Development of a Consensus-Derived Synoptic Operative Report for Rectal Prolapse: A Report From the Pelvic Floor Disorders Consortium.

BACKGROUND: Narrative operative reports may omit or obscure data from an operation. OBJECTIVE: To develop a synoptic operative report for rectal prolapse that includes core descriptors as developed by an international consensus of expert pelvic floor surgeons. DESIGN: Descriptors for patients undergoing rectal prolapse surgery were generated through review. Members of the Pelvic Floor Disorders Consortium were recruited to participate in a 3-round Delphi process using a 9-point Likert scale. Descriptors that achieved 70% agreement were kept from the first round, and descriptors scoring 40% to 70% agreement were recirculated in subsequent rounds. A final list of operative descriptors was determined at a consensus meeting, with a final consensus meeting more than 70% agreement. SETTINGS: This survey was administered to members of the Pelvic Floor Disorders Consortium. PATIENTS: No patient data are included in this study. MAIN OUTCOME MEASURES: Descriptors meeting greater than 70% agreement were selected. RESULTS: One hundred seventy-six surgeons representing colorectal surgeons, urogynecologists, and urologists distributed throughout North America (56%), Latin America (4%), Western Europe (29%), Asia (4%), and Africa (1%) participated in the first round of Delphi voting. After 2 additional rounds and a final consensus meeting, 16 of 30 descriptors met 70% consensus. Descriptors that met consensus were surgery type, posterior dissection, ventral dissection, mesh used, type of mesh used, mesh location, sutures used, suture type, pouch of Douglas and peritoneum reclosed, length of rectum imbricated, length of bowel resected, levatoroplasty, simultaneous vaginal procedure, simultaneous gynecologic procedure, simultaneous enterocele repair, and simultaneous urinary incontinence procedure. LIMITATIONS: The survey represents the views of members of the Delphi panel and may not represent the viewpoints of all surgeons. CONCLUSIONS: This Delphi survey establishes international consensus descriptors for intraoperative variables that have been used to produce a synoptic operative report. This will help establish defined operative reporting to improve clinical communication, quality measures, and clinical research. See Video Abstract . DESARROLLO DE UN PROTOCOLO OPERATORIO SINPTICO DERIVADO DE CONSENSO PARA EL PROLAPSO RECTAL UN INFORME DEL CONSORCIO DE TRASTORNOS DEL PISO PLVICO: ANTECEDENTES:Los protocolos operativos narrativos frecuentemente pueden omitir u oscurecer datos de un procedimiento.OBJETIVO:Nuestro objetivo es desarrollar un protocolo operatorio sinóptico para el prolapso rectal que incluya descriptores básicos desarrollados por un consenso internacional de cirujanos expertos en piso pélvico.DISEÑO:Los descriptores para pacientes sometidos a cirugía de prolapso rectal se generaron mediante revisión. Se reclutó a miembros del Consorcio de Trastornos del Piso Pélvico para participar en un proceso Delphi de 3 rondas utilizando una escala Likert de 9 puntos. Los descriptores que lograron un 70% de acuerdo se mantuvieron en la primera ronda, los descriptores que obtuvieron un 40-70% de acuerdo se recircularon en rondas posteriores. Se determinó una lista final de descriptores operativos en una reunión de consenso, con una reunión de consenso final de más del 70% de acuerdo.ESCENARIO:Esta fue una encuesta administrada a miembros del Consorcio de Trastornos del Piso Pélvico.PRINCIPALES MEDIDAS DE RESULTADO:Se seleccionaron los descriptores que cumplieron más del 70% de acuerdo.RESULTADOS:Ciento setenta y seis cirujanos en representación de cirujanos colorrectales, uroginecólogos y urólogos distribuidos en América del Norte (56%), América Latina (4%), Europa Occidental (29%), Asia (4%) y África (1%) participaron en la primera ronda de votación Delphi. Después de dos rondas adicionales y una reunión de consenso final, 16 de 30 descriptores alcanzaron un 70% de consenso. Los descriptores que alcanzaron consenso fueron: tipo de cirugía, disección posterior, disección ventral, malla utilizada, tipo de malla utilizada, ubicación de la malla, suturas utilizadas, tipo de sutura, cierre del fondo de saco de Douglas y peritoneo, longitud del recto superpuesto, longitud del intestino resecado, plastía de los elevadores , procedimiento vaginal simultáneo, procedimiento ginecológico simultáneo, reparación simultánea de enterocele y procedimiento simultáneo de incontinencia urinaria.LIMITACIONES:La encuesta representa las opiniones de los miembros del panel Delphi y puede no representar los puntos de vista de todos los cirujanos.CONCLUSIONES/DISCUSIÓN:Esta encuesta Delphi establece descriptores de consenso internacional para las variables intraoperatorias que se han utilizado para producir un protocolo operatorio sinóptico. Esto ayudará a establecer protocolos operativos definidos para mejorar la comunicación clínica, las medidas de calidad y la investigación clínica. (Traducción-Dr. Felipe Bellolio ).

