Autologous platelet rich plasma (A-PRP) combined with pelvic floor muscle training for the treatment of female stress urinary incontinence (SUI): A randomized control clinical trial.

IMPORTANCE: Autologous platelet-rich plasma (A-PRP) injection is a novel intervention for stress urinary incontinence (SUI) in women. However, no Phase II clinical trial has compared the outcomes of A-PRP injection combined with pelvic floor muscle training (PFMT) with those of PFMT alone in these women. OBJECTIVE: The primary aim was to compare the efficacy of A-PRP + PFMT versus PFMT alone in women with SUI. The secondary aim was to determine any adverse effects of A-PRP injection. DESIGN: Randomized clinical trial, single-blind assessment. SETTING: Urogynecology clinic at a tertiary medical center. PARTICIPANTS: Women with previously untreated SUI. Women in whom there was any suspicion of urgency, those with an Overactive Bladder Symptoms Score of ≥1, and those with obesity, pelvic organ prolapse, thrombocytopenia, or coagulopathy were excluded. INTERVENTIONS: Two injections of A-PRP were administered with a 1-month interval between injections in the A-PRP injection + PFMT group. Both groups received PFMT. MAIN OUTCOMES AND MEASURES: The primary outcome was determined using the 1-h pad weight test (PWT). Secondary outcomes were measured using the Incontinence Quality of Life Questionnaire, item 11 on the International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms questionnaire, Patient Global Impression of Improvement, and the percentage subjective improvement score. RESULTS: Data for 60 study participants were available for analysis (A-PRP + PFMT group, n = 31; PFMT group, n = 29). The 1-h PWT decreased significantly in the A-PRP + PFMT group but only slightly in the PFMT group at the 5-month follow-up. There was a statistically significant between-group difference in the 1-h pad weight of about 8 g in favor of the A-PRP + PFMT group. A statistically significant difference in symptoms of SUI measured by the questionnaires was found between the A-PRP + PFMT group and the PFMT group at the 2- and 5-month follow-up assessments. There were no reports of adverse events following injection of A-PRP. CONCLUSIONS AND RELEVANCE: A-PRP + PFMT could be a treatment option for women with SUI. Large Phase III randomized controlled trials are required to confirm our findings.

Defecatory dysfunction and anal incontinence symptoms among women with pelvic organ prolapse: 5-year retrospective study in a tertiary center.

OBJECTIVE: To investigate the prevalence of DD and AI with POP symptoms in females attending a urogynecology clinic, and to identify factors associated with DD and AI in POP symptoms patients. METHODS: Computer-based medical records of women with POP symptoms attending a urogynecology clinic in a referral tertiary center between January 2016 and December 2020 were reviewed. Demographic data were collected. Selected defecatory dysfunction (DD) and anal incontinence (AI) were recorded. The associations between patient characteristics, site and severity of prolapse, and DD and AI symptoms in POP patients were investigated for identified associated factors. RESULTS: The mean age of the 754 participants was 65.77 ± 9.44 years. Seven hundred and fifteen (94.83%) were menopause. The prevalence of DD and AI in patients with POP symptoms was 44.03% (332/754) and 42.04% (317/754) according to the PFBQ and medical history records, respectively. Advanced posterior wall prolapse (OR 1.59, 95% CI 1.10-2.30) and wider GH (OR1.23, 95% CI 1.05-1.43) were identified as risk factors for DD by multivariate analysis. Additionally, single-compartment prolapse (OR 0.4, 95% CI 0.21-0.76) and a stronger pelvic floor muscle assessed with brink score (OR 0.94, 95% CI 0.88-0.98) are protective factors for AI. CONCLUSION: DD and AI are prevalent among women with POP symptoms who visit a urogynecology clinic. DD should be evaluated in women with POP symptoms especially in women with increased genital hiatus and point Ap beyond the hymen. To prevent AI, women with POP should be encouraged to perform pelvic floor muscle training in order to increase pelvic floor muscle strength.

