Efficacy of surgical revision of mesh complications in prolapse and urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: Women with mesh-related complications in prolapse (POP) and stress-urinary incontinence (SUI) surgery may benefit from operative mesh resection to alleviate symptoms. We hypothesized that mesh resection would alleviate symptoms and aimed to evaluate risks and benefits in these women. METHODS: We carried out a cross-sectional study. Primary outcome was improvement specified as better, unchanged or worsened symptoms after mesh revision surgery. Secondary outcomes were health-related quality of life (HrQol) scores of validated questionnaires, surgical characteristics and physical findings at follow-up visits. Descriptive data were reported with mean and medians. Associations were calculated with Spearman correlation coefficient and chi-square test to determine statistical differences between groups. RESULTS: Fifty-nine women who underwent mesh revision surgery between 2009 and 2016 were included. After a median follow-up of 1.7 (IQR: 1.1-2.4) years, 44 women (75%) reported improvement of symptoms. No significant surgical or patient characteristics were identified that could differentiate which patients did or did not experience cure or complications.A trend was observed to better HrQol scores in women who reported overall improvement after mesh revision surgery. Seventeen (29%) women needed a subsequent operation after mesh removal. CONCLUSIONS: This cross-sectional study shows that mesh revision surgery alleviates symptoms in 75% of women with mesh-related complications. Type of revision surgery and individual characteristics did not seem to matter to the individual chance of cure or complications. These data can facilitate the counseling of women considering mesh revision surgery.

Effects of mesh-related complications in vaginal surgery on quality of life.

INTRODUCTION AND HYPOTHESIS: Vaginal mesh surgery is subject of debate due to the impact of mesh-related complications on patient's lives. Not all of these complications are symptomatic. Restoration of the anatomy and improvement of pelvic floor function as a result may counter the experienced discomfort related to adverse events. We hypothesized that health-related quality of life (HR-QoL) is comparable in women after vaginal mesh surgery regardless of the presence or absence of a mesh-specific complication. METHODS: This was a cross-sectional study of 128 women who had vaginal mesh surgery in a Dutch university hospital between 2007 and 2012. HR-QoL was measured in women with and without mesh complications using standardized QoL questionnaires Urogenital Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire (IIQ), Defecation Distress Inventory (DDI), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). Complications were scored according to the International Urogynecological Association (IUGA) complication classification. Comparisons between groups were performed with Student's t test and analysis of variance (ANOVA) test. RESULTS: In 29 (23%) women, a mesh-related complication occurred. The domain scores of the UDI-6, DDI, IIQ, and PISQ showed no statistically significant differences between women with and without a mesh-related complication. A post hoc analysis showed similar HR-QoL for those in whom the complication had been resolved and those with persistent symptoms of the complication. CONCLUSION: Mesh surgery imposes specific complications. When counseling patients about the potential adverse events related to vaginal mesh surgery, it is important to inform them that mesh-related complications do not negatively affect QoL related to micturition, defecation, and sexual functioning.

Urinary tract infections in women with urogynaecological symptoms.

PURPOSE OF REVIEW: Urinary tract infections are common in the field of urogynaecology. Women with persistent urinary symptoms seem more likely to have bacteriuria despite negative cultures. In this review, we will give an overview of the recent insights on the relationship between urinary tract infection and persistent urinary symptoms and possible new therapeutic options. RECENT FINDINGS: Recently published articles evaluated the prevalence of low-count bacteriuria (≥10 CFU/ml) or intracellular bacterial communities in women with overactive bladder symptoms (OAB). Differences in urinary microbioma observed in women with and without OAB symptoms were evaluated. In the light of these findings, current screening strategies were discussed and alternative screening methods for bacteriuria developed. SUMMARY: Low-count bacteriuria (≥10 CFU/ml) seems to be more prevalent in women with OAB. Also intracellular bacterial communities are more commonly detected in these women. The microbioma found in women with urinary symptoms appeared to differ from healthy controls. The current screening methods might be insufficient as they are targeted at detecting uropathogenic Escherichia coli, mostly using a detection threshold of at least 10 CFU/ml and failing to detect intracellular bacterial communities. Studies evaluating the efficacy of treating women with low-count bacteriuria are limited but promising.

Predictors of task-persistent and fear-avoiding behaviors in women with sexual pain disorders.

