[Overview of risk factors for stress urinary incontinence and strategies in its prevention and treatment].

Stress urinary incontinence is a medical problem that afflicts women worldwide. The causes can be mainly divided into 4 parts: increased abdominal pressure and chronic ischemia of pelvic floor muscles, endocrine changes, pelvic structural damages, inflammatory and consumptive states. The choice of prevention and treatment should also be based on a comprehensive assessment of individualized factors. Treatment techniques which are more minimally invasive or even non-invasive than surgery are currently a hot topic of research in the field of pelvic floor and urinary control, including laser and radiofrequency therapy, periurethral injection therapy, exogenous stem cell therapy and technology for activation of endogenous stem cells. They are expected to solve the clinical problem of stress urinary incontinence with a wider scope of application, lower trauma and fewer complications in the future.

Femistina versus Canephron as a prevention of urinary tract infections after midurethral sling surgery - Non-inferiority study.

OBJECTIVE: Urinary tract infection (UTI) is relatively common post-operative complication following midurethral sling placement (MUS), even in cases where intraoperative antibiotic prophylaxis was given. The primary aim of this study was to investigate the non-inferiority of Femistina as compared with Canephron in reducing symptomatic UTI in first six months following surgery. STUDY DESIGN: A sample size of 144 patients per group was established, to provide at least 90% power to demonstrate the non-inferiority of phytodrug Femistina versus Canephron as a prevention of post-MUS urinary tract infection. RESULTS: Women suffering from stress urinary incontinence and mixed urinary incontinence (MUI) with predominant SUI symptoms as confirmed by urodymamics (n = 320) were randomized in a 1:1 ratio to Femistina (40 mg, oral, twice daily for 20 days) or Canephron (3 × 5 ml taken orally-three times daily for 4 weeks). Both groups were homogenous for age, type of operation (only TOT outside-in) and severity of illness as indicated by ICIQ-SF questionnaire. We found that symptoms of UTI were significantly lower in patients receiving Femistina. During first 6 months after surgery UTI was confirmed in only 10 patients receiving Femistina (6,25%) when compared to 25 (15,63%) subjects receiving Canephron, p < 0.007. CONCLUSION: Femistina is not inferior to Canephron in preventing lower urinary tract infection after midurethral sling surgery.

Cost-effectiveness of prophylactic retropubic sling at the time of vaginal prolapse surgery.

BACKGROUND: Prophylactic midurethral sling placement at the time of prolapse repair significantly reduces the risk for de novo stress urinary incontinence, but it is associated with some small but significant morbidities. Because there has not been a standardized approach to midurethral sling utilization, decision analysis provides a method to evaluate the cost and effectiveness associated with varying midurethral sling placement strategies in addressing the risk for de novo stress urinary incontinence. OBJECTIVE: We aimed to compare the cost effectiveness of the 3 midurethral sling utilization strategies in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. The 3 approaches are (1) staged strategy in which prolapse repair is done without prophylactic midurethral sling placement, (2) universal sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement, and (3) selective sling placement in which prolapse repair is accompanied by prophylactic midurethral sling placement only in patients with a positive prolapse-reduced cough stress test. STUDY DESIGN: We created a decision analysis model to compare staged strategy, universal sling placement, and selective sling placement. We modeled probabilities of de novo stress urinary incontinence, patients choosing subsequent midurethral sling surgery for de novo stress urinary incontinence, and outcomes related to midurethral sling placement. De novo stress urinary incontinence rates were determined for each strategy from published data. The likelihood of patients with de novo stress urinary incontinence choosing midurethral sling surgery as their first-line treatment was also determined from the literature, and this scenario was only applied to patients without prophylactic midurethral sling placement at their index prolapse repair. Finally, outcomes related to midurethral sling placement, including recurrent or persistent stress urinary incontinence, voiding dysfunction requiring sling lysis, mesh exposure requiring excision, and de novo overactive bladder requiring medications, were all derived from publicly available data. All midurethral sling placement procedures were assumed to be retropubic. The costs for each procedure were obtained from the 2020 Centers for Medicare & Medicaid Services Physician Fee Schedule or from previous literature with convertion to 2020 equivalent US dollar prices using the Consumer Price Index. The primary outcome was modeled as the incremental cost-effectiveness ratio. We performed multiple 1-way sensitivity analyses to assess model robustness. RESULTS: The lowest-cost strategy was the staged strategy, which cost $1051.70 per patient, followed by $1093.75 for selective sling placement and $1125.54 for universal sling placement. The selective sling approach, however, had the highest health utility value; therefore, universal sling placement was dominated by selective sling placement because it is both less costly and more effective. When compared with the staged strategy, selective sling placement was cost effective with an incremental cost-effectiveness ratio of $2664 per quality adjusted life-years, meeting the predetermined threshold. In multiple 1-way sensitivity analyses, the variable with the largest effect was the percentage of patients electing to undergo subsequent midurethral sling surgery for de novo stress urinary incontinence after the index surgery. Only when this proportion exceeded 62% did universal sling placement become the cost-effective option because selective sling placement surpassed the predetermined incremental cost-effectiveness ratio threshold and became dominated. CONCLUSION: Selective sling placement was the preferred and cost-effective strategy in treating de novo stress urinary incontinence 1 year after vaginal prolapse repair. Surgeons should counsel their patients preoperatively regarding the possibility of de novo stress urinary incontinence after prolapse repair, as well as on the benefits and risks of prophylactic midurethral sling placement surgery.

Trends in Performance of Anti-Incontinence Treatment at the Time of Pelvic Organ Prolapse Repair From 2011 to 2019.