The effects of vaginal surgery and pelvic floor disorders on female sexual function.

BACKGROUND: The effects of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) on sexual activity and female sexual dysfunction (FSD) remain unknown. How female sexual function is affected by surgery to treat SUI and/or POP remains controversial. AIM: The objectives of this study were to identify the prevalence of FSD and potential risk factors in women with POP and/or SUI and to assess whether pelvic floor surgery leads to alterations in female sexual function. METHODS: This investigation was prospective and observational. Informed consent was obtained from women who were scheduled to undergo pelvic floor surgery to manage POP and/or SUI at Peking University People's Hospital, which is an urban medical center. Sexual function was assessed by an investigator preoperatively and 12 months postoperatively. OUTCOMES: Sexual activity and sexual function before and after surgery were investigated with potential risk factors. Sexual function was measured by 2 validated questionnaires: the Female Sexual Function Index and the PISQ-12 (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Short Form). RESULTS: A total of 233 women were recruited, and all were ethnically Chinese. The average age was 63 years (range, 31-83), and 47.2% were sexually active. The lack of sexual activity before surgery was associated with increasing age (mean ± SD, 56.3 ± 9.5 vs 68.4 ± 8.1 years; P < .001) and postmenopausal status (70.0% vs 97.6%, P < .001). Among the sexually active women, 62.7% were diagnosed with FSD. Increasing age (58.6 ± 9.6 vs 52.3 ± 7.8 years, P < .001) and postmenopausal status (82.6% vs 48.8%, P < .001) were associated with the presence of FSD. Overall there was no significant difference between the PISQ-12 score before and 12 months after surgery (34.7 ± 6.7 vs 33.9 ± 6.6, P = .14). Lubrication of the vagina (P = .044) was an independent factor associated with the improvement in quality of sexual life after surgery. Menopause negatively affected the improvement in quality of sexual life after surgery (P = .024). CLINICAL IMPLICATIONS: Menopause and lubrication of the vagina might affect the improvement in sexual function after surgery. STRENGTHS AND LIMITATIONS: Strengths include the prospective design, validated questionnaires, and adequate follow-up time. As a limitation, this study is a single-center study that included only Chinese patients with advanced POP/SUI, so it may not be generalizable to other populations. CONCLUSION: Nearly half of women with symptomatic POP and/or SUI are still sexually active. Increasing age and menopause are associated with a lack of sexual activity. Premenopausal status and better lubrication of the vagina before surgery might lead to an improvement in sexual function after pelvic floor surgery.

Total pelvic floor ultrasound can reliably predict long-term treatment outcomes for patients with pelvic floor defaecatory dysfunction.

AIM: Integrated total pelvic floor ultrasound (TPFUS) may provide an alternative to defaecation proctography (DP) in decision making and treatment planning for patients with pelvic floor defaecatory dysfunction (PFDD). This study evaluates the use of TPUS as a screening tool, and its likelihood to predict long-term treatment outcomes. METHODS: Two blinded clinicians reviewed 100 women who had historically presented to a tertiary referral colorectal unit with PFDD from October 2014 to April 2015. The clinical history of the patients together with TPFUS or DP results were used to decide on main impression, treatment plan, likelihood of surgery and certainty of plan. These were compared to the actual treatment received six months later and again after a median follow-up of 68 months (range 48-84). RESULTS: A total of 82 patients were treated with biofeedback only and 18 also underwent surgery. There were no complications in any of the patients who had surgery. When compared with the actual treatment received, 99 of the 100 of the TPFUS group would have been treated appropriately. The number of false positives for surgical treatment was lower with TPFUS compared to DP. Clinician confidence in the overall decision was significantly higher after review with DP. CONCLUSIONS: TPFUS is a reliable assessment tool for PFDD. It can identify patients who can go straight to biofeedback and is just as good as DP at predicting likelihood of surgery. We might be able to rely on TPFUS more significantly in the future, even for surgical planning.

Is robotic ventral mesh rectopexy for pelvic floor disorders better than laparoscopic approach at the beginning of the experience? A retrospective single-center study.

PURPOSE: To compare perioperative results of laparoscopic and robotic ventral mesh rectopexy for pelvic floor disorders at the beginning of the surgical experience. METHODS: Between 2017 and 2022, the first 30 laparoscopic ventral mesh rectopexies and the first 30 robotic ventral mesh rectopexies at the beginning of the experience of 2 surgeons were retrospectively analyzed. Perioperative (demographic characteristics, surgical indication, conversion rate, operative time), and postoperative (complications, length of stay, unplanned reintervention) data were compared between groups. RESULTS: Demographic characteristics were similar between groups. Conversion rate was lower (0 vs 17%, p = 0.05), but the operative time was significantly longer (182 [146-290] vs 150 [75-240] minutes, p < 0.0001) during robotic procedure when compared with laparoscopic approach. In terms of learning curve, the number of procedures to obtain the same operative time between the 2 approaches was 15. Postoperative results were similar between groups, in terms of pain (visual analogic scale = 2 [0-8] vs 4 [0-9], p = 0.07), morbidity (17 vs 3%, p = 0.2), and unplanned reintervention (1 vs 0%, p = 0.99). Mean length of stay was significantly reduced after robotic approach when compared with laparoscopic approach (3 [2-10] vs 5 [2-11] days, p < 0.01). Functional results were better after robotic than laparoscopic ventral mesh rectopexy, with higher satisfaction rate (93 vs 75%, p = 0.05), and reduced recurrence rate (0 vs 14%, p = 0.048). CONCLUSION: Despite longer operative time at the beginning of the learning curve, robotic ventral mesh rectopexy was associated with similar or better perioperative results than laparoscopic ventral mesh rectopexy.