The Surgical Management of Large Bladder Calculi and Irreducible Uterine Prolapse: A Case Report and Review of Literature.

Bladder calculi are rare in women. We report a case of bladder calculi complicating irreducible uterovaginal prolapse. It provides diagnostic and operative challenges to the management team. A 77-year-old woman presented with irreducible complete uterovaginal prolapse. Bladder stones were appreciated on examination and confirmed with imaging. The patient was managed surgically with transabdominal hysterectomy with bilateral uterosacral colpopexy followed by cystolithotomy. The patient's postoperative course was uncomplicated, and she had an uneventful recovery at her 3-month postoperative visit without a recurrence of prolapse and gained good continence. The presence of bladder calculi should be considered in the setting of irreducible pelvic organ prolapse. The abdominal approach of cystolithotomy with a concomitant hysterectomy and vaginal apical suspension is safe and effective.

Vesicovaginal Fistulas: Prevalence, Impact, and Management Challenges.

Background and Objectives: Vesicovaginal fistulas (VVFs) are an abnormal communication between the vagina and bladder and the most common type of acquired genital fistulas. This review will address the prevalence, impact, and management challenges of VVFs. Materials and Methods: Epidemiologic studies examining VVFs are considered. In addition, publications addressing the treatment of VVFs are reviewed. Results: VVFs in developing countries are often caused by obstructed labor, while most VVFs in developed countries have iatrogenic causes, such as hysterectomy, radiation therapy, and infection. The reported prevalence of VVFs is approximately 1 in 1000 post-hysterectomy patients and 1 in 1000 deliveries. VVFs affect every aspect of quality of life, including physical, mental, social, and sexual aspects. Prevention of VVFs is essential. Early diagnosis is necessary to reduce morbidity. Nutrition, infection control, and malignancy detection are important considerations during evaluation and treatment. Conservative and surgical treatment options are available; however, these approaches should be customized to the individual patient. The success rate of combined conservative and surgical treatments exceeds 90%. Conclusions: VVFs are considered debilitating and devastating. However, they are preventable and treatable; key factors include the avoidance of prolonged labor, careful performance of gynecologic surgery, and early detection.

Incidence of complete vaginal cuff wound healing at sixth and eighth week after total abdominal hysterectomy.

AIM: To assess the incidence and risk factors of complete vaginal cuff wound healing at sixth and eighth week after total abdominal hysterectomy (TAH). METHODS: A retrospective chart review of women who underwent TAH for benign conditions from January 2015 to December 2015 at Ramathibodi Hospital was conducted. The primary outcome was the incidence of complete vaginal cuff healing at 6 and 8 weeks after operation as determined by complete vaginal mucosal approximation without the presence of suture material or granulation tissue. RESULTS: The medical records of 235 patients who underwent TAH for benign conditions were reviewed. The incidence of complete vaginal cuff wound healing at 6 and 8 weeks after operation were 189 and 225 cases, respectively (80.4% vs 95.7%, P value <0.001). Forty-six (19.6%) patients had incomplete vaginal cuff healing at 6 weeks after operation. Of those, 33 patients had vaginal cuff granulation. Spontaneous regression of lesions had occurred in 69.7% at 8 weeks. Independent risk factors of delay vaginal cuff healing were the used of electrosurgery for vaginal incision (adjusted odds ratio 13.4, 95% confidence interval 2.63-67.74) and suturing cuff with continuous technique (adjusted odds ratio 9.1, 95% confidence interval 2.12-39.01). CONCLUSION: The incidence of complete vaginal cuff wound healing was significantly higher at 8 weeks than at 6 weeks after TAH for benign conditions. Therefore, 8 weeks after operation would be an appropriate time for the first vaginal cuff examination.