IMPORTANCE: There are no publications on national trends in performance of concomitant stress urinary incontinence (SUI) treatment with pelvic organ prolapse surgery over the past decade. OBJECTIVES: The objective of this study was to describe trends in the performance and type of concomitant SUI treatment from 2011 to 2019. STUDY DESIGN: Surgical procedures for pelvic organ prolapse and coding for prolapse repair were identified from the American College of Surgeons National Surgical Quality Improvement Program database. An autoregressive interrupted time series model estimated temporal trends in concomitant SUI treatment associated with 3 consequential events: U.S. Food and Drug Administration's (FDA) requirement for postmarketing studies from mesh manufacturers (January 2012), publication of the Outcomes following Vaginal Prolapse Repair and Midurethral Sling (OPUS) trial (June 2012), and the FDA's reclassification of vaginal mesh as a high-risk device (January 2016). RESULTS: There were 43,370 cases identified. The rate of concomitant SUI treatment decreased from 46.1% to 35.7% across the analysis period. No significant trend before postmarketing studies (-0.2%; 95% confidence interval [CI], -0.8 to 1.1) was observed. After postmarketing studies, there was a downward deflection of -2.0% per quarter (95% CI, -3.6 to -0.4). After OPUS, we observed a flattening of the trend to -0.2% (95% CI, -0.8 to 0.4) that persisted after FDA reclassification. Sling procedures remained predominant (96.2% of SUI procedures) and performance of urethropexy decreased across the analysis period (-0.1%; 95% CI, -0.08 to -0.2). CONCLUSIONS: After the FDA's order for postmarketing studies, rates of concomitant SUI treatment significantly decreased. Rates stabilized after the OPUS trial at around 35% and did not subsequently change. Rates of nonmesh concomitant SUI treatment decreased during the analysis period.

Success of Concomitant Versus Interval Slings for Prevention and Treatment of Bothersome de Novo Stress Urinary Incontinence.

BACKGROUND: Despite large trials designed to guide management on whether to perform a prophylactic continence procedure at the time of pelvic organ prolapse (POP) repair, it remains unclear if a staged or interval approach confers advantages in treatment of bothersome stress urinary incontinence (SUI) in women without bothersome SUI before their POP repair. OBJECTIVE: The objective of this study was to compare success of concomitant versus interval slings for the prevention/treatment of de novo bothersome SUI after POP repair. STUDY DESIGN: This multicenter retrospective cohort with prospective follow-up enrolled women with minimal or no SUI symptoms who underwent minimally invasive apical surgery for stage 2 or higher POP between 2011 and 2018 and had a concomitant sling placed at the time of POP surgery or an interval sling placed. Prospectively, all patients were administered the Urogenital Distress Inventory Short-Form 6, the Patient Global Impression of Improvement, and questions on reoperation/retreatment and complications. RESULTS: A total of 120 patients had concomitant slings, and 60 had interval slings. There were no differences in the proportion of patients who had intrinsic sphincter deficiency (22% vs 20%), although the concomitant sling group was more likely to have a positive cough stress test result (30% vs 8%, P = 0.006). The interval sling group was more likely to report "yes" to SUI symptoms on Urogenital Distress Inventory Short-Form 6 (3% vs 30%, P = 0.0006) and during their postoperative visit (0% vs 24%, P < 0.0001). There were no differences in surgical complications. CONCLUSIONS: Among women with minimal or no SUI symptoms undergoing prolapse repair, concomitant slings resulted in lower rates of bothersome SUI compared with similar women undergoing interval sling placement.

Surgical Removal of Midurethral Sling in Women Undergoing Surgery for Presumed Mesh-Related Complications: A Systematic Review.

OBJECTIVE: To assess whether some, or all, of the mesh needs to be removed when a midurethral sling is removed for complications. DATA SOURCES: A systematic review and meta-analysis was conducted. MEDLINE, Cochrane, and ClinicalTrials.gov databases from January 1, 1996, through May 1, 2021, were searched for articles that met the eligibility criteria with total, partial, or a combination of anti-incontinence mesh removal. METHODS OF STUDY SELECTION: All study designs were included (N≥10), and a priori criteria were used for acceptance standards. Studies were extracted for demographics, operative outcomes, and adverse events. Meta-analysis was performed when possible. TABULATION, INTEGRATION, AND RESULTS: We double-screened 11,887 abstracts; 45 eligible and unique studies were identified. Thirty-five were single-group studies that evaluated partial mesh removal, five were single-group studies that evaluated total mesh removal, and five were studies that compared partial mesh removal with total mesh removal. All of the studies were retrospective in nature; there were no randomized controlled studies. Comparative studies demonstrated that partial mesh removal had lower rates of postoperative stress urinary incontinence (SUI) than total mesh removal (odds ratio 0.46, 95% CI 0.22-0.96). Single-group studies supported lower rates of postoperative SUI with partial mesh removal compared with total mesh removal (19.2% [95% CI 13.5-25.7] vs 48.7% [95% CI 31.2-66.4]). Both methods were similar with respect to associated pain, bladder outlet obstruction, mesh erosion or exposure, and lower urinary tract symptoms. Adverse events were infrequent. CONCLUSION: Postoperative SUI may be lower with partial mesh removal compared with total mesh removal. Other outcomes were similar regardless of the amount of mesh removed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD 42018093099.

An In Vitro Study on Extracellular Vesicles From Adipose-Derived Mesenchymal Stem Cells in Protecting Stress Urinary Incontinence Through MicroRNA-93/F3 Axis.