INTRODUCTION: Dyspareunia and vaginismus are the most common sexual pain disorders (SPDs). Literature suggests that many women with dyspareunia continue with intercourse despite pain (task persistence), whereas many women with vaginismus avoid penetrative activities that may cause pain (fear avoidance). Both forms of sexual pain behavior may maintain or aggravate complaints. AIM: This study examined (i) whether women with SPD differ from pain-free controls in motives for sexual intercourse, sexual autonomy, maladaptive beliefs regarding vaginal penetration, and partner responses to pain; and (ii) which of these factors best predict whether women with SPD stop or continue painful intercourse (attempts). METHODS: Women with superficial dyspareunia (n = 50), women with lifelong vaginismus (n = 20), and pain-free controls (n = 45) completed questionnaires. MAIN OUTCOME MEASURES: For Aim 1, the main outcome measures were (i) motives for intercourse; (ii) sexual autonomy; (iii) maladaptive beliefs regarding vaginal penetration; and (iv) partner responses to pain. For Aim 2, sexual pain behavior (to continue or discontinue with painful intercourse) was the outcome measure. RESULTS: (i) Women with dyspareunia exhibited more mate guarding and duty/pressure motives for intercourse and were less sexually autonomous than controls. (ii) Symptomatic women had more maladaptive penetration-related beliefs than controls, with women with vaginismus reporting the strongest maladaptive beliefs. (iii) Partners of women with dyspareunia self-reported more negative responses to pain than those of women with vaginismus. (iv) The factors that best predicted sexual pain behavior were the partner responses to pain and the woman's maladaptive beliefs regarding vaginal penetration. CONCLUSIONS: Our findings reveal support for task persistence in women with dyspareunia and fear avoidance in women with lifelong vaginismus. As such, it is important to consider these distinct types of responding to sexual pain when treating SPD.

The effects of vaginal prolapse surgery using synthetic mesh on vaginal wall sensibility, vaginal vasocongestion, and sexual function: a prospective single-center study.

INTRODUCTION: Vaginal mesh surgery in patients with pelvic organ prolapse (POP) has been associated with sexual dysfunction. Implantation of synthetic mesh might damage vaginal innervation and vascularization, which could cause sexual dysfunction. AIM: We aim to evaluate the effects of vaginal mesh surgery on vaginal vasocongestion and vaginal wall sensibility in patients with recurrent POP. METHODS: A prospective study was performed among patients with previous native tissue repair, scheduled for vaginal mesh surgery. Measurements were performed before and 6 months after surgery, during nonerotic and erotic visual stimuli, using a validated vaginal combi-probe. MAIN OUTCOME MEASURES: The combi-probe involves vaginal photoplethysmography to assess Vaginal Pulse Amplitude (VPA) (representing vaginal vasocongestion) and four pulse-generating electrodes to measure vaginal wall sensibility (representing vaginal innervation). Sexual function was assessed using validated questionnaires (Female Sexual Function Index, Female Sexual Distress Scale-Revised, and Subjective sexual arousal and affect questionnaire). RESULTS: Sixteen women were included, 14 completed the 6-month follow-up visit. Vaginal vasocongestion under erotic conditions did not significantly alter after mesh implantation. Vaginal wall sensibility of the distal posterior wall was significantly increased after mesh surgery (preoperative threshold 6.3 mA vs. postoperative 3.4 mA, P = 0.03). Sexual function as assessed with questionnaires was not significantly affected. CONCLUSIONS: In women with a history of vaginal prolapse surgery, vaginal mesh surgery did not decrease vaginal vasocongestion or vaginal wall sensibility. Vaginal vasocongestion prior to mesh surgery appeared to be lower than that of women never operated on. Apparently, native tissue repair decreased preoperative vaginal vasocongestion levels to such extent that subsequent mesh surgery had no additional detrimental effect. Our findings should be interpreted cautiously. Replication of the findings in future studies is essential.

The effects of prolapse surgery on vaginal wall sensibility, vaginal vasocongestion, and sexual function: a prospective single centre study.

AIMS: Prolapse surgery has been shown to positively alter body image and decrease pelvic floor symptoms, hereby possibly improving sexual function. However, the surgical trauma itself may adversely affect sexual function, by damaging vaginal innervation and vascularization. The aim of this study is to evaluate the effects of vaginal prolapse surgery on vaginal vasocongestion, vaginal wall sensibility, and sexual function. METHODS: A prospective study was performed, including patients scheduled for vaginal prolapse surgery. Participants underwent measurements before and 6 months after surgery, during non-erotic and erotic visual stimuli. Measurements were performed using a vaginal combi-probe which includes vaginal photoplethysmography to assess vaginal pulse amplitude (VPA) (representing vaginal vasocongestion), and four pulse-generating electrodes to measure vaginal wall sensibility (representing vaginal innervation). Sexual function was assessed using validated questionnaires (FSFI, FSDS-R, SSAQ). RESULTS: Twenty-nine women were included, 24 (83%) completed the 6 months follow-up. VPA analysis showed a significant reduction in vaginal vasocongestion during sexual stimulation post-operatively (pre-op 2.4 mV (SD 2.5) vs. post-op 1.7 mV (SD 2.4), P = 0.05). Vaginal wall sensibility in the cranial posterior vaginal wall was significantly reduced after surgery (pre-op 13.3 mA vs. post-op 17.5 mA, P < 0.05). Vaginal wall sensibility in the other three locations was not affected by surgery. Sexual function as assessed with questionnaires, was not significantly affected. CONCLUSION: Prolapse surgery negatively impacted levels of vaginal vasocongestion during erotic stimuli as well as vaginal wall sensibility in the cranial posterior wall. Future studies are needed to tease out if these changes in physiological factors are relevant for subjective sexual function.

