PEOPLE: Lifestyle and comorbidities as risk factors for pelvic organ prolapse-a systematic review and meta-analysis PEOPLE: PElvic Organ Prolapse Lifestyle comorbiditiEs.

INTRODUCTION AND HYPOTHESIS: The literature is scarce regarding the effects of comorbidities, clinical parameters, and lifestyle as risk factors for pelvic organ prolapse (POP). This study was performed to systematically review the literature related to body mass index (BMI), waist circumference, diabetes mellitus (DM), hypertension (HT), dyslipidemia, chronic constipation, smoking, chronic cough, occupation, and striae and varicose veins as determinants for POP. METHODS: Search terms in accordance with Medical Subject Headings were used in PubMed, Embase, LILACS, and the Cochrane Library. Clinical comparative studies between women with and without POP and containing demographic and/or clinical raw data related to lifestyle and/or comorbidities were included. The ROBINS-I (risk of bias in non-randomized studies of interventions) instrument was used. Fixed-effects and random-effects models were used for homogeneous and heterogeneous studies, respectively. RESULTS: Forty-three studies were included in the meta-analysis. BMI < 25 kg/m2 was found to be a protective factor for POP [OR 0.71 (0.51, 0.99); p = 0.04], and BMI > 30 kg/m2 was a risk factor for POP [OR 1.44 (1.37, 1.52); p < 0.00001]. Waist circumference (≥ 88 cm) was reported as a risk factor for POP [OR 1.80 (1.37, 2.38); p < 0.00001], along with HT [OR 1.18 (1.09, 1.27); p = 0.04], constipation [OR 1.77 (1.23, 2.54); p < 0.00001], occupation [OR 1.86 (1.21, 2.86); p < 0.00001], persistent cough [OR 1.52 (1.18, 1.94); p < 0.0001]), and varicose veins [OR 2.01 (1.50, 2.70); p = 0.12]. CONCLUSIONS: BMI < 25 kg/m2 is protective while BMI > 30 kg/m2 is a risk factor for POP. Large waist circumference, dyslipidemia, HT, constipation, occupation, persistent cough, and varicose veins are also determinants for POP.

Vaginal Sacrospinous Ligament Fixation Using Tissue Anchoring System Versus a Traditional Technique for Women With Apical Vaginal Prolapse: A Randomized Controlled Trial.

OBJECTIVE: The aim of the study was to compare the efficacy and safety of the tissue anchoring system (TAS) kit versus the traditional technique for sacrospinous ligament fixation (SSLF) to treat apical vaginal wall prolapse. METHODS: A prospective randomized controlled multicenter study of noninferiority involving women with apical prolapse (C-point≥+1). Primary outcome is surgical success as C-point≤-4 at the 1-year follow-up. Secondary outcomes are success according to the composite criteria as C-point≤-4, Ba-point ≤0, and Bp-point ≤0; POP-Q measures of the vaginal compartments; intraoperative findings, complications; reoperation rate; hospital stay; and quality of life and sexual functioning (PISQ-12). It was estimated that 50 individuals per group would yield an 80% power for a noninferiority margin of 15%. RESULTS: Ninety-nine women were randomized: TAS (n = 55) and traditional SSLF (n = 44). The groups' preoperative data were similar. Drop-out rate was 11% for 12-month follow-up. Success rates were 90% for TAS and 80% for traditional SSLF (P = 0.0006; absolute difference, 9.8%; 90% confidence interval, -5.2 to 24.8) with the sensivity analyses per-protocol considering only the subjects that completed the 12-month follow-up and 80% versus 73%, respectively (P = 0.0048; absolute difference, 7.3%; 90% confidence interval, -9.6 to 24.2) by sensivity analyses considering the total number of participants randomized and treated with drop-out cases as failure. We detected shorter intraoperative time to dissect and reach the SSL, shorter length of hospitalization, lower rates of urinary tract infection, and lower pain scores in the first 30 days postoperative in the TAS compared with the traditional SSLF groups (P < 0.05). There was an improvement in women's quality of life that did not differ between groups. CONCLUSIONS: The modified technique of SSLF using the TAS kit is noninferior to the traditional technique for the treatment of apical compartment in 12-month follow-up.

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.

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.