Establishing urogynecology subspecialty in Armenia: The Armenia project.

It is well known that there are many countries in the world where Urogynecology is not an existing subspecialty, and women are not receiving appropriate care for their pelvic floor disorders (PFD). One of these countries is the Republic of Armenia. Given the lack of expertise in the field of Urogynecology in Armenia, we conducted a study on the prevalence of PFDs and the degree of bother among women of all ages across the country, which was published in 2020. This led to the creation of the International Urogynecology Association for Armenia, comprising seven physicians from different countries: five from the USA, one urogynecologist from Lebanon, and one urologist from Russia. We implemented hybrid teaching based on Zoom lectures, case presentations, journal clubs, and live visits of mentors to Armenia on a regular basis to see patients and operate with our five fellows. We introduced our fellows to research and statistics by assigning research topics for different projects. Our fellows presented evidence-based presentations and extensive literature reviews on a regular basis. Our program will continue to grow the next 2-3 years. The success of this project holds significance for governmental, public, and healthcare entities in Armenia and across the world, where this subspecialty is non-existent, in preparing future female pelvic surgeons to care for the growing needs of women with these conditions. Replicating this program in other parts of the world will compound the benefits and successes of Urogynecology care across different societies, cultures, and people around the globe.

A pilot study to evaluate changes in pelvic floor muscle tone following pelvic organ prolapse surgery using a novel intra-vaginal pressure sensor device.

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle weakness is a common cause of pelvic organ prolapse and urinary incontinence. Surgical repair of prolapse is commonly undertaken; however, the impact on pelvic floor muscle tone is unknown. The aim of this study was to compare the effect of anterior and posterior colporrhaphy on pelvic floor activation. METHODS: Patients aged under 70 undergoing primary anterior or posterior colporrhaphy were recruited. Intra-vaginal pressure was measured at rest and during pelvic floor contraction using the Femfit® device (an intra-vaginal pressure sensor device [IVPSD]). Peak pressure and mean pressure over 3 s were measured in millimetres of mercury. The pre- and post-operative measurements were compared. The difference between the means was assessed using Cohen's D test, with significance set at p<0.05 RESULTS: A total of 37 patients completed pre- and post-operative analysis, 25 in the anterior colporrhaphy group and 12 in the posterior colporrhaphy group. Anterior colporrhaphy showed no significant change in pelvic floor tone. Change in peak pressure was -1.71mmHg (-5.75 to 2.33; p=0.16) and change in mean pressure was -0.86 mmHg (-4.38 to 2.66; p=0.31). Posterior colporrhaphy showed a significant increase in peak pelvic floor muscle tone of 7.2 mmHg (0.82 to 13.58; p=0.005) and mean pressure of 4.19 mmHg (-0.09 to 8.47; p=0.016). CONCLUSIONS: Posterior colporrhaphy significantly improves pelvic floor muscle tone, whereas anterior colporrhaphy does not. Improved understanding of the impact of pelvic floor surgery may guide future management options for other pelvic floor disorders. Further work is needed to confirm the association of this improvement in pelvic floor disorders.

Validation of the Surgical Preparedness Assessment in women with pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: We sought to further develop and validate the Surgical Preparedness Assessment (SPA) scale to evaluate patient preparedness for urogynecological surgery. METHODS: This was a planned ancillary analysis of a randomized controlled trial (RCT) evaluating the impact of a preoperative telehealth call on patient preparedness for urogynecological surgery. Patients completed the Preoperative Preparedness Questionnaire (PPQ), the modified Preparedness for Colorectal Cancer Surgery Questionnaire (PCSQ), the Pelvic Floor Distress Inventory (PFDI-20), the Satisfaction Decision Scale (SDS), and the Decision Regret Scale (DRS). Content validity was established through expert opinion and patient cognitive interviews. Factor analysis identified item grouping into domains. Cronbach's alpha reported internal consistency. Known group validity was assessed by comparing intervention arms. External validity was evaluated by comparing intervention arms and correlations with SDS and DRS. RESULTS: Eleven items and 3 domains met the criteria (information needs, satisfaction and pain, and catheterization). Cronbach's alpha values were acceptable for domains and ranged from 0.74 to 0.93. SPA scores did not correlate with other patient-reported outcomes. Mean SPA scores were lower among women who received a telehealth call vs those who did not (1.30 ± 0.31 vs 1.51 ± 0.44; p = 0.002). CONCLUSIONS: The content-valid SPA demonstrates high internal consistency and known group validity.