Peri-operative physiotherapy to prevent recurrent symptoms and treatment following prolapse surgery: supported by evidence or not?

INTRODUCTION AND HYPOTHESIS: To provide a clinical opinion based on current literature reporting on the effects of peri-operative pelvic floor muscle training (PFMT) on postoperative pelvic floor symptoms, recurrent treatment after pelvic organ prolapse (POP) surgery and current clinical practice in the Netherlands. METHODS: The PubMed database was searched, with dates from 1966 to May 2012, for all types of studies reporting on the effects of peri-operative PFMT on recurrent treatment and/or pelvic floor symptoms after POP surgery. Also, current clinical practice in the Netherlands was evaluated. RESULTS: Two small randomised controlled trials (RCTs), with differences in the population included, were identified. The first RCT concluded that peri-operative PFMT reduced the risk of pelvic floor symptoms 12 weeks after surgery and improved the quality of life. The second trial concluded that there is no significant beneficial effect 12 months after surgery. However, when looking at the reported outcomes in this trial micturition symptoms and quality of life improved more in the treatment group too. Studies evaluating whether peri-operative PFMT reduced the rate of recurrent treatment for POP-related symptoms, were not identified. This lack of evidence reflects the current clinical practice, as most gynaecologists do not offer peri-operative PFMT to their patients. CONCLUSIONS: Peri-operative PFMT may reduce the risk of pelvic floor symptoms and improve the quality of life after POP surgery, although evidence is insufficient to implement this in current clinical practice. Since the results of the two RCTs on this topic are promising, there is an urgent need for robust, well-designed trials to evaluate the efficacy and (cost-)effectiveness of peri-operative PFMT.

Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: reliability of assessment and correlation with clinical findings and pelvic floor symptoms.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the interobserver agreement of magnetic resonance imaging (MRI)-based staging of pelvic organ prolapse (POP) and to quantify associations between MRI-based POP staging, findings at pelvic examination, and pelvic floor symptoms. METHODS: This was a cross-sectional study of ten symptomatic POP patients, ten symptomatic patients without POP, and ten nulliparous asymptomatic women. Three different observers performed MRI-based POP staging using the pubococcygeal line (PCL), midpubic line (MPL), perineal line, and H line as references. RESULTS: The interobserver agreement of MRI-based staging of the anterior and middle compartment was good to excellent. In symptomatic women without prolapse, MRI-based and pelvic-examination-based POP staging were poorly correlated. In none of the women were MRI-based POP Quantification (POP-Q) staging and pelvic floor symptoms strongly associated. CONCLUSION: The interobserver agreement of MRI-based POP staging is excellent, but the added clinical value of such staging is questionable due to poor association with clinical findings and pelvic floor symptoms.

Predicting the development of stress urinary incontinence 3 years after hysterectomy.

INTRODUCTION AND HYPOTHESIS: We aimed to develop a prediction rule to predict the individual risk to develop stress urinary incontinence (SUI) after hysterectomy. METHODS: Prospective observational study with 3-year follow-up among women who underwent abdominal or vaginal hysterectomy for benign conditions, excluding vaginal prolapse, and who did not report SUI before surgery (n = 183). The presence of SUI was assessed using a validated questionnaire. RESULTS: Significant prognostic factors for de novo SUI were BMI (OR 1.1 per kg/m(2), 95% CI 1.0-1.2), younger age at time of hysterectomy (OR 0.9 per year, 95% CI 0.8-1.0) and vaginal hysterectomy (OR 2.3, 95% CI 1.0-5.2). Using these variables, we developed the following rule to predict the risk of developing SUI: 32 + BMI-age + (7.5 × route of surgery). CONCLUSIONS: We defined a prediction rule that can be used to counsel patients about their individual risk on developing SUI following hysterectomy.

A randomized, controlled trial comparing an innovative single incision sling with an established transobturator sling to treat female stress urinary incontinence.