Treatment of non-neurogenic overactive bladder with onabotulinumtoxina: systematic review and meta-analysis of prospective, randomized, placebo-controlled clinical trials / Tratamento da bexiga hiperativa não neurogênica com toxina botulínica A: revisão sistemática e metanálise de ensaios clínicos prospectivos, randomizados e placebo-controlados

Abstract We performed a systematic review and meta-analysis of randomized placebo-controlled trials that studied non-neurogenic overactive bladder patients who were treated with 100 units of onabotulinumtoxinA or placebo. The primary purpose of our study was to evaluate the clinical effectiveness with regard to urinary urgency, urinary frequency, nocturia, and incontinence episodes. Our secondary purpose consisted of evaluating the adverse effects. Our initial search yielded 532 entries. Of these, seven studies met all the inclusion criteria (prospective, randomized, placebo-controlled studies, ≥ 3 points on the Jadad scale) and were selected for analysis. For all primary endpoints, the toxin was more effective than placebo (p < 0.0001; 95% confidence interval [95CI]), namely: urgency (mean difference = -2.07; 95CI = [-2.55-1.58]), voiding frequency (mean difference = - 1.64; 95CI = [-2.10-1.18]), nocturia (mean difference = -0.25; 95CI = [-0.39-0.11]) and incontinence episodes (mean difference = -2.06; 95CI= [-2.60-1.52]). The need for intermittent catheterization and the occurrence of urinary tract infection (UTI) were more frequent in patients treated with onabotulinumtoxinA than in patients treated with placebo (p < 0.0001). Compared with placebo, onabotulinumtoxinA had significantly and clinically relevant reductions in overactive bladder symptoms and is associated with higher incidence of intermittent catheterization and UTI.

Resumo Realizou-se revisão sistemática emetanálise de estudos clínicos prospectivos, randomizados e placebo-controlados que comparavam a toxina botulínica ao placebo no tratamento da bexiga hiperativa. O objetivo primário desta metanálise foi avaliar a eficácia da toxina botulínica em relação à urgência urinária, frequência miccional, noctúria e episódios de incontinência. O objetivo secundário foi avaliar os efeitos adversos. Selecionamos estudos que incluíram somente pacientes com bexiga hiperativa não-neurogênica tratada com 100 unidades de onabotulinum toxina A ou placebo (grupo controle). Foram encontrados 532 estudos após as buscas iniciais, dos quais sete apresentaram todos os critérios de inclusão (estudos prospectivos, randomizados, placebo-controlados, ≥ 3pontosnaescalade Jadad) e fizeram parte desta análise. Para todos os objetivosprimários a toxina foimais eficaz do que o placebo, comp < 0,0001 e intervalo de confiança (IC) de 95%: urgência (diferençamédia = -2,07, IC=[-2,55; -1,58]), freqüênciamiccional (diferençamédia=-1,64, IC=[-2,10; -1,18]), noctúria (diferençamédia=-0,25, IC=[-0,39; -0,11]) e episódios de incontinência (diferença média = -2,06, IC= [-2,60; -1,52]). A necessidade de cateterização intermitente e a ocorrência de infecção urinária (ITU) forammais frequentes no grupo toxina na comparação como grupo placebo (p < 0,0001). A toxina botulínica promoveu melhora significativa dos sintomas de bexiga hiperativa na comparação com o placebo. Entretanto, está associada a uma maior incidência de cateterismo intermitente e infecção do trato urinário.

Description and evaluation of experimental models for uterine transplantation in pigs.

OBJECTIVE: To evaluate the technique of uterine transplantation and the use of drugs used in the process of immunosuppression. METHODS: We included 12 sows, and immunosuppression was performed with minimal doses of cyclosporine, and cross-match was done to exclude the possibility of blood incompatibility. Hysterectomy was performed in the donor under general anesthesia, with the removal of the aorta and inferior vena cava in monobloc, and anastomosis of these vessels was made in the recipient. RESULTS: Six experiments were performed, and on the immediate postoperative period, five animals had good reperfusion. However, on the seventh postoperative day, histological analysis showed rejection in five animals. CONCLUSION: The experimental model of uterine transplantation is feasible, but monitoring doses of immunosuppressants is pivotal to prevent rejection episodes.

Description and evaluation of experimental models for uterine transplantation in pigs / Descrição e avaliação de modelos experimentais para transplante uterino em suínos

ABSTRACT Objective: To evaluate the technique of uterine transplantation and the use of drugs used in the process of immunosuppression. Methods: We included 12 sows, and immunosuppression was performed with minimal doses of cyclosporine, and cross-match was done to exclude the possibility of blood incompatibility. Hysterectomy was performed in the donor under general anesthesia, with the removal of the aorta and inferior vena cava in monobloc, and anastomosis of these vessels was made in the recipient. Results: Six experiments were performed, and on the immediate postoperative period, five animals had good reperfusion. However, on the seventh postoperative day, histological analysis showed rejection in five animals. Conclusion: The experimental model of uterine transplantation is feasible, but monitoring doses of immunosuppressants is pivotal to prevent rejection episodes.