Opioid use following pelvic reconstructive surgery: a predictive calculator.

INTRODUCTION AND HYPOTHESIS: Our objective was to evaluate the amount of opioids used by patients undergoing surgery for pelvic floor disorders and identify risk factors for opioid consumption greater than the median. METHODS: This was a prospective cohort study of 18- to 89-year-old women undergoing major urogynecological surgery between 1 November2020 and 15 October 2021. Subjects completed one preoperative questionnaire ("questionnaire 1") that surveyed factors expected to influence postoperative pain and opioid use. At approximately 1 and 2 weeks following surgery, patients completed two additional questionnaires ("questionnaire 2" and "questionnaire 3") about their pain scores and opioid use. Risk factors for opioid use greater than the median were assessed. Finally, a calculator was created to predict the amount of opioid used at 1 week following surgery. RESULTS: One hundred and ninety patients were included. The median amount of milligram morphine equivalents prescribed was 100 (IQR 100-120), whereas the median amount used by questionnaire 2 was 15 (IQR 0-50) and by questionnaire 3 was 20 (IQR 0-75). On multivariate logistic regression, longer operative time (aOR 1.64 per hour of operative time, 95% CI 1.07-2.58) was associated with using greater than the median opioid consumption at the time of questionnaire 2; whereas for questionnaire 3, a diagnosis of fibromyalgia (aOR=16.9, 95% CI 2.24-362.9) was associated. A preliminary calculator was created using the information collected through questionnaires and chart review. CONCLUSIONS: Patients undergoing surgery for pelvic floor disorders use far fewer opioids than they are prescribed.

Does Concomitant Pelvic Organ Prolapse Repair at the Time of Rectopexy Impact Rectal Prolapse Recurrence Rates? A Retrospective Review of the Prospectively Collected Pelvic Floor Disorders Consortium Quality Improvement Database Pilot.

