in 2 patients, the procedure had failed. The measurement of the tape position from the bladder neck at the first and third year compared with the tape position at 1 month revealed no statistically significant differences. The tapes were located at the mid-urethra in 60 patients (85.7%) and at the proximal urethra in 10. The measurement of the tape from the lower margin of the symphysis pubis using the rectangular coordinate system showed the tape had a downward descent of 1.7 mm at 3 years of follow-up. The rate of descent decreased during the study period. The mean thickness and width of the tape increased with time. A urethral knee angulation during maximal straining was found in 60 patients (92%), with the tape positioned at the mid-urethra for the follow-up period. CONCLUSIONS: The observations of the tape position and characteristics suggest that shrinkage and compromise of the TVT sling does not occur. The TVT sling fixes to its original implanted site along the urethra and appears to slowly descend with the surrounding tissue with time. The urethra dynamic kinking contributes to the postoperative urinary continence when the TVT sling is placed at the mid-urethra.