Since the potential roles of extracellular vesicles secreted by adipose-derived mesenchymal stem cells (ADSCs) are not well understood in collagen metabolism, the purpose of this research was to evaluate the effects of ADSCs-extracellular vesicles in stress urinary incontinence and the regulatory mechanism of delivered microRNA-93 (miR-93). ADSCs were isolated and cultured, and ADSCs-extracellular vesicles were extracted and identified. Stress urinary incontinence primary fibroblasts or satellite cells were treated with ADSCs-extracellular vesicles to detect the expression of Elastin, Collagen I, and Collagen III in fibroblasts and Pax7 and MyoD in satellite cells. After transfecting ADSCs with miR-93 mimics or inhibitors, extracellular vesicles were isolated and treated with stress urinary incontinence primary fibroblasts or satellite cells to observe cell function changes. The online prediction and luciferase activity assay confirmed the targeting relationship between miR-93 and coagulation factor III (F3). The rescue experiment verified the role of ADSCs-extracellular vesicles carrying miR-93 in stress urinary incontinence primary fibroblasts and satellite cells by targeting F3. ADSCs-extracellular vesicles treatment upregulated expression of Elastin, Collagen I, and Collagen III in stress urinary incontinence primary fibroblasts and expression of Pax7 and MyoD in stress urinary incontinence primary satellite cells. miR-93 expression was increased in stress urinary incontinence primary fibroblasts or satellite cells treated with ADSCs-extracellular vesicles. Extracellular vesicles secreted by ADSCs could deliver miR-93 to fibroblasts and then negatively regulate F3 expression; ADSCs-extracellular vesicles could reverse the effect of F3 on extracellular matrix remodeling in stress urinary incontinence fibroblasts. miR-93 expression was also increased in stress urinary incontinence primary satellite cells treated by ADSCs-extracellular vesicles. Extracellular vesicles secreted by ADSCs were delivered to satellite cells through miR-93, which directly targets F3 expression and upregulates Pax7 and MyoD expression in satellite cells. Our study indicates that miR-93 delivered by ADSCs-extracellular vesicles could regulate extracellular matrix remodeling of stress urinary incontinence fibroblasts and promote activation of stress urinary incontinence satellite cells through targeting F3.

The "Omega Sign": a novel HoLEP technique that improves continence outcomes after enucleation.

PURPOSE: Holmium-laser enucleation of the prostate (HoLEP) has been a promising prostate surgery since its first introduction. Although there are 10 different HoLEP techniques in the literature, stress urinary incontinence (SUI) is common, because surgery is not performed based on the topographic anatomy of the external sphincter. We have developed a new HoLEP method named as the ''Omega Sign technique", which is based on the topographic anatomy of the external sphincter and could provide better continence outcomes by decreasing SUI rates. MATERIALS AND METHODS: The data of 400 patients who underwent HoLEP by a single surgeon between May 2016 and February 2019 were retrospectively reviewed. The patients were divided into two groups, the first underwent the Gilling's technique (Group 1) and the second the novel ''Omega Sign'' technique (Group 2). Continence status and post-micturition symptoms (PMS) were evaluated according to the standards recommended by the international continence status. RESULTS: The data of 400 HoLEP procedures between May 2016 and February 2019 were analyzed, comparing Group 1 (n = 200) and Group 2(n = 200). SUI rate was significantly lower in Group 2 at the day of catheter removal and first month (p < 0.005). In addition, urge urinary incontinence (UUI) rate and PMS were significantly lower in Group 2. CONCLUSIONS: We could demonstrate improved continence results, comparable functional outcomes and equally minimal complications with the standard HoLEP technique. We believe that, the novel 'Omega sign' technique decreases SUI rates and will become standardised and easy to understand, thereby bringing and creating a shorter learning curve.

Outcomes of Prophylactic Mid-Urethral Sling at the Time of Robotic Sacrocolpopexy.

OBJECTIVE: To compare outcomes of patients who underwent robotic sacrocolpopexy (RSC) with and without concomitant mid-urethral sling (MUS) placement for prophylaxis or treatment of preoperative stress urinary incontinence (SUI) METHODS: We performed a retrospective review of all patients without prior incontinence procedures who underwent RSC with or without MUS placement by 3 surgeons (JA, LA, KE) at a single institution from 2012 to 2017 for treatment of pelvic organ prolapse. Patients had a MUS placed for either documented SUI or prophylaxis of SUI. We compared patient characteristics, operative details, postoperative outcomes, and complications between the groups. RESULTS: A total of 134 patients were identified. 58 (43%) had a MUS placed for documented SUI, 43 (32%) had prophylactic MUS, and 33 (25%) did not have a MUS placed. There were no differences in baseline characteristics between the 3 groups. Patients who did not have a MUS placed had less estimated blood loss (76.4 vs 63.8 vs 36.9 mL, P = .018) but no difference in operative time (P = .408), length of stay (P = .427), or postoperative urinary retention (P = .988). A total of 4 (7%) patients who had a MUS placed for SUI had persistent SUI postoperatively. There were 2 (5%) patients who had a MUS placed prophylactically and 4 (12%) patients who did not have a MUS that developed de novo SUI. CONCLUSION: In this series, we demonstrate the safety and efficacy of prophylactic MUS placement at the time of RSC. Randomized studies evaluating concomitant prophylactic sling at time of robotic sacrocolpopexy could further guide preoperative patient counseling and decision-making.

The effect of sacrospinous ligament fixation during vaginal hysterectomy on postoperative de novo stress incontinence occurrence: a prospective study with 2-year follow-up

Background/aim: To investigate the risk of de novo stress urinary incontinence (SUI) occurrence in women who were treated for pelvic organ prolapse (POP) with sacrospinous ligament fixation (SSLF) in addition to vaginal hysterectomy (VAH) and antero-posterior colporrhaphy (CAP) over a 24-month follow-up period. Materials and methods: A prospective randomized study was designed. Women without occult or obvious SUI were randomized into either one of the study groups: Group 1: VAH + CAP, and Group 2: VAH + CAP + SSLF. Postoperatively, the patients were reevaluated for de novo SUI occurrence. Results: A total of 150 women were analyzed [G1 = VAH + CAP (n: 77) and G2 = VAH + CAP + SSLF (n: 73)]. Mean age, parity, body mass index, menopausal status, and preoperative POP degree, grade 1 and grade 2-3 cystocele and rectocele frequencies were similar between the 2 groups. During follow-up period, de novo SUI developed in 7 patients (9.1%) of Group 1, and in 6 patients (8.2%) of Group 2 (P > 0.05). In Groups 1 and 2, POP recurrence occurred in 5 (6.4%) vs. 1 (1.3%) cases,respectively (P < 0.05). Conclusion: In patients undergoing surgery for POP, the addition of SSLF did not result in an increased rate of de novo SUI. Careful patient selection, and informing the patients about the risks and benefits of the planned surgical procedure are essential steps in each case of POP.