BACKGROUND: Pelvic organ prolapse is reported in 30% of women presenting with rectal prolapse. Combined repair is a viable option to avoid the need for future pelvic floor interventions. However, the added impact of adding a modicum of middle compartment suspension by closing the pouch of Douglas during a rectal prolapse repair has not been studied. OBJECTIVE: The study aimed to assess the impact of middle compartment suspension on the durability of rectal prolapse repair. We also aimed to determine whether adding some form of pouch of Douglas closure to achieve middle compartment suspension leads to any improvements in the rates or severity of postoperative constipation or in the rates or severity of postoperative fecal incontinence. DESIGN: This study was a retrospective analysis of a multicenter prospective database. SETTING: Data were analyzed from the Pelvic Floor Disorders Consortium Quality Improvement in Rectal Prolapse Surgery database. Deidentified surgeons at more than 20 sites (75% academic, 81% high volume) self-reported patient demographics, previous repairs, symptoms of fecal incontinence and obstructed defecation, and operative details, including addition of concomitant gynecologic repairs, use of mesh, posterior or ventral dissection, and sigmoidectomy. PATIENTS: Patients were included who underwent abdominal repair for rectal prolapse. INTERVENTIONS: Abdominal rectopexy procedures with and without middle compartment suspension were compared. Middle compartment suspension was defined as excision and closure of the pouch of Douglas with some degree of colpopexy or culdoplasty. MAIN OUTCOME MEASURES: The primary outcome of prolapse recurrence and secondary outcomes of incontinence and constipation were calculated via univariate and multivariable regression by comparing those who underwent rectopexy with and without middle compartment suspension. RESULTS: Of the 198 patients (98% female, age 60.2 ± 15.6 years) who underwent abdominal repairs (59% robotic), 138 patients (70%) underwent some concomitant middle compartment suspension. Patients who had an added middle compartment suspension seemed to have lower early rectal prolapse recurrences. On multivariable regression to control for age, previous repairs, and the use of mesh, addition of some form of pouch of Douglas repair was associated with a decrease in short-term recurrences. LIMITATIONS: Our data need to be interpreted cautiously. Future studies are critically needed to further explore this observation, with an a priori, prospective definition of middle compartment suspension, validated measurement of concomitant pathology, and longer follow-up. CONCLUSION: Our results suggest that some middle compartment suspension at the time of rectal prolapse repair may improve short-term durability of rectal prolapse repair. See Video Abstract at http://links.lww.com/DCR/C30 . LA REPARACIN CONCOMITANTE DEL PROLAPSO DE RGANOS PLVICOS EN EL MOMENTO DE LA RECTOPEXIA AFECTA LAS TASAS DE RECURRENCIA DEL PROLAPSO RECTAL UNA REVISIN RETROSPECTIVA DE UNA BASE DE DATOS RECOPILADA PROSPECTIVAMENTE DEL CONSORCIO SOBRE LA MEJORA DE LA CALIDAD DE TRASTORNOS DEL PISO PLVICO: ANTECEDENTES:El prolapso de órganos pélvicos se informa en el 30 % de las mujeres que presentan prolapso rectal y la reparación combinada es una opción viable para evitar la necesidad de futuras intervenciones del suelo pélvico. Sin embargo, no se ha estudiado el impacto adicional de agregar un mínimo de suspensión del compartimento medio cerrando el fonde de saco de Douglas durante una reparación de prolapso rectal.OBJETIVO:Nuestro objetivo fue evaluar el impacto de la suspensión del compartimento medio con respecto a la durabilidad de la reparación del prolapso rectal. Quisimos de igual manera determinar si el agregado de algún tipo de cierre del fondo de saco de Douglas para lograr la suspensión del compartimento medio conduce a alguna mejora en las tasas o la gravedad del estreñimiento posoperatorio así como en las tasas o la gravedad de la incontinencia fecal posoperatoria.DISEÑO:Análisis retrospectivo de una base de datos prospectiva.ESCENARIO:Base de datos Multicenter Pelvic Floor Disorders Consortium Prospective Quality Improvement. Cirujanos no identificados en >20 sitios (75% académicos, 81% de alto volumen) datos demográficos de pacientes auto informados, reparaciones previas, síntomas de incontinencia fecal y defecación obstruida, y detalles quirúrgicos, incluida la suma de reparaciones ginecológicas concomitantes, uso de malla, disección anterior o posterior y sigmoidectomía.INTERVENCIONES:Se compararon los procedimientos de rectopexia abdominal con y sin suspensión del compartimento medio). La suspensión del compartimento medio se definió como la escisión y cierre del fondo de saco de Douglas con algún grado de colpopexia o culdoplastia.RESULTADOS:El resultado principal de la recurrencia del prolapso y los resultados secundarios de incontinencia y estreñimiento se calcularon mediante regresión uni y multivariable al comparar los que fueron sometidos a rectopexia con y sin suspensión del compartimento medio.PACIENTES:Pacientes sometidos a reparación abdominal por prolapso rectal.RESULTADOS:De los 198 pacientes (98% mujeres, edad 60,2 ± 15,6 años) sometidas a reparaciones abdominales (59% robótica), 138 (70%) fueron sometidas igualmente y de manera concomitante a alguna suspensión del compartimento medio. Los pacientes a los que se les añadió una suspensión del compartimento medio parecían tener menores recurrencias tempranas del prolapso rectal y, en la regresión multivariable para controlar la edad, las reparaciones previas y el uso de malla, la adición de alguna forma de reparación del fondo de saco de Douglas se asoció con una disminución de las recurrencias a corto plazo.LIMITACIONES:Nuestros datos deben interpretarse con cautela. Se necesitan de manera critica, estudios futuros para explorar más a fondo esta observación, con una definición prospectiva a priori de la suspensión del compartimento medio, una medición validada de la patología concomitante y un seguimiento más prolongado.CONCLUSIONES:Nuestros resultados sugieren que alguna suspensión del compartimento medio en el momento de la reparación del prolapso rectal puede mejorar la durabilidad a corto plazo de la reparación del prolapso rectal. Consulte Video Resumen en http://links.lww.com/DCR/C30 . (Traducción-Dr. Osvaldo Gauto ).

Prevalence of pelvic floor disorders, associations of endocrine therapy, and surgical intervention among breast cancer survivors.

INTRODUCTION AND HYPOTHESIS: To evaluate prevalence of pelvic floor disorders, association of endocrine therapy with pelvic floor disorders, and rates of pelvic floor surgery among breast cancer survivors compared to matched controls without history of cancer. METHODS: This is a retrospective, cohort study using electronic medical record data from a ten-hospital regional healthcare system. A total of 19,483 women diagnosed with breast cancer between January 2008 and April 2020 were propensity score matched to 19,483 women without a history of cancer. Medical charts were abstracted for ICD-9 and ICD-10 codes for pelvic floor disorders, use of endocrine therapy, and CPT codes for pelvic floor surgeries and procedures. RESULTS: Overall, the prevalence of pelvic floor disorders was lower among breast cancer survivors (8.8% vs. 22.6%, p < 0.001), and mean time to development of pelvic floor disorders among breast cancer survivors was 3 years. Selective estrogen receptor modulators and aromatase inhibitors were associated with pelvic organ prolapse and stress urinary incontinence, while estrogen antagonists were associated with urge urinary incontinence and lower urinary tract symptoms. Women with breast cancer had similar or higher rates of pelvic floor surgery compared to matched controls. CONCLUSIONS: Rates of pelvic floor disorders were lower among breast cancer survivors compared to controls but rates of surgical intervention did not differ and were higher for some conditions among breast cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS: Screening for these disorders should be considered as part of routine survivorship care.

Effects of Non-Invasive Radiofrequency Diathermy in Pelvic Floor Disorders: A Systematic Review.