Quality of life following vaginal reconstructive versus obliterative surgery for treating advanced pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Although colpocleisis is effective in selected women, the low-morbidity obliterative procedure for treating pelvic organ prolapse (POP) and its impact on postoperative quality of life (QOL) have rarely been studied. Our aim was to assess QOL in women after colpocleisis and compare it with that of women after reconstructive vaginal surgery. METHODS: This retrospective cohort study included women (aged 35-85 years) with POP who underwent obliterative or reconstructive surgical correction during 2009-2015. Patients who met the inclusion criteria underwent telephone interviews that included the validated Prolapse QOL questionnaire (P-QOL Thai). RESULTS: Of 295 potential participants, 197 (67%) completed the questionnaire: 93 (47%) with obliterative and 104 (53%) with reconstructive surgery. Most were Thai (95.4%), multiparous (87%), and sexually inactive (76%). Their histories included hysterectomy (12%), incontinence or prolapse surgery (11%), and POP stage 3/4 (77%). Patients undergoing obliterative surgery were significantly older than those undergoing a reconstructive procedure (69 vs 58 years, P < 0.05). The obliterative group had more children, less education, and more advanced POP. There were no significant differences in operative parameters or complications. The obliterative surgery group had a significantly shorter hospital stay: median 2 (range 1-17) days vs 3 (1-20) days (P = 0.016). P-QOL scale revealed significantly less postoperative impairment in the obliterative surgery group (1.75 vs 5.26, P = 0.023). There were no significant differences in other P-QOL domains. CONCLUSIONS: Colpocleisis improves condition-specific QOL in selected patients with advanced POP and remains an option for this group. Surgeons should consider counseling elderly women with advanced POP about obliterative vaginal surgery.

"Without this program, women can lose their lives": migrant women's experiences with the Safe Abortion Referral Programme in Chiang Mai, Thailand.

For displaced and migrant women in northern Thailand, access to health care is often limited, unwanted pregnancy is common, and unsafe abortion is a major contributor to maternal death and disability. Based on a pilot project and situational analysis research, in 2015 a multinational team introduced the Safe Abortion Referral Programme (SARP) in Chiang Mai, Thailand, to reduce the socio-linguistic, economic, documentation, and transportation barriers women from Burma face in accessing safe and legal abortion care in Thailand. Our qualitative study documented the experiences of women with unwanted pregnancies who accessed the SARP in order to inform programme improvement and expansion. We conducted 22 in-depth, in-person interviews and analysed them for content and themes using deductive and inductive techniques. Women were overwhelmingly positive about their experiences using the SARP. They reported lack of costs, friendly programme staff, accompaniment to and interpretation at the providing facility, and safety of services as key features. Financial and legal circumstances shaped access to the programme and women learned about the SARP through word-of-mouth and community workshops. After accessing the SARP and receiving support, women became community advocates for reproductive health. Efforts to expand the programme and raise awareness in migrant communities appear warranted. Our findings suggest that referral programmes for safe and legal abortion can be successful in settings with large displaced and migrant populations. Identifying ways to work within legal constraints to expand access to safe services has the potential to reduce harm from unsafe abortion even in humanitarian settings.

Laparoscopic sacrocolpopexy: operative times and efficiency in a high-volume female pelvic medicine and laparoscopic surgery practice.

INTRODUCTION AND HYPOTHESIS: There has been a trend toward robotic sacrocolpopexy in the United States despite longer operating times and higher costs compared with traditional laparoscopy. The current study objective was to evaluate incision to closure times of laparoscopic sacrocolpopexy in a urogynecologic practice with extensive experience in the laparoscopic approach for pelvic reconstruction. METHODS: We conducted a single-center retrospective evaluation of consecutive patients undergoing laparoscopic sacrocolpopexy for vaginal vault prolapse using a permanent polypropylene Y-mesh over a 1-year period. Standard operative technique for sacrocolpopexy was used. Four to six sutures were placed on the anterior leaflet of the mesh, and six to eight sutures were placed posteriorly. Two sutures were placed in the presacral ligament. Mesh was retroperitonealized with a running 2-0 monocryl suture. Primary outcomes were total operating time and time to complete laparoscopic sacrocolpopexy. RESULTS: One hundred and twenty-seven consecutive patients with an average age of 60.04 ± 10.14 years, body mass index (BMI) 25.79 ± 4.52 kg/m2, underwent laparoscopic sacrocolpopexy for vaginal vault prolapse. Ninety-two patients had other procedures performed intraoperatively: laparoscopic-assisted vaginal hysterectomy, laparoscopic paravaginal repair, laparoscopic enterocele repair, and/or laparoscopic enterolysis. Mean total operative time for all laparoscopic procedures completed was 107.45 ± 34.00 min. The average time to perform sacrocolpopexy, including incision and closure, was 52.78 ± 13.09 min. CONCLUSION: This retrospective evaluation provides further evidence that traditional laparoscopic sacrocolpopexy should be considered a primary therapy for vaginal vault prolapse.