PURPOSE: Mid urethral sling procedures have become the surgical treatment of choice for female stress urinary incontinence. Innovative modifications of mid urethral sling procedures were recently introduced with the claim of offering similar efficacy and decreased morbidity. We compared the efficacy and morbidity of an innovative single incision mid urethral tape and an established transobturator procedure. MATERIALS AND METHODS: We performed a prospective, randomized, controlled trial in 6 teaching hospitals in Belgium and The Netherlands between 2007 and 2009. A total of 96 patients received a TVT Secur™ single incision sling and 98 received a TVT™ Obturator System. We collected data on patient characteristics, surgery related parameters, adverse events, clinical followup, Urogenital Distress Inventory and SF-36® scores, validated questionnaires on daily life activities and visual analog scores objectifying pain. Followup was 1 year. RESULTS: One-year followup was available for 75 single incision sling and 85 obturator system cases. Stress urinary incontinence could be objectified in 16.4% of the patients with a single incision sling and in 2.4% with an obturator system (p <0.05). Stress urinary incontinence was subjectively reported by 24% of single incision sling and 8% of obturator system patients (p <0.05). One year after surgery the mean ± SD UDI incontinence domain score in the single incision sling and obturator system groups was 21 ± 24 and 13 ± 21, respectively (p <0.01). Patients with a single incision sling experienced significantly less pain during the first 2 weeks after surgery (p <0.05) and returned significantly earlier to normal daily activity. The OR of re-intervention for stress urinary incontinence 1 year after receiving a single incision sling vs an obturator system was 2.3 (95% CI 1.9-2.7). CONCLUSIONS: The single incision sling procedure is associated with less postoperative pain and a lower objective cure rate than the obturator system procedure.

The effect of prolapse surgery on vaginal sensibility.

INTRODUCTION: Prolapse surgery has been shown to have major impact on sexual function. Since prolapse surgery not only influences psychological factors but might also influence physiological conditions such as vaginal innervation, there is a need for objective outcome measurements to better understand the effects of prolapse surgery on sexual function. AIMS: To assess the effects of prolapse surgery with or without stress incontinence surgery on vaginal sensibility and to assess the relationship between vaginal wall sensibility and sexual well-being. METHODS: This study was performed parallel to a randomized controlled trial comparing vaginal and abdominal prolapse surgery with or without incontinence surgery in women with uterine prolapse stage 2 or more. MAIN OUTCOME MEASURES: Vaginal wall sensibility was defined as mean sensation threshold to electrical stimulation of the vaginal wall at four standardized places, measured before and 6 months after surgery. Higher sensation thresholds postsurgery relative to presurgery indicate diminished vaginal wall sensibility. Sexual function was assessed at the same time points using a questionnaire. RESULTS: Data on vaginal wall sensibility were obtained from 65 patients. The sensibility of the distal posterior (P = 0.02) and distal anterior (P = 0.10) vaginal wall decreased after vaginal surgery compared to abdominal surgery. Abdominal prolapse surgery with incontinence surgery decreased sensibility of the distal part of the anterior vaginal wall significantly more than abdominal prolapse surgery only (P = 0.01). Before surgery, vaginal wall sensibility was lower in women who reported vaginal dryness or anorgasmia. The presence of genital pain was associated with higher vaginal wall sensibility. Postoperative vaginal wall sensibility was similar in women with and without sexual problems. CONCLUSION: Vaginal prolapse surgery as well as abdominal prolapse surgery with additional incontinence surgery resulted in decreased vaginal wall sensibility. This pilot study shows no influence of the decreased vaginal wall sensibility on sexual well-being. Larger studies are needed to better understand the association between changes in vaginal wall sensibility and changes in sexual well-being.

Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for total abdominal hysterectomy: a randomized trial.

STUDY OBJECTIVE: To compare the effects of bipolar vessel sealing versus conventional clamping and suturing in women undergoing total abdominal hysterectomy. DESIGN: A randomized controlled trial was performed. Patients were randomized to vessel sealing or conventional surgery. Postoperative pain was the primary outcome. An intention-to-treat analysis was performed (Canadian Task Force classification I). SETTING: Two Dutch teaching hospitals. PATIENTS: A total of 57 women undergoing abdominal hysterectomy for benign conditions. MEASUREMENTS AND MAIN RESULTS: During the first 3 postoperative days, patients operated on using vessel sealing had statistically significantly lower pain scores. The amount of blood loss, surgery time, complication risk, and duration of hospitalization were similar between both groups. Patients in the vessel-sealing group resumed their normal daily activities on average 8 days earlier as compared with the conventional group. Postoperative pelvic floor function was similar in both groups. CONCLUSION: The use of vessel sealing during abdominal hysterectomy for benign conditions appears to be associated with reduced postoperative pain and faster recovery.