A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling.

BACKGROUND: Urethral diverticulum is a rare entity and requires a high suspicion for diagnosis based on symptoms and physical exam with confirmation by imaging. A common presenting symptom is stress urinary incontinence (SUI). The recommended treatment is surgical excision with urethral diverticulectomy. Postoperatively, approximately 37% of patients may have persistent and 16% may have de novo SUI. An autologous fascial pubovaginal sling (PVS) placed at the time of urethral diverticulectomy (UD) has the potential to prevent and treat postoperative SUI. However, little has been published about the safety and efficacy of a concomitant pubovaginal sling. OBJECTIVE: The objective of this study was to compare the clinical presentation, outcomes, complications, and diverticulum recurrence rates in women who underwent a urethral diverticulectomy with vs without a concurrent pubovaginal sling. STUDY DESIGN: This multicenter, retrospective cohort study included women who underwent a urethral diverticulectomy between January 1, 2000, and December 31, 2016. Study participants were identified by Current Procedure Terminology codes, and their records were reviewed for demographics, medical or surgical history, symptoms, preoperative testing, concomitant surgeries, and postoperative outcomes. Symptoms, recurrence rates, and complications were compared between women with and without a concomitant pubovaginal sling. The primary outcome was the presence of postoperative stress urinary incontinence symptoms. Based on a stress urinary incontinence rate of 50% with no pubovaginal sling and 10% with a pubovaginal sling, we needed a sample size of 141 participants who underwent diverticulectomy without a pubovaginal sling and 8 participants with a pubovaginal sling to achieve 83% power with P<.05. RESULTS: We identified 485 diverticulectomy cases from 11 institutions who met the inclusion criteria; of these, 96 (19.7%) cases had a concomitant pubovaginal sling. Women with a pubovaginal sling were older than those without a pubovaginal sling (53 years vs 46 years; P<.001), and a greater number of women with pubovaginal sling had undergone diverticulectomy previously (31% vs 8%; P<.001). Postoperative follow-up period (14.6±26.9 months) was similar between the groups. The pubovaginal sling group had greater preoperative stress urinary incontinence (71% vs 33%; P<.0001), dysuria (47% vs 30%; P=.002), and recurrent urinary tract infection (49% vs 33%; P=.004). The addition of a pubovaginal sling at the time of diverticulectomy significantly improved the odds of stress urinary incontinence resolution after adjusting for prior diverticulectomy, prior incontinence surgery, age, race, and parity (adjusted odds ratio, 2.27; 95% confidence interval, 1.02-5.03; P=.043). It was not significantly protective against de novo stress urinary incontinence (adjusted odds ratio, 0.86; 95% confidence interval, 0.25-2.92; P=.807). Concomitant pubovaginal sling increased the odds of postoperative short-term (<6 weeks) urinary retention (adjusted odds ratio, 2.5; 95% confidence interval, 1.04-6.22; P=.039) and long-term urinary retention (>6 weeks) (adjusted odds ratio, 6.98; 95% confidence interval, 2.20-22.11; P=.001), as well as recurrent urinary tract infections (adjusted odds ratio, 3.27; 95% confidence interval, 1.26-7.76; P=.013). There was no significant risk to develop a de novo overactive bladder (adjusted odds ratio, 1.48; 95% confidence interval, 0.56-3.91; P=.423) or urgency urinary incontinence (adjusted odds ratio, 1.47; 95% confidence interval, 0.71-3.06; P=.30). A concomitant pubovaginal sling was not protective against a recurrent diverticulum (adjusted odds ratio, 1.38; 95% confidence interval, 0.67-2.82; P=.374). Overall, the diverticulum recurrence rate was 10.1% and did not differ between the groups. CONCLUSION: This large retrospective cohort study demonstrated a greater resolution of stress urinary incontinence with the addition of a pubovaginal sling at the time of a urethral diverticulectomy. There was a considerable risk of postoperative urinary retention and recurrent urinary tract infections in the pubovaginal sling group.

Effect of preoperative pelvic floor muscle training on pelvic floor muscle contraction and symptomatic and anatomical pelvic organ prolapse after surgery: randomized controlled trial.