RESUMO Objetivo: Avaliar a técnica de transplante uterino e o uso de drogas no processo de imunossupressão. Métodos: Foram incluídas 12 porcas, sendo realizada imunossupressão com doses mínimas de ciclosporina, e prova cruzada para afastar a possibilidade de incompatibilidade sanguínea. Realizou-se, na doadora, histerectomia sob anestesia geral, com a retirada, em monobloco, da aorta e da veia cava inferior, de tal forma que, na receptora, fosse possível realizar a anastomose com estes vasos. Resultados: Foram realizados seis experimentos e, no pós-operatório imediato, houve boa reperfusão em cinco animais. Entretanto, no sétimo dia de pós-operatório, as análises histológicas demonstraram rejeição em cinco deles. Conclusão: O modelo experimental de transplante uterino é factível, mas a monitorização das doses de imunossupressores é importante, a fim de impedir os episódios de rejeição.

Evaluation of the isoflavones and estrogen effects on the rat adrenal.

The aim of this study was to evaluate the morphometry and the gene expression of Ki-67, VEGF and caspase 3 and the stress oxidative in the adrenal gland of ovariectomized rats treated with estrogen or isoflavones. We used 15 Wistar rats ovariectomized treated with isoflavones or estrogen during 30 days. At the end of the treatment, the left adrenal gland was removed for subsequent histological studies and the right was used to evaluate gene expression of angiogenesis (VEGF-A), cell proliferation (Ki-67), apoptose (caspase 3 clivated) and oxidative stress. Treatment with estrogen showed a largest increase in the layers of the adrenal cortex than with isoflavones. These hypertrofic effects agree with higher expression elevation of Ki67 and VEGF, which did not occur with the caspase 3, indicating that isoflavones have great proliferative effect on the adrenal gland. Similar results were also observed on superoxide quantification show that isoflavone has a protective effect against oxidative stress. Our results indicate positively the trophic therapeutic potential of isoflavones has a protective effect and can contribute to the development of effective therapies to decrease the symptoms of menopause.

The Effectiveness of Anticholinergic Therapy for Overactive Bladders: Systematic Review and Meta-Analysis / Eficácia da terapia anticolinérgica na bexiga hiperativa: revisão sistemática e metanálise

Abstract The overactive bladder (OAB) has a significant negative impact on the quality of life of patients. Antimuscarinics have become the pharmacological treatment of choice for this condition. The objective of this systematic review and meta-analysis is to examine the evidence from randomized clinical trials about the outcomes of the antimuscarinic drugs available in Brazil on OABs. We searched MEDLINE and the Cochrane Central Register of Controlled Trials from the inception of these databases through to September 2015. The primary outcome measures were the mean decrease in urge urinary incontinence episodes and the mean decrease in the frequency of micturition. The results suggest that there is a moderate to high amount of evidence supporting the benefit of using anticholinergic drugs in alleviating OAB symptoms when compared with placebo. It is still not clear whether any of the specific drugs that are available in Brazil offer advantages over the others. These drugs are associated with adverse effects (dry mouth and constipation), although they are not related to an increase in the number of withdrawals.

Resumo A bexiga hiperativa determina um impacto negativo na qualidade de vida dos nossos pacientes. Os antimuscarínicos tornaram-se o tratamento farmacológico de escolha para essa condição. O objetivo desta revisão sistemática e metanálise é examinar as melhores evidências científicas sobre estas medicações disponíveis no Brasil no tratamento de mulheres com bexiga hiperativa. As bases de dados utilizadas foram MEDLINE e a biblioteca da Cochrane, das quais selecionamos os ensaios clínicos randomizados até setembro de 2015. Os principais desfechos analisados foram a diminuição dos episódios de incontinência urinária de urgência e a diminuição da frequência de micção. Os resultados sugerem que as drogas existentes no Brasil sustentam o benefício dos anticolinérgicos no alívio dos sintomas da bexiga hiperativa quando comparadas como placebo. Emtermos de eficácia, as medicações apresentam resultados semelhantes no controle dos sintomas. Essas drogas estão associadas a efeitos adversos importantes, tais como boca seca e constipação, e esses efeitos adversos não influenciaram no uso da medicação.