Are suburethral slings less successful in the elderly?

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate the success of suburethral slings in women ≥70 years of age. METHODS: This was a retrospective cohort study of women who underwent suburethral sling placement. Subjects were separated into three groups: ≤50 years of age (group 1), 51 to 69 years of age (group 2), and ≥70 years of age (group 3). The primary aim was to evaluate success as defined by ≥ improved on a validated patient improvement satisfaction score and a negative postoperative standardized stress test. RESULTS: There were 1,464 subjects. Mean age was 44.51 ± 4.25 (n = 296) for group 1, 60.5 ± 5.28 (n = 680) for group 2, and 77.68 ± 5.41 (n = 488) for group 3. The median follow-up was 26 (6-498) weeks, 45 (6-498) weeks, and 42 (6-543) weeks, for groups 1, 2, and 3 respectively. Multiple logistic regression analysis demonstrated no difference in sling success according to age stratification. Lower success was associated with having had a previous sling (adjusted OR 0.25, 95 % CI 0.12-0.5), having detrusor overactivity (adjusted OR 0.44, 95 % CI 0.28-0.69), and having a history of urge urinary incontinence (UUI) for ≥ 4 years (adjusted OR 0.54, 95 % CI 0.31-0.95). CONCLUSIONS: There is no difference in sling success between the elderly and younger populations. However, those with previous sling surgery or a long standing history of UUI may be at a higher risk of failure.

De novo stress urinary incontinence after pelvic organ prolapse surgery in women without occult incontinence.

INTRODUCTION AND HYPOTHESIS: There is a paucity of data evaluating the risk of de novo stress urinary incontinence (SUI) after surgery for pelvic organ prolapse (POP) in women with no preoperative occult SUI. We hypothesized that apical suspension procedures would have higher rates of de novo SUI. METHODS: This was a retrospective database review of women who had surgery for POP from 2003 to 2013 and developed de novo SUI at ≥6 months postoperatively. Preoperatively, all patients had a negative stress test and no evidence of occult SUI on prolapse reduction urodynamics. The primary objective was to establish the incidence of de novo SUI in women with no objective evidence of preoperative occult SUI after POP surgeries at ≥6 months. RESULTS: A total number of 274 patients underwent POP surgery. The overall incidence of de novo SUI was 9.9 % [95 % confidence interval (CI) 0.07-0.14]. However, the incidence of de novo SUI in those with no baseline complaint of SUI was 4.4 % (95 % CI 0.03-0.1). There was no difference in de novo SUI rates between apical [9.7 % (n = 57)] and nonapical [10.5 %, (n = 217] procedures (p = 0.8482). Multivariate logistic regression identified sacrocolpopexy [adjusted odds ratio (OR) 4.54, 95 % CI 1.2-14.7] and those with a baseline complaint of SUI (adjusted OR 5.1; 95 % CI 2.2-12) as risk factors for de novo SUI. CONCLUSIONS: The incidence of de novo SUI after surgery for POP without occult SUI was 9.9 %. We recommend counseling patients about the risk of de novo SUI and offering a staged procedure.

