A comparison of native vaginal and ligament surgery for cure of pelvic organ prolapse and overactive bladder.

The key messages from the Shkarupa et al. native cardinal/uterosacral ligament (CL/USL) study, was that, in premenopausal women, ligament repair alone is sufficient for cure of pelvic organ prolapse (POP) and urgency, achieving cure rates of 85.7% for POP and 81.6% for urgency at 12 months. However, in postmenopausal women, the cure rates were 20.5% for POP and 33.3% for urge at 12 months. The Lancet Prospect Trial recorded 21% for native vaginal repair at 12 months. The poor POP cure rate in the Prospect Trial, and the rapid deterioration in the post-menopausal CL/USL repair group, can be explained by known biomechanics. The vagina has little structural strength. Ligaments, with a much higher breaking strain, are the main structural support of pelvic organs. Yet, even native ligament repair reported very low cure rates at 12 months. The poor results in postmenopausal women with native ligament repair can be explained by collagen breakdown after the menopause, as collagen is the key structural component of ligaments. An important question posed in the ligament repair study was, "What happens to women cured by ligament repair after the menopause when the collagen leaches out of the ligaments?". One recommendation was that collagen creating tapes be routinely applied in prolapse surgery and OAB, at least in postmenopausal women. The recommendation for routine collagen-creating ligament repair methods, especially in older women, are supported by high 5-year surgical cure rates in 70-year-old Japanese women, 91.2% for POP, at 12 months, falling to 79.0 at 60 months, using collagen creating Tissue Fixation System (TFS) minislings.

Prevalence of choroidal nevi in patients with central serous chorioretinopathy.

Background: A number of articles report the association of polypoidal lesions and choroidal nevi; however, the relationship between choroidal nevi and pachychoroidal disorders has not been studied. Objectives: To study the prevalence of choroidal nevi in central serous chorioretinopathy (CSCR) patients and to elucidate potential differences in the clinical characteristics of CSCR in patients with and without choroidal nevi. Design: Case-control study. Methods: This study included a retrospective analysis of medical records and multimodal imaging data of CSCR patients and a prospective evaluation of the prevalence of the choroidal nevi in age- and sex-matched healthy controls. All participants received comprehensive ophthalmic examination and multimodal imaging including infrared scanning laser ophthalmoscopy in dark-field mode to detect choroidal nevi in the central 40° × 60° region. Results: A total of 199 CSCR patients (160 males and 39 females, 47.9 ± 9.4 years) and 184 age-matched healthy individuals (139 males and 45 females, 44.8 ± 12.5 years) were included. Choroidal nevi were detected in 24 (12.1%) CSCR patients and 10 (5.4%) healthy controls (p = 0.01). CSCR patients with choroidal nevi had statistically significantly higher subfoveal choroidal thickness, lower best-corrected visual acuity, and lower central retinal thickness (p < 0.05) than CSCR patients without choroidal nevi. The odds ratio for the presence of chronic CSCR in patients with choroidal nevi was 27.0 (95% CI: 3.1-231.9, p = 0.003). Conclusion: The prevalence of choroidal nevi among patients with CSCR is higher than in age- and sex-matched healthy population. Choroidal nevi may be associated with chronic CSCR.

Native tissue repair of cardinal/uterosacral ligaments cures overactive bladder and prolapse, but only in pre-menopausal women.