OBJECTIVES: To evaluate the effect of preoperative pelvic floor muscle training (PFMT) on pelvic floor muscle (PFM) contraction, symptoms of pelvic organ prolapse (POP) and anatomical POP, 6 months after prolapse surgery, and to assess the overall changes in PFM contraction, POP symptoms and pelvic organ descent after surgery. METHODS: This was a randomized controlled trial of 159 women with symptomatic POP, Stage 2 or higher, scheduled for surgery. Participants were randomized to intervention including daily PFMT from inclusion to surgery (n = 81) or no intervention (controls; n = 78). Participants were examined at inclusion, on the day of surgery and 6 months after surgery. PFM contraction was assessed by: vaginal palpation using the Modified Oxford scale (MOS; 0-5); transperineal ultrasound, measuring the percentage change in levator hiatal anteroposterior diameter (APD) from rest to maximum PFM contraction; vaginal manometry; and surface electromyography (EMG). POP distance from the hymen in the compartment with the most dominant prolapse and organ descent in the anterior, central and posterior compartments were measured on maximum Valsalva maneuver. POP symptoms were assessed based on the sensation of vaginal bulge, which was graded using a visual analog scale (VAS; 0-100 mm). Linear mixed models were used to assess the effect of PFMT on outcome variables. RESULTS: Of the 159 women randomized, 151 completed the study, comprising 75 in the intervention and 76 in the control group. Mean waiting time for surgery was 22 ± 9.7 weeks and follow-up was performed on average 28 ± 7.8 weeks after surgery. Postoperatively, no difference was found between the intervention and control groups with respect to PFM contraction assessed by vaginal palpation (MOS, 2.4 vs 2.2; P = 0.101), manometry (19.4 vs 19.7 cmH2 O; P = 0.793), surface EMG (33.5 vs 33.1 mV; P = 0.815) and ultrasound (change in hiatal APD, 20.9% vs 19.3%; P = 0.211). Furthermore, no difference between groups was found for sensation of vaginal bulge (VAS, 7.4 vs 6.0 mm; P = 0.598), POP distance from the hymen in the dominant prolapse compartment (-1.8 vs -2.0 cm; P = 0.556) and sonographic descent of the bladder (0.5 vs 0.8 cm; P = 0.058), cervix (-1.3 vs -1.1 cm; P = 0.569) and rectal ampulla (0.3 vs 0.4 cm; P = 0.434). In all patients, compared with findings at initial examination, muscle contraction improved after surgery, as assessed by palpation (MOS, 2.1 vs 2.3; P = 0.007) and ultrasound (change in hiatal APD, 17.5% vs 20.1%; P = 0.001), and sensation of vaginal bulge was reduced (VAS, 57.6 vs 6.7 mm; P < 0.001). In addition, compared with the baseline examination, POP distance from the hymen in the dominant prolapse compartment (1.9 vs -1.9 cm; P < 0.001) and sonographic descent of the bladder (1.3 vs 0.6 cm; P < 0.001), cervix (0.0 vs -1.2 cm; P < 0.001) and rectal ampulla (0.9 vs 0.4 cm; P = 0.001) were reduced. CONCLUSIONS: We found no effect of preoperative PFMT on PFM contraction, POP symptoms or anatomical prolapse after surgery. In all patients, PFM contraction and POP symptoms were improved at the 6-month follow-up, most likely due to the anatomical correction of POP. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Efecto de los ejercicios preoperatorios de los músculos del suelo pélvico en la contracción de los músculos del suelo pélvico y en el prolapso sintomático y anatómico de los órganos pélvicos después de la cirugía: ensayo controlado aleatorizado OBJETIVOS: Evaluar el efecto de los ejercicios preoperatorios para los músculos del suelo pélvico (EMSP) en la contracción de los músculos del suelo pélvico (MSP), los síntomas del prolapso de órganos pélvicos (POP) y el POP anatómico, seis meses después de la cirugía de prolapso, y evaluar los cambios generales en la contracción de los MSP, los síntomas del POP y el descenso de los órganos pélvicos después de la cirugía. MÉTODOS: Este fue un ensayo controlado aleatorizado de 159 mujeres con POP sintomático, en Etapa 2 o superior, y en lista de espera para cirugía. Las participantes se asignaron al azar a una intervención que incluía EMSP diarios desde el ingreso hasta la cirugía (n=81) o ninguna intervención (controles; n=78). Las participantes fueron examinadas en el momento de su ingreso, el día de la cirugía y 6 meses después de la cirugía. La contracción de los MSP se evaluó mediante: palpación vaginal mediante la escala Oxford modificada (EOM; 0-5); ecografía transperineal, medición del porcentaje de cambio en el diámetro anteroposterior (DAP) del levador hiatal desde el reposo hasta la máxima contracción de los MSP; manometría vaginal; y electromiografía (EMG) de superficie. Se midió la distancia del POP desde el himen en el compartimento con el prolapso más dominante y el descenso de los órganos en los compartimentos anterior, central y posterior en la maniobra de Valsalva máxima. Los síntomas del POP fueron evaluados en base a la sensación de abultamiento vaginal, la cual fue calificada usando una escala análoga visual (EAV; 0-100 mm). Se utilizaron modelos mixtos lineales para evaluar el efecto de los EMSP en las variables de resultado. RESULTADOS: De las 159 mujeres asignadas al azar, 151 completaron el estudio, de las cuales 75 eran el grupo bajo intervención y 76 el grupo de control. El tiempo medio de espera para la cirugía fue de 22±9,7 semanas y el seguimiento se realizó en promedio a las 28±7,8 semanas después de la cirugía. En el postoperatorio, no se encontraron diferencias entre los grupos de intervención y de control con respecto a la contracción de los MSP evaluada mediante palpación vaginal (EOM, 2,4 vs 2,2; P=0,101), manometría (19,4 vs 19,7cm H2O; P=0,793), EMG de superficie (33,5 vs 33,1 mV; P=0,815) y ecografía (cambio en DAP del hiato, 20,9% vs 19,3%; P=0,211). Además, no se encontró ninguna diferencia entre los grupos en cuanto a la sensación de abultamiento vaginal (EAV, 7,4 vs 6,0 mm; P=0,598), la distancia del POP desde el himen en el compartimento dominante del prolapso (-1.8 vs -2,0 cm; P=0,556) y el descenso de la vejiga medido en ecografía (0,5 vs 0,8 cm; P=0,058), del cuello uterino (-1,3 vs -1,1 cm; P=0,569) y de la ampolla rectal (0,3 vs 0,4 cm; P=0,434). En todas las pacientes, en comparación con los hallazgos del examen inicial, la contracción muscular mejoró después de la cirugía, según se evaluó mediante la palpación (EOM, 2,1 vs 2,3; P=0,007) y la ecografía (cambio en la DPA del hiato, 17,5% vs 20,1%; P=0,001), y se redujo la sensación de abultamiento vaginal (EAV, 57.6 vs 6.7 mm; P<0.001). Además, en comparación con el examen de referencia, se redujeron la distancia del POP del himen en el compartimento dominante del prolapso (1,9 vs -1,9 cm; P<0.001) y el descenso de la vejiga medido en ecografía (1,3 vs 0,6 cm; P<0.001), del cuello uterino (0,0 vs −1,2 cm; P<0.001) y de la ampolla rectal (0,9 vs 0,4 cm; P=0.001). CONCLUSIONES: No se encontró ningún efecto de los EMSP preoperatorios en la contracción de los MSP, los síntomas del POP o el prolapso anatómico después de la cirugía. En todas las pacientes, la contracción de los MSP y los síntomas del POP mejoraron en el seguimiento a los 6 meses, debido muy probablemente a la corrección anatómica del POP. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