The IUGA/ICS classification of synthetic mesh complications in female pelvic floor reconstructive surgery: a multicenter study.

INTRODUCTION AND HYPOTHESIS: The objective was to report patterns of sling and transvaginal mesh-related complications using the IUGA/ICS classification of prosthesis-related complications. METHODS: This was a retrospective chart review of all patients who underwent surgical removal of sling, transvaginal mesh, and sacrocolpopexy for mesh-related complications from 2011 to 2013 at three tertiary referral centers. The International Urogynecological Association (IUGA)/International Continence Society (ICS) classification system was utilized. RESULTS: We identified 445 patients with mesh complications, 506 pieces of synthetic mesh were removed, and 587 prostheses-related complications were classified. 3.7 % of patients had viscus organ penetration or vaginal exposure as their presenting chief complaint and 59.7 % were classified as not having any vaginal epithelial separation or category 1. The most common category was spontaneous pain (1Be: 32.5 %) followed by dyspareunia (1Bc: 14.7 %). The sling group was 20 % more likely to have pain compared with the pelvic organ prolapse (POP) mesh group (OR 1.2, 95 % CI 0.8-1.6). The most commonly affected site (S2) was away from the suture line (49 %). Compared with the sling group, the POP group had a higher rate of mesh exposure, which mostly occurred at the suture line area. The majority of patients presented with mesh-related complications more than 1 year post-insertion (T4; average 3.68 ± 2.47 years). CONCLUSION: Surgeons should be aware that patients with vaginal mesh complications routinely exhibit complications more than 1 year after the implantation with pain as the most common presenting symptom.

The Indication and Surgical Treatment of 286 Midurethral Synthetic Sling Complications: A Multicenter Study.

INTRODUCTION AND HYPOTHESIS: 1) Evaluate the most common indication for sling removal in patients with synthetic mesh slings; 2) identify the location of pain for each of the three types of synthetic sling procedures including retropubic (RP) sling, transobturator (TOT) sling, and single incision slings (SIS), and 3) describe the surgical approach to each of the above and its associated complications. MATERIALS AND METHODS: A retrospective chart review of all patients who underwent surgical removal of a sling due to a mesh-related complications from 2011 to 2013 at three referral centers. RESULTS: There were 337 sling complications followed by the IUGA/ICS mesh complication classification. RP slings were more likely to have urinary tract complications (category 4) and intra-abdominal site complications (S5). Of those, 286 slings were removed, 106 (37.1%) were RP, 131 (45.8%) TOT, and 44 (15.4%) SIS. Vaginal pain was the most common reason for sling removal. Twenty-one percent of the TOT had groin pain which was a five times higher risk than RP (OR 5.3, 95% CI 1.5-18.7), and the RP was three times more likely to have suprapubic pain than the TOT (OR 2.97, 95% CI 1.3-7.0). Fifteen percent of the TOT had either unilateral or bilateral groin mesh removal. CONCLUSION: The most common indication for sling removal was vaginal pain. RP sling had a higher risk of suprapubic pain and TOT sling had a higher risk of groin pain. Patients with a history of SIS had a higher incidence of urethral erosion. TOT removal had the highest intraoperative complication rate.

Indications and Complications Associated with the Removal of 506 Pieces of Vaginal Mesh Used in Pelvic Floor Reconstruction: A Multicenter Study.