Background and Objectives: In recent years, the use of radiofrequency diathermy in pelvic floor disorders has grown proportionally to the interest in this specialty. Despite the common use of this therapy among pelvic floor physiotherapists, little is known about its effects and effectiveness in pelvic floor disorders. For this reason, the aim of the present review is to assess the effects of non-invasive 300 kHz-1 MHz radiofrequency diathermy in the treatment of pelvic floor disorders. Materials and Methods: A literature search was performed in PubMed, Scopus and Web of Science, searching for any type of study that included pelvic floor disorder participants and an experimental group treated with non-invasive nor ablative radiofrequency diathermy. Results: There were a total of 578 studies after removing duplicates. The inclusion and exclusion criteria were applied, resulting in a total of 15 studies, which were methodologically assessed with PEDro and the Newcastle and Ottawa scale. Conclusions: Despite the low quality of most of them, the studies showed improvements in urinary incontinence, pelvic pain conditions, pelvic floor muscles strength and sexual function. These findings must be considered with caution until more randomized clinical trials are performed to solve the biases detected.

Association between 3D endovaginal and 2D perineal pelvic floor ultrasound findings and symptoms in women presenting with mid-urethral sling complications.

OBJECTIVES: To present the characteristics of women attending a tertiary urogynecology pelvic floor scan clinic with mid-urethral sling (MUS) complications and examine the association between patient symptoms and findings on two-dimensional (2D) perineal and three-dimensional (3D) endovaginal ultrasound. METHODS: This was a cross-sectional study of all women with MUS complications referred to a specialist pelvic floor ultrasound clinic between October 2016 and October 2018. Detailed history was obtained regarding their symptoms and time of onset. All patients underwent 2D perineal and 3D endovaginal ultrasound assessment. The association between patient symptoms and ultrasound findings was evaluated using logistic regression analysis. Only symptomatic women with a single MUS, without other pelvic floor mesh, prior mesh excision or bulking agents, were included in the regression analysis. RESULTS: A total of 311 women with a history of MUS surgery were seen during the study period. Vaginal and/or non-vaginal pain was reported by 80% of patients and this was the primary presenting complaint in 59% of the patients. One-third of the patients reported symptoms starting within 4 weeks after surgery. The data of 172 patients were included in the regression analysis. MUS position within the rhabdosphincter was significantly associated with voiding dysfunction (odds ratio (OR), 10.6 (95% CI, 2.2-50.9); P = 0.003). Voiding dysfunction was highest in those with C-shaped MUS both at rest and on Valsalva maneuver (OR, 3.2 (95% CI, 1.3-7.6); P < 0.001). MUS position in the distal third of the urethra was significantly associated with a higher rate of recurrent urinary tract infection (OR, 2.9 (95% CI, 1.3-6.3); P = 0.01). CONCLUSIONS: Pelvic floor ultrasound can provide insight into the position and shape of the MUS, which could explain some patient symptoms and guide management or surgical planning. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

[Influence of complex rehabilitation programs on the uterine blood flow in patients of different age after plastic surgery for rectocele]. / Vliyanie reabilitatsionnykh kompleksnykh programm na pokazateli matochnogo krovotoka po dannym 3D-ekhodopplerografii u patsientok raznykh vozrastnykh grupp posle plasticheskoi operatsii po povodu rektotsele.

OBJECTIVE: To develop the optimized complex programs, including general magnetotherapy, fractional microablative therapy with a CO2 laser, electromyostimulation with biofeedback of the pelvic floor muscles, and a special exercise therapy complex in late rehabilitation programs for women of different age after reconstructive plastic surgery for rectocele. MATERIAL AND METHODS: There were 200 women of childbearing, peri- and menopausal age with rectocele grade II-III and 20 healthy women of comparable age. All patients were divided into 4 groups by 50 womes: main group, two comparison groups and control group. Surgical treatment of rectocele was followed by long-term postoperative rehabilitation including symptomatic therapy, general magnetotherapy, and electromyostimulation with biofeedback of the pelvic floor muscles, intra-vaginal fractional microablative therapy with a CO2 laser and special complex of therapeutic physical education. RESULTS: General magnetotherapy in early (1 day) postoperative period and complex rehabilitation in long-term postoperative period (within a month after surgery) including 2 procedures of intra-vaginal microablative fractional therapy with carbon dioxide laser, electromyostimulation with biological connection of the pelvic floor muscles and special complex of therapeutic physical education ensured more significant improvement of uterine blood flow regardless age and baseline disorders in the uterine arteries in patients with rectocele. In our opinion, this is primarily due to vasoactive effects of general magnetotherapy, recovery of circulation via relief of spasm in the arteries and arterioles, improved vein contractility and venous outflow. These processes combined with electrical stimulation and therapeutic exercises of pelvic floor muscle followed by their reinforcement, as well as fractional microablative therapy ensured significant vascular effect.

A Rapid Method to Preoperatively Assess Frailty for Older Patients with Pelvic Floor Conditions.

