Local oestrogen therapy modulates extracellular matrix and immune response in the vaginal tissue of post-menopausal women with severe pelvic organ prolapse.

This study investigates the effect of local oestrogen therapy (LET) on the expression of proteins participating in collagen/elastin biogenesis and immune markers in vaginal tissues of post-menopausal women with severe pelvic organ prolapse (POP). Vaginal biopsies were collected from the anterior vaginal wall of informed and consented 52 post-menopausal women with severe POP undergoing total hysterectomy. Twenty-nine of the 52 women were treated with LET (in the form of vaginal oestrogen cream or tablet), while the remaining 23 untreated patients served as the controls. This study was approved by Sinai Health System REB. Vaginal tissue specimens were analysed for gene and protein expression using real-time RT-PCR and Luminex assays, protein localization and immune cell infiltration were assessed by immunohistochemistry. Forty-four cytokines were detected. We found that LET application: (a) significantly increased (P < 0.05) gene and protein expression levels of extracellular matrix (ECM) structural proteins, collagen and elastin, as well as the expression of ECM maturation enzyme BMP1; (b) decreased protein expression level of ECM degradation enzymes MMP1, MMP2 and MMP3 accompanied by an increase in their tissue inhibitors, TIMP1 and TIMP4; (c) significantly increased (P < 0.05) the gene and protein expression levels of 14 vaginal cytokines involved in leucocyte infiltration, which was confirmed by immunohistochemistry. Our results indicate that LET plays an important role in the activation of immune system within the local vaginal environment, limiting the undesirable ECM degradation, which supports the strengthening of vaginal ECM in post-menopausal women, therefore resisting menopause/age-related changes and inducing urogenital tract tissue regeneration.

Association between method of pelvic organ prolapse repair involving the vaginal apex and re-operation: a population-based, retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Vaginal apical suspension is essential for the surgical treatment of pelvic organ prolapse (POP). We aim to evaluate whether the method of apical repair is associated with different re-operation rates for POP recurrence or surgical complications. METHODS: Population-based, retrospective cohort study of all Ontario women receiving primary apical POP repairs from 2003 to 2015. Primary exposure was the method of apical POP repair. Primary outcome was re-operation for recurrent POP, and secondary outcomes were surgical procedures for genito-intestinal (GI) or genitourinary (GU) complications, fistula repair, and mesh revision or removal. RESULTS: Forty-three thousand four hundred fifty-eight women were included. Overall, the number of mesh-based apical repairs decreased over time, while the number of native-tissue repairs slightly increased (p < 0.001). Multivariable Cox proportional hazards (Cox PH) analysis demonstrated a significant increase in repeat POP operations for transvaginal mesh apical repairs (adjusted HR 1.28 [95% CI: 1.10-1.48]), but not in abdominal mesh repairs (adjusted HR 0.96 [95% CI: 0.81-1.13]) compared with vaginal native tissue apical repairs. Overall risk of repeat surgery for fistulas or GI and GU complications remained low (< 0.5%). Risk of mesh removal or revision was 11.5-11.9%, with no difference between abdominal versus vaginal mesh on multivariable analysis (adjusted HR 0.99 [95% CI: 0.78-1.26]). CONCLUSIONS: Re-operation for recurrent POP is highest in transvaginal mesh apical repairs; however, this risk did not differ between abdominal mesh and vaginal native tissue apical repairs. GI and GU re-operations are rare. There is no difference in mesh removal or revision rates between abdominal and vaginal mesh repairs.

Hysterectomy in Ontario: A Population-Based Study of Outcomes and Complications in Minimally Invasive Compared with Abdominal Approaches.

OBJECTIVE: As quality-based procedures (QBPs) are being established across the province of Ontario, it is important to identify reliable quality indicators (QIs) to ensure that compensation coincides with quality. Hysterectomy is the most commonly performed gynaecologic procedure and as such is a care process for which a QBP is being developed. The aim of this study was to evaluate the technicity index (TI) as a QI for hysterectomy by defining it in the context of specific surgical outcomes and complications. METHODS: This population-based, retrospective cohort study included all women who underwent hysterectomy from April 2003 to October 2014 in the province of Ontario. Unadjusted and adjusted generalized linear models were created to assess the effect of a minimally invasive hysterectomy (MIH) approach on the primary outcome measure: all hysterectomy-associated complications (Canadian Task Force Classification II-2). RESULTS: Of the procedures meeting the study's inclusion criteria, 56.8% were performed using an abdominal hysterectomy approach, whereas 43.2% were performed using an MIH approach. Over the study period, TI improved significantly from 33.23% in 2003 to 58.47% in 2014. During this time span, the overall incidence of all hysterectomy-associated complications was 13.1%. CONCLUSION: The composite risk of all hysterectomy-associated complications was reduced by 46% with an MIH approach. The uptake of MIH improved significantly in Ontario from 2003 to 2014 and is adequately assessed by the TI. The TI is an appropriate QI for hysterectomy that can be used to track patients' outcomes and direct hysterectomy funding.