STUDY OBJECTIVE: Synthetic mesh utilized to treat stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can often result in postoperative complications. The objectives of this study were to determine: 1) the most common indications for mesh removal; 2) the incidences of the removal of specific mesh procedures (such as suburethral sling [SUS], transvaginal mesh [TVM], or sacrocolpopexy); and 3) the idences and types of surgical complications associated with mesh removal. DESIGN: This was a retrospective study. Design Classification: Canadian Task Force II-3. SETTING: Three tertiary referral centers in the United States. PATIENTS: We examined data from all patients at the three centers who underwent surgical removal of synthetic materials from previous SUS, TVM, and sacrocolpopexy procedures for mesh-related complications from 2011 to 2013. INTERVENTION: Patients underwent vaginal, intra-abdominal, and inguinal mesh revisions by cutting, partial removal, or total removal of the mesh for mesh-related complications. MEASUREMENTS AND RESULTS: Overall, 445 patients with complications underwent mesh removal laparoscopically, via groin dissection and/or transvaginally. There were a total of 506 mesh products removed. Of these, 56.5% were slings and 43.5% were for pelvic organ prolapse (POP). Synthetic mesh removed from patients included: transvaginal mesh (TVM) anterior for anterior vaginal prolapse, TVM posterior for posterior vaginal prolapse, sacrocolpopexy mesh, and suburethral slings (SUS) for stress urinary incontinence. Synthetic SUS removed included: retropubic (RPS), transobturator (TOT), and single-incision slings (SIS). TOT was the most common type of sling removed. Patients with a sling who only complained of vaginal pain with or without intercourse underwent a vaginal approach for surgical revision/removal of the sling (86.6%). Patients with an RPS with lower abdominal/suprapubic pain and vaginal pain underwent a vaginal and laparoscopic approach for sling removal (18.4%). Patients with a TOT sling who complained of vaginal and groin pain underwent a vaginal and inguinal approach for sling removal (4.3%). In patients who had POP mesh removal, 42.3% had an anterior TVM, 30.6% had a posterior TVM, 14% had both anterior and posterior TVMs, and 13.1% underwent sacrocolpopexy mesh removal. Complications encountered during mesh revision/removal surgery were: two blood transfusions from complete RPS removal (vaginal and laparoscopic approach), three urethral injuries during TOT sling removal (vaginal approach), two ureteral injuries during anterior vaginal wall mesh removal, and two rectal injuries during posterior vaginal wall mesh removal. All injuries were repaired at the time of mesh removal without recurrence. CONCLUSION: In our study, the most common indication for mesh removal was pain with or without intercourse. The most common mesh procedure resulting in removal was the TOT sling. Use of a vaginal approach only for sling removal had the lowest incidence of intraoperative complications. Laparoscopic RPS removal had the highest incidence of required blood transfusions, anterior TVM had the highest incidence of ureteral injury, and posterior TVM had the highest incidence of rectal injury. Overall, sling, TVM, and sacrocolpopexy mesh removal are safe procedures when performed by experienced surgeons.

Laparoscopic and Robotic-assisted Vesicovaginal Fistula Repair: A Systematic Review of the Literature.

Two types of laparoscopic or robotic-assisted vesicovaginal fistula (VVF) repairs, the traditional transvesical (O'Conor) and extravesical techniques, dominate the literature. The objectives of this study are to compare success rates between laparoscopic or robotic transvesical and extravesical laparoscopic VVF repair techniques and to evaluate the impact of the number of layers in the closure, interposition flaps, and intraoperative testing of the integrity of the bladder repair. Eligible studies, published between 1994 and March 10, 2014, were retrieved through Medline and bibliography searches. All study designs of laparoscopic/robotic VVF repair were included. Open laparotomy and vaginal approaches were excluded. Only 1 retrospective cohort study was included, with the remaining articles consisting of case reports and case series. Ultimately, only 44 studies were included in a systematic review: 9 articles of robotic-assisted approach, 3 laparoscopic single-site surgeries, and 32 conventional laparoscopic approaches. A literature review revealed a balanced number of reports for both transvesical and extravesical approaches. Statistical meta-analysis was not performed because of high heterogeneity. The overall success rate of laparoscopic VVF repair was 80% to 100% with a follow-up period of 1 to 74 months. The success rate of transvesical and extravesical techniques were 95.89% and 98.04% (relative risk, .98; 95% confidence interval, .94-1.02). There was no statistical difference in success rates of VVF repair with different number of layers in the fistula closure or with use of interposition flaps, but there was a small increase in success in the cases that documented intraoperative bladder filling to test the integrity of the bladder closure. In conclusion, transperitoneal extravesical VVF repair has cure rates similar to the traditional transvesical approach. Laparoscopic extravesical VVF repair is a safe, effective, minimally invasive technique with excellent cure rates similar to those of the conventional transvesical approach in experienced surgeons' hands.