INTRODUCTION: The aim of this article was to study the effect of native tissue cardinal/uterosacral ligament repair on overactive bladder (OAB) and pelvic organ prolapse (POP). MATERIAL AND METHODS: Inclusion criteria included decrease of urge symptoms following insertion of a gauze tampon in the posterior fornix of vagina ('simulated operation'). Exclusion criteria included SUI, POP grades 3-4. The surgery consisted of plication of cardinal/uterosacral ligaments. Post-operative assessment was performed at3, 6, 12 and 18 months after surgery and included evaluation by stage of prolapse, Urinary Distress Inventory Short Form 6 (UDI-6), Overactive Bladder Questionnaire (OAB-q), Pelvic Floor Impact Questionnaire- Short Form 7 (PFIQ-7), and International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (ICIQ-SF) questionnaires and voiding diary. RESULTS: At 3 months, cure rates for frequency, urgency, nocturia and prolapse were comparable. By the 6-month review, catastrophic failure commenced in the postmenopausal group, parallel for all pa-rameters, starkly contrasting with premenopausal group. At 18 months, % cure rates for pre-menopausal (post-menopausal in brackets) were 79.6 (15.4) for POP, 67.3 (20.5) for urgency, 87.7 (20.5) for nocturia and 59.2 (15.4) for frequency. CONCLUSIONS: We hypothesize the stepwise parallel recurrence of POP and symptoms in the menopausal group was a consequence of collagen deficiency in the plicated ligaments. Nevertheless, plication of uterosacral-cardinal ligament complex is simple, inexpensive, effective, especially applicable pre-menopausally for POP and as an alternative treatment option in that difficult group of pre-menopausal women who have major OAB/nocturia symptoms but only minimal prolapse.

The resurrection of sacrospinous fixation: unilateral apical sling hysteropexy.

INTRODUCTION AND HYPOTHESIS: The apical compartment is a keystone in POP treatment. Sacrospinous fixation, suggested half a century ago, today is still one of the most popular and efficient methods of colpo-hysteropexy. However, it has specific side effects: chronic pain syndrome, dyspareunia and а high rate of cystocele de novo. We aimed to evaluate the efficacy and safety of unilateral sacrospinous hysteropexy with a synthetic apical sling combined with anterior subfascial colporrhaphy. METHODS: Following the suggested technique, 174 women with anterior-apical prolapse underwent surgery. The follow-up period took 12 months. Pre- and postoperative examination included: urogynecological examination (POP-Q), uroflowmetry, ultrasound of the bladder and filling in of validated questionnaires (PFDI-20, PISQ-12). RESULTS: The mean surgery time was 26 ± 7.84 min. No cases of damage of the bladder or rectum or of intraoperative clinically significant bleeding were noted. At the 12-month follow-up, the recurrence rate in the apical compartment was 0.7% (1/147) and in the anterior compartment 7.4% (11/147). The efficacy of the surgery reached 96.5%. During 12 months of follow-up, no cases of mesh exposure or chronic pelvic pain syndrome were detected. The incidence of dyspareunia de novo was observed in just one patient. CONCLUSIONS: A unilateral sacrospinous fixation with a synthetic mesh (apical sling) combined with anterior subfascial colporrhaphy enhances the anatomical efficacy of surgery. It also helps to avoid specific side effects of traditional sacrospinous fixation.

Adjustable transobturator sling for the treatment of primary stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: The purpose of the study was to evaluate the rate of postoperative voiding dysfunction after the insertion of an adjustable transobturator sling for the treatment of primary stress urinary incontinence (SUI). The secondary aim was to assess the objective and subjective cure rates and the impact of the surgery on quality of life. METHODS: This prospective study included 171 patients with primary SUI who underwent insertion of an adjustable transobturator tape. A postoperative tension adjustment algorithm that included a cough stress test (CST), uroflowmetry and postvoid residual volume (PVR) measurement was applied in all patients the day after surgery. The baseline and control postoperative evaluations included vaginal examination, CST, Q-tip test, uroflowmetry and PVR measurement, 1-h pad test and administration questionnaires (UDI-6, IIQ-7, PISQ-12, ICIQ-SF). RESULTS: The day after surgery 65 patients (38.0%) required tape tension adjustment: an increase in tension in 53 patients (31.0%) and a decrease in 12 (7.0%). Continence was achieved in all patients. No patients showed voiding dysfunction after adjustment. Follow-up data for 12 months were available in 157 patients (91.8%). The objective and subjective cure rates were 96.2% and 97.5%, respectively. There was no statistically significant decrease in Qmax (p = 0.899) or increase in PVR (p = 0.187). According to the questionnaires scores, quality of life was improved in all patients. CONCLUSION: The adjustable transobturator sling minimizes the risk of postoperative voiding dysfunction and allows high objective and subjective cure rates to be achieved in patients with primary SUI. The technique also improves the patient's quality of life.