A Comparison of Health-Related Quality of Life of Women Awaiting Pelvic Organ Prolapse Surgery versus Hip or Knee Replacement.

OBJECTIVE: Pelvic organ prolapse (POP) can significantly decrease the health-related quality of life (HRQOL) of women. In 2005, provincial and territorial wait time benchmarks were set in areas such as hip and knee replacement, but such efforts were lagging for urogynaecological surgeries. This study aimed to compare wait times and HRQOL scores of females awaiting surgery for POP with those of women awaiting hip or knee replacement. METHODS: This was a prospectively planned study comparing women undergoing surgical repair of POP to women having a hip or knee replacement. All women completed a validated HRQOL questionnaire, the Short Form 36 Health Survey. The date of the decision to operate was recorded and patients were followed up prospectively to determine surgical wait time. RESULTS: Three of four physical health concepts were significantly worse for orthopedic patients compared with urogynaecology patients, including the physical component summary (29.2 vs. 41.5, respectively, P < 0.001). Urogynaecology and orthopedic patients had similar emotional and mental well-being, as demonstrated by similar mental component summaries (41.5 vs. 44.6, respectively, P = 0.09). The mean wait time at our institution for hip or knee replacement was 98 days, which was significantly shorter than the mean wait time of 210 days for POP surgery (P < 0.001). CONCLUSION: Despite less physical and pain impact, urogynaecology patients showed similar emotional distress and mental impact compared with orthopedic patients based on a validated HRQOL questionnaire. Because urogynaecology patients waited more than twice as long for their surgery, resources should be directed to prioritize and improve the surgical wait time for urogynaecology patients.

Pelvic Floor Muscle Training Versus Watchful Waiting and Pelvic Floor Disorders in Postpartum Women: A Systematic Review and Meta-analysis.

OBJECTIVES: Pelvic floor muscle training (PFMT) is often recommended to treat postpartum urinary incontinence (UI). However, the role of postpartum PFMT in pelvic organ prolapse (POP), sexual function, and anal incontinence (AI) remains unclear. We therefore aim to assess the efficacy of postpartum PFMT on these pelvic floor disorders. METHODS: This study is a meta-analysis consisting of randomized controlled trials (RCTs). We searched databases including CENTRAL, MEDLINE, EMBASE, CINAHL, and PEDro. We also sought after grey literature including conference proceedings. We included RCTs comparing PFMT versus watchful waiting in women with stage II or less POP within 1 year postpartum. Two authors independently performed study screening, risk of bias assessments, and data extraction. RESULTS: Fifteen RCTs (3845 patients) were included. Women undergoing PFMT less likely report bothersome POP symptoms (risk ratio [RR], 0.48 [0.30-0.76]; very low-quality evidence). There is no significant difference in the number of women with stage II or greater POP (RR, 0.74 [0.45-1.24]; moderate-quality evidence). Fewer women receiving PFMT report the presence of sexual dysfunction (RR, 0.48 [0.30-0.77]; low-quality evidence). There is no significant difference in AI symptoms (RR, 1.11 [0.82-1.51]), but PFMT may be more beneficial for women with anal sphincter injuries (standardized mean differencein AI scores, -0.57 [-1.12 to -0.02]; low-quality evidence). Women receiving PFMT less likely report UI (RR, 0.44 [0.25-0.75]; moderate-quality evidence) with a more pronounced effect on stress UI (SUI). CONCLUSIONS: At present, it remains uncertain whether postpartum PFMT improves POP symptoms because of very low-quality evidence, and more high-quality RCTs are needed in this area. The POP staging will likely not change with postpartum PFMT. The PFMT may result in improved postpartum sexual function compared to watchful waiting, and may provide benefit for AI in women with anal sphincter injuries. Postpartum PFMT likely reduces the risk of UI, particularly stress urinary incontinence symptoms. There is currently little evidence about postpartum PFMT and long-term pelvic floor function.