Obturator Neuralgia: A Rare Complication of Tension-free Vaginal Tape Sling-Complete Resolution After Laparoscopic Tension-free Vaginal Tape Removal.

STUDY OBJECTIVE: To show a technique of retropubic tension-free vaginal tape (TVT) removal using both a transvaginal and laparoscopic approach in the treatment of a rare condition, obturator neuralgia. DESIGN: A step-by-step explanation of the patient's condition, diagnosis, surgical technique, and postoperative results using video, pictures, and medical illustrations (education video). SETTING: TVT retropubic slings have become the gold standard for the treatment of stress urine incontinence over the last decade. Despite high cure rates, the TVT is not without potential complications. Typical complications include urine retention, incomplete bladder emptying, frequency, urgency, urethral erosion, vaginal extrusion, vaginal pain, and dyspareunia. The most common complication for sling removal/revision is chronic pain. The TVT obturator neuralgia is a rare and specific type of chronic pain that is normally associated with transobturator tape slings. The purpose of this video is to present an extremely rare complication of TVT retropubic slings, present symptoms and signs of obturator nerve compression, show the normal and the actual position of this patient's TVT sling, describe the laparoscopic removal of the TVT sling, and present the postoperative course and resolution of the patient's pain. The patient signed a release for her video to be used for educational and teaching purposes. INTERVENTION: A combined transvaginal and laparoscopic approach in a patient with lower abdominal, levator, and obturator-type pain after a TVT retropubic procedure. CONCLUSION: In patients suffering from obturator neuralgia after a retropubic sling, surgeons should include the sling as a potential causative factor in the differential diagnosis. Surgeons should consider removing the sling based on the patient's symptoms. If the patient suffers from only vaginal pain and dyspareunia, then the surgeon should consider only the removal of the vaginal portion of the sling. In patients with obturator neuralgia, retropubic, and/or lower abdominal pain, one should consider a combined transvaginal and laparoscopic approach in an attempt to remove the majority of the sling and release tension between 2 points of fixation.

Laparoscopic Paravaginal Defect Repair: Surgical Technique and a Literature Review.

Paravaginal defects, commonly seen in patients with anterior vaginal wall prolapse, are due to the detachment of pubocervical fascia from the arcus tendineus fascia pelvis (ATFP), at or near its lateral attachment. The majority of anterior vaginal wall prolapse is thought to be caused by paravaginal defects. Richardson et al. first described and demonstrated the anatomy of the paravaginal defect, as well as described the initial technique of the abdominal approach to repair. Since that time, the laparoscopic approach for repair has been developed and described with success rates of laparoscopic paravaginal defect repair reported in the range of 60% to 89%. This minimally invasive approach to address anterior wall prolapse eliminates the need for a vaginal incision, reduces risk of vaginal shortening and can be completed at the same time as other laparoscopic procedures, such as hysterectomy, sacralcolpopexy, and/or Burch Urethropexy. Compared to the open abdominal approach, there is improved visualization, less risk of bleeding, and faster recovery with the laparoscopic method. Compared to an anterior colporrhaphy, laparoscopic paravaginal repair is a much more anatomic repair of lateral defects and does not result in vaginal shortening. The laparoscopic paravaginal repair should be considered as the first-line treatment of anterior vaginal wall prolapse caused by lateral defects, including at time of laparoscopic/robotic sacralcolpopexy.

Iatrogenic lower urinary tract injury at the time of pelvic reconstructive surgery: does previous pelvic surgery increase the risk?