The novel technique of post-hysterectomy vaginal vault prolapse repair: Apical sling and "neocervix" formation.

OBJECTIVE: We primarily aimed to evaluate the effectiveness of the novel technique: bilateral sacrospinous fixation by monofilament polypropylene apical sling combined with "neocervix" formation in surgical treatment of post - hysterectomy vaginal vault prolapse. The secondary objective was to estimate the impact of the surgery on voiding function and quality of life. STUDY DESIGN: This prospective study involved 61 women suffering from post-hysterectomy prolapse. We used the following criteria to evaluate the results of surgical treatment: results of vaginal examination (POP-Q system), uroflowmetry, bladder ultrasound, validated questionnaires were used. All listed parameters were determined before the surgery and at control examinations in 1, 6, 12 months after the treatment. RESULTS: Mean operation time was 35min. No cases of intraoperative damage to the bladder/rectum, as well as clinically significant bleeding were noted.At 12-month follow-up anatomical cure rate (≤stage I, POP-Q) was 100%, 94,4% and 100% for vaginal apex, anterior and posterior vaginal walls, respectively. The following long-term complications were noted stress urinary incontinence de novo and urgency de novo were noted in 6.5% and 4,9%, respectively. Statistically significant (P<0.05) improvement in peak flow rate was observed according to uroflowmetry. Comparison of the scores by the questionnaires revealed a significant improvement in the quality of life in the postoperative period. CONCLUSION: The novel technique: combination of the apical sling and purse-string "neocervix" formation appears to be effective and safe method for treatment patients with vaginal vault prolapse. The technique improves voiding function and quality of life.

The hybrid technique of pelvic organ prolapse treatment: apical sling and subfascial colporrhaphy.

INTRODUCTION AND HYPOTHESIS: The majority of patients with cystocele undergoing reconstructive surgery have combined defects of pubocervical fascia and uterosacral/cardinal ligament complex. In this regard, the simultaneous correction of both defects is rational. Furthermore, decreasing the use of synthetic materials in pelvic floor surgery is an important goal. The aim was to evaluate the objective and subjective cure rate of a hybrid technique: bilateral sacrospinous fixation using modern monofilament synthetic tape (apical sling) combined with the original technique of subfascial colporrhaphy. MATERIALS AND METHODS: This prospective study involved 148 women suffering from cystocele combined with apical prolapse. We used the following criteria to evaluate the results of surgical treatment: results of the vaginal examination (POP-Q system), urodynamic tests, bladder ultrasound, special questionnaires (Pelvic Floor Distress Inventory [PFDI-20], Pelvic Floor Impact Questionnaire [PFIQ-7], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire [PISQ-12], International Consultation on Incontinence Modular Questionnaire Short Form [ICIQ-SF]). All listed parameters were determined before the surgery and at control examinations at 1, 6, and 12 months after the treatment. RESULTS: At the 1-year follow-up, the objective cure rate for prolapse was 97.8%. The rate of anatomical recurrence was 2.2% (3 out of 138). The following long-term complications were noted: de novo urgency and stress urinary incontinence de novo in 2 (1.4%) and 4 (2.9%) patients, respectively. Comparison of the scores by the questionnaires also revealed a significant improvement in the quality of life in the postoperative period. Patient satisfaction rate was 97.1%. CONCLUSION: The hybrid technique is an effective and safe uterus-sparing method for patients with advanced forms of cystocele combined with apical prolapse. This technique improves voiding function, quality of life, and provides a high satisfaction rate.