PURPOSE: Assessment of frailty can help surgeons predict perioperative risk and guide preoperative counseling. However, current methods are often cumbersome in the clinical setting. We prospectively compared the effectiveness of a rapid picture based Clinical Frailty Scale (CFS-9) assessed by patient and surgeon against reference standard Fried Frailty Index in older patients with pelvic floor conditions. MATERIALS AND METHODS: We enrolled 71 patients between March 2018 and June 2019. Frailty assessment using CFS-9 (scale ranging from very fit to terminally ill) was performed followed by the Fried Frailty Index, a validated tool of 5 measures (shrinking, physical energy, activity, grip strength, walking speed). Correlations and agreement between Fried Frailty Index and CFS-9 scores from the treating surgeon, a second surgeon (surgeon 2) and patient were analyzed using sensitivity, specificity, area under the curve and Cohen's Kappa. RESULTS: The patient cohort was mostly female (97.2%), with a mean age (±SD) of 73.0 (±5.9) years and 23.9% were frail using the Fried Frailty Index. Compared to the Fried Frailty Index, CFS-9 scores of the treating surgeon, surgeon 2 and patient had AUC values (95% CI) of 0.86 (0.77-0.86), 0.91 (0.84-0.91) and 0.88 (0.79-0.88), respectively. As assessed by Cohen's Kappa the CFS-9 scores all had substantial (surgeon 2, Kappa 0.66, 95% CI 0.46-0.85 or moderate (all other CFS-9 measures, Kappa 0.44 to 0.58) agreement with the Fried Frailty Index scores. CONCLUSIONS: Rapid and effective validated tools to screen for frailty are needed in the clinical setting. CFS-9 is an excellent predictor of frailty compared to the Fried Frailty Index for patients with pelvic floor conditions.

Citation classics: the 100 most cited articles in Urogynecology.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to utilize objective citation analyses to describe the 100 most cited articles in the field of Female Pelvic Medicine & Reconstructive Surgery (FPMRS) and to review their characteristics. METHODS: We searched the Thomas Reuters Web of Science database for the most cited articles within all journals classified as Obstetrics and Gynecology (Ob/Gyn), Urology (Uro), Colorectal Surgery (CRS), and vital General Medicine (GM) journals (New England Journal of Medicine; Journal of the American Medical Association; Lancet; The BMJ). We reviewed search results for FPMRS content and compiled a list of the top 100 most cited articles relevant to FPMRS. RESULTS: We screened 34,934 articles yielded by the initial search and compiled the 100 most cited articles relevant to FPMRS. Of these 100 titles, 40% (42 out of 105) were published in Ob/Gyn, 46.7% (49 out of 105) in Uro, 1.9% (2 out of 105) in CRS, and 11.4% (12 out of 105) in GM journals. The most cited FPMRS article was "The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society" (3,810 total and 242 citations per year). Over half the articles were observational in nature and the majority (58%) of them were related to urinary incontinence in women. CONCLUSIONS: Highly cited FPMRS articles come from a variety of journals, and nearly 50% of the 100 most cited FPMRS articles are from the urology literature. The most cited articles were largely observational rather than interventional studies and mostly related to female urinary incontinence.

Patient attitudes toward pooled surgical waitlists in urogynecology.

INTRODUCTION AND HYPOTHESIS: Pooled surgical waitlists are used to maximize the use of surgical resources; however, patients' views of this strategy are poorly understood. We sought to evaluate patients' attitudes toward a pooled waitlist for urogynecology and pelvic reconstructive surgical procedures. METHODS: Patient and provider focus groups were used to inform the design of a survey that was distributed to patients at the time of consent for female pelvic reconstructive surgical procedures. All responses were collected anonymously. Patient attitudes toward surgical wait times and the potential for a pooled surgical waitlist were explored. Grouped responses by age, procedure type, and perceived disease severity were examined. RESULTS: One hundred seventy-six patients were surveyed. Thirty-four percent were amenable to the option of a pooled surgical waitlist; 86% agreed or strongly agreed that they preferred to have their surgery performed by their own care provider. Only 18% would agree to be on a pooled surgical waitlist if it shortened their wait time. Older women (≥ 65 years) were more likely to disagree or strongly disagree that they "would like the option of having surgery done by the next available skilled surgeon" (56.2% vs. 72.0%, p = 0.028). Self-perceived severe disease and mid-urethral sling surgery were not associated with a higher acceptance of pooled surgical waitlists. CONCLUSIONS: Acceptance of pooled surgical waitlists among urogynecology patients was overall low, irrespective of disease severity. Improving our understanding of urogynecology patients' concerns and potentially negative perceptions of surgical waitlists is needed to ensure patient comfort and satisfaction are not compromised if this strategy is adopted.

Capacity building in female pelvic medicine and reconstructive surgery: Global Health Partnership beyond fistula care in Ethiopia.