The Use of a Vaginal Pessary to Decide Whether a Mid Urethral Sling should be Added to Prolapse Surgery.

PURPOSE: Women with pelvic organ prolapse are at risk for stress urinary incontinence after prolapse surgery. Combining pelvic organ prolapse repair with anti-incontinence surgery reduces the incontinence rate but leads to overtreatment. Performing only pelvic organ prolapse repair leads to under treatment. Is a vaginal ring pessary a useful tool when deciding whether a mid urethral sling should be added to prolapse surgery? MATERIALS AND METHODS: We performed a retrospective cohort study in women with symptomatic pelvic organ prolapse but without bothersome stress urinary incontinence who underwent vaginal prolapse repair between January 1, 2008 and December 31, 2017. Preoperatively a pessary was inserted in all women to detect occult stress urinary incontinence. If the pessary revealed bothersome stress urinary incontinence, a concomitant mid urethral sling was proposed. The primary outcome at followup was de novo stress urinary incontinence. RESULTS: Included in study were 220 women. After pessary insertion 132 women (60%) remained continent, 20 (9%) reported nonbothersome stress urinary incontinence and 68 (31%) had bothersome stress urinary incontinence. The latter group was offered combined surgery. At followup bothersome stress urinary incontinence was present in 12 of the 132 women (9%) who had been continent preoperatively and in 7 of the 20 (35%) who had had nonbothersome stress urinary incontinence. In 132 women who were continent with the pessary a total of 11 mid urethral sling procedures would have been needed to prevent postoperative stress urinary incontinence in 1 (number needed to treat was 11). In the 20 women who had nonbothersome stress urinary incontinence only 3 mid urethral sling procedures would have been necessary (number needed to treat was 3). CONCLUSIONS: In women with symptomatic pelvic organ prolapse a pessary is a useful tool when deciding whether to add a mid urethral sling.

Postoperative Outcomes Following Tension-Free Vaginal Mesh Surgery for Pelvic Organ Prolapse: A Retrospective Study.

PURPOSE: We retrospectively reviewed the postoperative outcomes of patients who underwent tension-free vaginal mesh (TVM) surgery in our institution. METHODS: In total, 195 TVM surgeries were performed at the Shimane University School of Medicine from January 2010 to May 2016 in patients with Pelvic Organ Prolapse-Quantification (POP-Q) stage II or higher. Perioperative complications and problems arising following surgery were assessed from medical charts. RESULTS: Among the 195 patients, only 1 patient required blood transfusion due to massive intraoperative blood loss. None of the patients experienced intraoperative complications, such as injury to the bladder or rectum during surgery. Mesh exposure was observed in 10 patients (5.1%). Overall, 6 of these 10 patients were asymptomatic, and surgical treatment was required in only 1 patient. Mesh exposure occurred at significantly higher frequencies in patients aged less than 60 years. Postoperative recurrence of POP, which was defined as recurrence over POP-Q stage 2, was noted in 13 of the 195 patients (6.6%). Re-operation was performed in 1 patient in whom recurrence was observed within 3 months postoperatively. Recurrence of POP was likely to occur in patients with higher POP-Q stages. Overall, 31 of the 195 patients (15.9%) required medication for postoperative stress urinary incontinence (SUI) after surgery. Among these, 2 patients underwent surgical treatment for SUI. CONCLUSION: Outcomes following the TVM procedure were satisfactory. However, caution should be exercisedagainst mesh exposure in younger patients and recurrence of POP in patients with advanced POP-Q stage.

Occult Urinary Incontinence Treatment: Systematic Review and Meta-analysis-Brazilian Guidelines.

OBJECTIVE: To evaluate if performing anti-incontinence procedures during surgical anterior and/or apical prolapse correction in women with asymptomatic urinary incontinence (UI) may prevent stress urinary incontinence (SUI) postoperatively. METHODS: We have performed a systematic review of articles published in the PubMed, Cochrane Library, and Lilacs databases until March 31, 2016. Two reviewers performed the data collection and analysis, independently. All of the selected studies were methodologically analyzed. The results are presented as relative risk (RR), with a 95% confidence interval (CI). RESULTS: After performing the selection of the studies, only nine trials fulfilled the necessary prerequisites. In the present review, 1,146 patients were included. Altogether, the review included trials of three different types of anti-incontinence procedures. We found that performing any anti-incontinence procedure at the same time of prolapse repair reduced the incidence of SUI postoperatively (RR = 0.50; 95% CI: 0.28-0.91). However, when we performed the analysis separately by the type of anti-incontinence procedure, we found different results. In the subgroup analysis with midurethral slings, it is beneficial to perform it to reduce the incidence of SUI (RR = 0.08; 95% CI: 0.02-0.28). On the other hand, in the subgroup analysis with Burch colposuspension, there was no significant difference with the control group (RR = 1.47; 95% CI: 0.28-7.79]). CONCLUSION: Performing any prophylactic anti-incontinence procedure at the same time as prolapse repair reduced the incidence of SUI postoperatively. The Burch colposuspension did not show any decrease in the incidence of SUI postoperatively.