Correlation between maximum voluntary contraction and endurance measured by digital palpation and manometry: An observational study / Correlação entre contração voluntária máxima e endurance avaliados por palpação digital e manometria: um estudo observacional

Summary Introduction: Digital palpation and manometry are methods that can provide information regarding maximum voluntary contraction (MVC) and endurance of the pelvic floor muscles (PFM), and a strong correlation between these variables can be expected. Objective: To investigate the correlation between MVC and endurance, measured by digital palpation and manometry. Method: Forty-two women, with mean age of 58.1 years (±10.2), and predominant symptoms of stress urinary incontinence (SUI), were included. Examination was firstly conducted by digital palpation and subsequently using a Peritron manometer. MVC was measured using a 0-5 score, based on the Oxford Grading Scale. Endurance was assessed based on the PERFECT scheme. Results: We found a significant positive correlation between the MVC measured by digital palpation and the peak manometric pressure (r=0.579, p<0.001), and between the measurements of the endurance by Peritron manometer and the PERFECT assessment scheme (r=0.559, P<0.001). Conclusion: Our results revealed a positive and significant correlation between the capacity and maintenance of PFM contraction using digital and manometer evaluations in women with predominant symptoms of SUI.

Resumo Introdução: a palpação digital e a manometria são métodos capazes de fornecer informações sobre contração voluntária máxima (CVM) e endurance da musculatura do assoalho pélvico (MAP), e pode-se esperar uma forte correlação entre essas variáveis. Objetivo: investigar a correlação entre CVM e endurance, avaliados por palpação digital e manometria. Método: incluíram-se 42 mulheres, com idade média de 58,1 anos (±10,2) e sintomas predominantes de incontinência urinária de esforço (IUE). Realizou-se primeiramente o exame digital, seguido pela manometria (Peritron®). Mensuraram-se a CVM de acordo com a escala de Oxford (0-5 pontos) e o endurance pelo esquema PERFECT. Resultados: encontrou-se correlação positiva entre CVM mensurada por palpação digital e pressão manométrica de pico (r=0,579; p<0,001), e entre as medições do endurance avaliado pelo Peritron e o esquema PERFECT (r=0,559; p<0,001). Conclusão: os resultados revelaram correlação positiva e significativa entre a capacidade e a manutenção de contração dos MAP por meio das avaliações digital e manométrica em mulheres com IUE.

Primary Human Uterine Leiomyoma Cell Culture Quality Control: Some Properties of Myometrial Cells Cultured under Serum Deprivation Conditions in the Presence of Ovarian Steroids.

Cell culture is considered the standard media used in research to emulate the in vivo cell environment. Crucial in vivo experiments cannot be conducted in humans and depend on in vitro methodologies such as cell culture systems. However, some procedures involving the quality control of cells in culture have been gradually neglected by failing to acknowledge that primary cells and cell lines change over time in culture. Thus, we report methods based on our experience for monitoring primary cell culture of human myometrial cells derived from uterine leiomyoma. We standardized the best procedure of tissue dissociation required for the study of multiple genetic marker systems that include species-specific antigens, expression of myofibroblast or myoblast markers, growth curve, serum deprivation, starvation by cell cycle synchronization, culture on collagen coated plates, and 17 ß-estradiol (E2) and progesterone (P4) effects. The results showed that primary myometrial cells from patients with uterine leiomyoma displayed myoblast phenotypes before and after in vitro cultivation, and leiomyoma cells differentiated into mature myocyte cells under the appropriate differentiation-inducing conditions (serum deprivation). These cells grew well on collagen coated plates and responded to E2 and P4, which may drive myometrial and leiomyoma cells to proliferate and adhere into a focal adhesion complex involvement in a paracrine manner. The establishment of these techniques as routine procedures will improve the understanding of the myometrial physiology and pathogenesis of myometrium-derived diseases such as leiomyoma. Mimicking the in vivo environment of fibrotic conditions can prevent false results and enhance results that are based on cell culture integrity.

Mesh Surgery for Anterior Vaginal Wall Prolapse: A Meta-analysis.