INTRODUCTION AND HYPOTHESIS: The objective of this study was to evaluate whether a history of previous pelvic surgery is associated with lower urinary tract (LUT) injury at the time of pelvic reconstructive surgery (PRS). METHODS: A retrospective analysis of patients undergoing pelvic reconstructive surgery from 2006 to 2011 was performed. Patients were divided into two groups: those with previous pelvic surgery and those without previous pelvic surgery. A sample size analysis was performed to determine the number needed to detect at least a 3-fold difference in the rate of LUT injury. Demographic, historical, clinical, intraoperative, and postoperative data were analyzed. Associations between LUT injury and demographics, previous pelvic surgery, or other clinical risk factors were assessed using univariate and multivariate analyses. RESULTS: 685 women were included in the analysis: 514 (74.9%) with and 171 (25.1%) without prior pelvic surgery. The overall rate of LUT injury was 6%. Of the injuries, 3.2% were cystotomies, and 1.9% were ureteral obstructions. Previous pelvic surgery did not significantly affect the rate of LUT injury (OR 0.76, 95%CI 0.38-1.54). A diagnosis of prolapse, concurrent hysterectomy, anterior repair, and apical repair were significantly associated with LUT injury. After controlling for age and race, a diagnosis of prolapse remained significantly associated with LUT injury (OR 3.38, 95% CI 1.11-14.75). CONCLUSIONS: Prior pelvic surgery does not affect the rate of LUT injury in pelvic reconstructive surgery. The diagnosis of prolapse is a risk factor for LUT injury in women undergoing pelvic reconstructive surgery.

Vaginal reconstruction/rejuvenation: is there data to support improved sexual function? An update and review of the literature.

Vaginal rejuvenation is a term that is commonly utilized to describe surgical repair of the vaginal canal and introitus following childbirth and/or aging to treat sexual dysfunction related to vaginal relaxation. It is well known that vaginal prolapse may lead to sexual dysfunction and in many studies repair of prolapse improves this dysfunction. During the progression of prolapse, sexual dysfunction or decreased vaginal sensation due to vaginal wall laxity may be one of the early symptoms that women suffer prior to the prolapse itself becoming symptomatic. Surgical repair or reconstruction of this type of vaginal defect may be indicated if repair will improve symptoms of sexual dysfunction caused by vaginal wall laxity. In this review, we will examine the existing data and make conclusions regarding vaginal rejuvenation and its impact on female sexual function. Core tip: This is the first review of vaginal rejuvenation that shows improvement of sexual function. In this review, we covered the topic of relaxed vagina and sexual function, prolapse repair and sexual function, vaginal rejuvenation surgical techniques, and data to support vaginal rejuvenation techniques.

Evaluation of sexual function outcomes in women undergoing vaginal rejuvenation/vaginoplasty procedures for symptoms of vaginal laxity/decreased vaginal sensation utilizing validated sexual function questionnaire (PISQ-12).

Sexual function outcomes were analyzed in a group of women (n = 78) presenting for vaginal rejuvenation/vaginoplasty procedure for a chief complaint of vaginal laxity and decreased sensation with intercourse. Outcomes were analyzed utilizing the validated Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) before and at least 6 months after repair with vaginal rejuvenation/vaginoplasty procedure (VR). Mean age was 43.6 ± 7.9 (range 25-62), and 19 patients (24.3%) were found to have prolapse at time of initial exam and underwent vaginal vault suspension in addition to VR. Compared preoperatively and postoperatively, the overall sexual function (Total PISQ-12) statistically improved (30.3 ± 6.6 vs. 38.2 ± 5.2, P < 0.001). All individual scores statistically improved except in 3 categories in which there was no change (Q1-desire, Q5-pain, and Q11- partner premature ejaculation). Overall sexual satisfaction improved as well as subcategories of increased sexual excitement during intercourse and overall increase in intensity of orgasms. Pain with intercourse subscores were found to be no different from preoperatively to postoperatively. Previous studies have shown that sexual function improves with repair of prolapse; however, this is the first study to show improved function using a validated questionnaire in patients undergoing VR for laxity.