OBJETIVO: Avaliar se a realização de procedimentos anti-incontinência durante a correção cirúrgica do prolapso anterior e/ou apical em mulheres assintomáticas para incontinência urinária (IU) pode prevenir a incontinência urinária de esforço (IUE) no pós-operatório. MéTODOS:: Foi realizada uma revisão sistemática dos artigos publicados nas bases de dados PubMed, Cochrane Library e Lilacs até o dia 31 de março de 2016. Dois revisores realizaram a coleta e a análise de dados, de forma independente. Todos os estudos selecionados foram analisados metodologicamente. Os resultados estão apresentados como risco relativo (RR), com 95% de intervalo de confiança (IC). RESULTADOS: Após a seleção do estudo, apenas nove estudos preencheram os pré-requisitos necessários. Nesta revisão, 1.146 pacientes foram incluídos. No total, a revisão incluiu ensaios de três tipos diferentes de procedimentos anti-incontinência. Descobrimos que realizar qualquer procedimento anti-incontinência ao mesmo tempo que o reparo do prolapso reduziu a incidência de IU no pós-operatório (RR = 0,50; IC 95%: 0,28­0,91). No entanto, quando fizemos a análise separadamente pelo tipo de procedimento anti-incontinência, encontramos resultados diferentes. Na análise de subgrupos com slings miduretrais, é benéfico realizá-lo para reduzir a incidência de IU (RR = 0,08; IC 95%: 0,02­0,28). Por outro lado, na análise de subgrupo com colposuspensão de Burch, não houve diferença significativa com o grupo controle (RR = 1,47; IC 95%: 0,28­7,79]). CONCLUSãO:: A realização de qualquer procedimento profilático anti-incontinência ao mesmo tempo que o reparo do prolapso reduziu a incidência de IUE no pós-operatório. A colposuspensão de Burch não mostrou diminuição na incidência de IUE no pós-operatório.

'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia.

PURPOSE: HoLEP represents an excellent treatment option for benign prostatic hyperplasia. Recently, 'en bloc' techniques resulting in improved visualization, shorter surgical times, and easier recognition of the dissection plane have been described. In this paper we describe the 'En bloc' HoLEP technique with early apical release. MATERIALS AND METHODS: Between January 2015 and March 2017, 137 consecutive patients were subjected to this technique by a single surgeon. The following parameters were measured pre- and post-procedure: International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), post-void residual urine (PVR) and PSA. Complications were recorded. RESULTS: Mean (SD; range) age was 66 years (8.0; 51-84), mean PSA was 4.8 ng/ml (7.0; 0.3-70), mean prostate volume was 75.63 ml (42.1; 37-253), mean volume of prostatic tissue removed was 65.9 ml (35.8; 30-217). Mean surgical duration was 47.58 min (21.3; 15-120 min): enucleation 31.5 min (14.9; 5-80 min), morcellating 6.9 min (6.6; 1-60 min). Mean hospitalization duration was 1.2 days (range 1-3), mean catheterization time was 1.2 days (range 1-5). The rate of stress urinary incontinence (SUI) was 5.8, 1.5 and 0.7% at 1, 3, and 6 months post-operation, respectively. Compared to pre-operative values, IPSS, Qmax, and PVR showed significant improvements at 1, 3, 6, and 12 months following the operation (p < 0.05). CONCLUSIONS: 'En Bloc' HoLEP with early apical release is a safe technique that allows for easier recognition of the surgical plane and preserves the external sphincter's mucosa to provide low rates of post-operative stress incontinence and significant functional results.

Occult urinary incontinence treatment: systematic review and meta-analysis-brazilian guidelines / Tratamento de incontinência urinária oculta: revisão sistemática e metanálise - diretrizes brasileiras

Abstract Objective To evaluate if performing anti-incontinence procedures during surgical anterior and/or apical prolapse correction in women with asymptomatic urinary incontinence (UI) may prevent stress urinary incontinence (SUI) postoperatively. Methods We have performed a systematic review of articles published in the PubMed, Cochrane Library, and Lilacs databases until March 31, 2016. Two reviewers performed the data collection and analysis, independently. All of the selected studiesweremethodologically analyzed. The results are presented as relative risk (RR), with a 95% confidence interval (CI). Results After performing the selection of the studies, only nine trials fulfilled the necessary prerequisites. In the present review, 1,146 patients were included. Altogether, the review included trials of three different types of anti-incontinence procedures. We found that performing any anti-incontinence procedure at the same time of prolapse repair reduced the incidence of SUI postoperatively (RR = 0.50; 95% CI: 0.28-0.91). However, when we performed the analysis separately by the type of anti-incontinence procedure, we found different results. In the subgroup analysis with midurethral slings, it is beneficial to perform it to reduce the incidence of SUI (RR = 0.08; 95% CI: 0.02-0.28). On the other hand, in the subgroup analysis with Burch colposuspension, there was no significant difference with the control group (RR = 1.47; 95% CI: 0.28-7.79]). Conclusion Performing any prophylactic anti-incontinence procedure at the same time as prolapse repair reduced the incidence of SUI postoperatively. The Burch colposuspension did not show any decrease in the incidence of SUI postoperatively.