OBJECTIVE: Obstetric fistula is a devastating childbirth injury that leaves women incontinent, stigmatized and often isolated from their families and communities. In Ethiopia, although much attention has focused on treating and preventing obstetric fistula, other more prevalent childbirth-related pelvic floor disorders, such as pelvic organ prolapse, non-fistula-related incontinence and post-fistula residual incontinence, remain largely unattended. The lack of international and local attention to addressing devastating pelvic floor disorders is concerning for women in low- and middle-income countries. The objective of this article is to highlight the need for a more comprehsive approach to pelvic floor care and to share our experience in addressing it. METHODS: Here, we share our experience launching one of the first formal training programs in Female Pelvic Medicine and Reconstructive Surgery (FPMRS) in Ethiopia. RESULTS: This fellowship program provides quality care while strengthening the health system in its local context. This program has positioned Ethiopia to be a regional leader by providing comprehensive training of surgeons and allied health professionals, building appropriate health system and research infrastructure, and developing a formal FPMRS training curriculum. CONCLUSION: We hope that sharing this experience will serve as a template for others championing comprehensive pelvic floor care for women in low- and middle-income countries.

Laparoscopic Mesh Repair for Perineal Hernia after En Bloc Resection of an Aggressive Angiomyxoma Using a Modified Sacral Colpopexy Technique.

STUDY OBJECTIVE: To demonstrate laparoscopic mesh repair of perineal hernia (PH) by a modified sacral colpopexy technique. DESIGN: Step-by-step demonstration of the technique used for the surgical repair of PH after gynecologic surgery. SETTING: PH is defined as a pelvic floor defect through which the intra-abdominal viscera may protrude [1]. The reported incidence of PH ranges from 0.6% to 3%, and it generally occurs after rectal or prostate surgery [2]. Owing to its low incidence, there is no standard procedure to treat PH [3]. Herein, we demonstrate a successful case of PH treatment with a composite mesh (Dual Mesh; W. L. Gore & Associates, Newark, DE) after gynecologic surgery by a modified laparoscopic sacral colpopexy technique, which was approved by our institutional review board. INTERVENTIONS: The patient had undergone extralevator abdominoperineal excision for an aggressive angiomyxoma and developed a sigmoid colon-protrudent PH after the surgery [4]. The patient suffered from defecatory dysfunction and dysmenorrhea. A total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and mesh repair of the PH were performed at 2 years after the primary surgery, and they were successful without any intra- or postoperative complications. Because the pelvic floor defect was too large to secure the mesh by a simple placement, we applied the modified sacral colpopexy technique using 2-0 proline (ETHICON, Tokyo, Japan) to cover and support this defect. At 12 months after the second surgery, there was no sign of recurrence of PH and aggressive angiomyxoma, and the preoperative symptoms had diminished. CONCLUSION: Laparoscopic mesh repair by the modified sacral colpopexy technique is safe and effective to manage PH.

Frozen Pelvis Surgical Strategy in 10 Steps.

STUDY OBJECTIVE: To describe a 10-step strategy to treat severe endometriosis with a frozen pelvis by laparoscopy. DESIGN: Educational video. SETTING: University Hospital of Strasbourg, France. INTERVENTIONS: The patient was a 33-year-old nulliparous woman suffering from endometriosis. Because of pain and a desire for pregnancy, she was scheduled for surgery. After setting the patient in gynecologic position, we used a uterine manipulator to facilitate exposure. We assessed the global situation and discovered a frozen pelvis. To treat the myoma, the surgeon should use traction and countertraction as much as possible. We started with the caecum and sigmoid detachment. Then we performed a bilateral ureterolysis. Once the ureters were identified, we could perform safely the adhesiolysis of the bowel from the uterus. The adnexas could be freed and suspended with a T-Lift device to facilitate exposure. After identifying the utero sacral ligament, we opened the para rectal fossa, leading to the opening of the recto vaginal space. The anatomy was then restored, and we could define the specific surgical strategies. CONCLUSION: Frozen pelvis is a situation where anatomy is distorted. The surgeon should find anatomic landmarks to restore anatomy and to establish specific strategies adapted to the patient.

Gaining the patient perspective on pelvic floor disorders' surgical adverse events.

BACKGROUND: The Institute for Healthcare Improvement defines an adverse event as an unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization or that results in death. The majority of research has focused on adverse events from the provider's perspective. OBJECTIVE: The objective of this qualitative study was to describe patient perceptions on adverse events following surgery for pelvic floor disorders. STUDY DESIGN: Women representing the following 3 separate surgical populations participated in focus groups: (1) preoperative (women <12 weeks prior to surgery); (2) short-term postoperative (women up to 12 weeks after surgery); and (3) long-term postoperative (women 1-5 years after surgery). Deidentified transcripts of audio recordings were coded and analyzed with NVivo 10 software to identify themes, concepts, and adverse events. Women were asked to rank patient-identified and surgeon-identified adverse events in order of perceived severity. RESULTS: Eighty-one women participated in 12 focus groups. Group demographics were similar between groups, and all groups shared similar perspectives regarding surgical expectations. Women commonly reported an unclear understanding of their surgery and categorized adverse events such as incontinence, constipation, nocturia, and lack of improvement in sexual function as very severe, ranking these comparably with intensive care unit admissions or other major surgical complications. Women also expressed a sense of personal failure and shame if symptoms recurred. CONCLUSION: Women consider functional outcomes such as incontinence, sexual dysfunction, and recurrence of symptoms as severe adverse events and rate them as similar in severity to intensive care unit admissions and death.