Resumo Objetivo: Avaliar se a realização de procedimentos anti-incontinência durante a correção cirúrgica do prolapso anterior e/ou apical em mulheres assintomáticas para incontinência urinária (IU) pode prevenir a incontinência urinária de esforço (IUE) no pós-operatório. Métodos: Foi realizada uma revisão sistemática dos artigos publicados nas bases de dados PubMed, Cochrane Library e Lilacs até o dia 31 de março de 2016. Dois revisores realizaram a coleta e a análise de dados, de forma independente. Todos os estudos selecionados foram analisados metodologicamente. Os resultados estão apresentados como risco relativo (RR), com 95% de intervalo de confiança (IC). Resultados: Após a seleção do estudo, apenas nove estudos preencheram os prérequisitos necessários. Nesta revisão, 1.146 pacientes foram incluídos. No total, a revisão incluiu ensaios de três tipos diferentes de procedimentos anti-incontinência. Descobrimos que realizar qualquer procedimento anti-incontinência ao mesmo tempo que o reparo do prolapso reduziu a incidência de IU no pós-operatório (RR = 0,50; IC 95%: 0,28-0,91). No entanto, quando fizemos a análise separadamente pelo tipo de procedimento antiincontinência, encontramos resultados diferentes. Na análise de subgrupos com slings miduretrais, é benéfico realizá-lo para reduzir a incidência de IU (RR = 0,08; IC 95%: 0,02- 0,28). Por outro lado, na análise de subgrupo com colposuspensão de Burch, não houve diferença significativa com o grupo controle (RR = 1,47; IC 95%: 0,28-7,79]). Conclusão: A realização de qualquer procedimento profilático anti-incontinência ao mesmo tempo que o reparo do prolapso reduziu a incidência de IUE no pós-operatório. A colposuspensão de Burch nãomostrou diminuição na incidência de IUE no pós-operatório.

Oestradiol-releasing Biodegradable Mesh Stimulates Collagen Production and Angiogenesis: An Approach to Improving Biomaterial Integration in Pelvic Floor Repair.

BACKGROUND: Polypropylene meshes cause severe complications in some patients. Materials that are biomechanically compatible and can better integrate into host tissues are urgently needed. OBJECTIVE: To design an oestradiol-releasing electrospun poly-l-lactic acid (PLA) mesh and evaluate its ability to stimulate new extracellular matrix and new blood vessel formation. DESIGN, SETTING, AND PARTICIPANTS: Human adipose derived mesenchymal cells (ADMSC) were isolated from fat. PLA meshes with micro- to nano-sized fibres containing 1%, 5%, and 10% oestradiol were constructed and used for in vitro and in vivo experiments. INTERVENTION: The angiogenic potential of the fibrous meshes was evaluated using an in vivo chorioallantoic membrane and an in vitro chick aortic arch assays. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Oestradiol release was measured fluorometrically. The effect of fibrous meshes on proliferation and extracellular matrix (ECM) production of ADMSC was assessed using immunohistology. Mechanical properties were tested using a tensiometer. RESULTS AND LIMITATIONS: The ultrastructure of the mesh was not affected by the inclusion of oestradiol and mechanical properties were only slightly modified. Oestradiol was released from PLA meshes over a 5-mo period. ADMSCs cultured on oestradiol-releasing PLA meshes produced more ECM involving collagen I, collagen III, and elastin. Oestradiol-releasing meshes doubled new blood vessel formation in the chorioallantoic membrane assay (p=0.001) and outgrowth of pro-angiogenic cells in the aortic arch assay (p=0.001). Further studies in longer-term animal models are required to confirm these results. CONCLUSIONS: Oestradiol-releasing PLA meshes increase ECM production and stimulate angiogenesis. As such, they are promising candidate materials to be used in pelvic floor repair and to improve the initial healing phase of a repair material following implantation. PATIENT SUMMARY: In this study, we designed a tissue engineered material to be used to support weakened pelvic floor tissues in women to avoid the complications associated with current surgical mesh. Our results showed that this material can stimulate new blood vessel formation in simple chick assays and tissue production in vitro. Both properties should help with the integration of this material into patients' tissues and merit further study in physiologically relevant animal models.

Prophylactic midurethral sling insertion during transvaginal pelvic reconstructive surgery for advanced prolapse patients with high-risk predictors of postoperative de novo stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Our aim was to evaluate the clinical outcome of continent women with high-risk predictors for de novo stress urinary incontinence (SUI) offered prophylactic midurethral sling (MUS) insertion during vaginal pelvic reconstructive surgery (PRS) for advanced pelvic organ prolapse (POP). MATERIALS AND METHODS: This was a prospective cohort study in patients with POP stage ≥ 3 and maximum urethral closure pressure (MUCP) <60 cmH2O and functional urethral length (FUL) <2 cm. Patients were divided into PRS and PRS + MUS groups. Surgery commenced with vaginal hysterectomy, application of Uphold® and insertion of MUS to the PRS + MUS group. Main outcome measures were incidence of de novo urodynamic stress incontinence (USI), lower urinary tract symptoms (LUTS), quality of life (QoL), and topographic and anatomical relationship of implanted mesh. RESULTS: Based on sample size calculation, 40 patients were recruited-20 in each group. Rate of de novo USI in PRS + MUS was 5% objectively and 10% subjectively, while in the PRS it was 50% objectively and 60% subjectively. No significant difference was noted in patient demographics. Intraoperative blood loss was greater for PRS + MUS but was not statistically significant. No organ injuries, mesh exposure, or infections occurred. Postoperatively, MUCP significantly increased from 43.3 ± 8.9 to 58.5 ± 19.2 cmH2O and FUL from 17.2 ± 1.9 to 20.3 ± 3.1 mm in the PRS + MUS group. Residual urine significantly decreased. No patient had bladder outlet obstruction (BOO). Sonographic assessment showed no difference in mesh mobility with urethral kinking observed in 11 (55%) patients with MUS. CONCLUSION: Based on a validated small sample, prophylactic MUS for continent women at high risk for postoperative USI with advanced POP lowers its incidence to 5%. Continence is achieved in 95%. Concern for complications, LUTS, and QoL did not significantly differ.