Purpose Pelvic organ prolapse (POP) is a major health issue worldwide, affecting 6-8% of women. The most affected site is the anterior vaginal wall. Multiple procedures and surgical techniques have been used, with or without the use of vaginal meshes, due to common treatment failure, reoperations, and complication rates in some studies. Methods Systematic review of the literature and meta-analysis regarding the use of vaginal mesh in anterior vaginal wall prolapse was performed. A total of 115 papers were retrieved after using the medical subject headings (MESH) terms: 'anterior pelvic organ prolapse OR cystocele AND surgery AND (mesh or colporrhaphy)' in the PubMed database. Exclusion criteria were: follow-up shorter than 1 year, use of biological or absorbable meshes, and inclusion of other vaginal wall prolapses. Studies were put in a data chart by two independent editors; results found in at least two studies were grouped for analysis. Results After the review of the titles by two independent editors, 70 studies were discarded, and after abstract assessment, 18 trials were eligible for full text screening. For final screening and meta-analysis, after applying the Jadad score (> 2), 12 studies were included. Objective cure was greater in the mesh surgery group (odds ratio [OR] = 1,28 [1,07-1,53]), which also had greater blood loss (mean deviation [MD] = 45,98 [9,72-82,25]), longer surgery time (MD = 15,08 [0,48-29,67]), but less prolapse recurrence (OR = 0,22 [01,3-0,38]). Dyspareunia, symptom resolution and reoperation rates were not statistically different between groups. Quality of life (QOL) assessment through the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ-12), the pelvic floor distress inventory (PFDI-20), the pelvic floor impact questionnaire (PFIQ-7), and the perceived quality of life scale (PQOL) was not significantly different. Conclusions Anterior vaginal prolapse mesh surgery has greater anatomic cure rates and less recurrence, although there were no differences regarding subjective cure, reoperation rates and quality of life. Furthermore, mesh surgery was associated with longer surgical time and greater blood loss. Mesh use should be individualized, considering prior history and risk factors for recurrence.

Mesh Surgery for Anterior Vaginal Wall Prolapse: A Meta-analysis / Cirurgia com tela para correção de prolapso de parede anterior: metanálise

Abstract Purpose Pelvic organ prolapse (POP) is a major health issue worldwide, affecting 6- 8% of women. The most affected site is the anterior vaginal wall. Multiple procedures and surgical techniques have been used,with or without the use of vaginalmeshes, due to common treatment failure, reoperations, and complication rates in some studies. Methods Systematic review of the literature and meta-analysis regarding the use of vaginal mesh in anterior vaginal wall prolapse was performed. A total of 115 papers were retrieved after using the medical subject headings (MESH) terms: 'anterior pelvic organ prolapse OR cystocele AND surgery AND (mesh or colporrhaphy)' in the PubMed database. Exclusion criteria were: follow-up shorter than 1 year, use of biological or absorbable meshes, and inclusion of other vaginal wall prolapses. Studies were put in a data chart by two independent editors; results found in at least two studies were grouped for analysis. Results After the review of the titles by two independent editors, 70 studies were discarded, and after abstract assessment, 18 trials were eligible for full text screening. For final screening and meta-analysis, after applying the Jadad score (> 2), 12 studies were included. Objective cure was greater in the mesh surgery group (odds ratio [OR] = 1,28 [1,07-1,53]), which also had greater blood loss (mean deviation [MD] = 45,98 [9,72-82,25]), longer surgery time (MD = 15,08 [0,48-29,67]), but less prolapse recurrence (OR = 0,22 [01,3-0,38]). Dyspareunia, symptom resolution and reoperation rates were not statistically different between groups. Quality of life (QOL) assessment through the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ-12), the pelvic floor distress inventory (PFDI-20), the pelvic floor impact questionnaire (PFIQ-7), and the perceived quality of life scale (PQOL) was not significantly different. Conclusions Anterior vaginal prolapse mesh surgery has greater anatomic cure rates and less recurrence, although there were no differences regarding subjective cure, reoperation rates and quality of life. Furthermore, mesh surgery was associated with longer surgical time and greater blood loss. Mesh use should be individualized, considering prior history and risk factors for recurrence.

Resumo Introdução Prolapso de órgãos pélvicos é problema de saúde públicas, sendo o mais comumo anterior. Para tratamento são utilizadas cirurgias, comou semtelas. O uso de telas é para diminuir recidivas, mas não h á consenso. Métodos Foi realizada revisão da literatura e metanálise, sobre uso de telas na correção do prolapso anterior. Base de dados foi PUBMED , com termos (MESH): "Anterior Pelvic Organ OR Cystocele AND Surgery AND (Mesh or Colporrhaphy)". Critérios de exclusão foram: seguimento menor que 1 ano, telas biológicas ou absorvíveis. Resultados: foram avaliados 115 artigos. Após revisão dos títulos, 70 estudos foram descartados e 18 após leitura de resumos. Após critérios de Jadad (>2), 12 estudos foram incluídos. Análise estatística foi razão de risco ou diferença entre médias dos grupos, e as análises com grande heterogeneidade foram avaliadas através de análise de efeito aleatório. Resultados Cura objetiva foi superior no grupo com tela - OR 1,28 (1,07-1,53, p 1 0,00001), maior perda sanguínea - diferença média (MD) 45,98 (9,72-82,25, p = 0,01), tempo cirúrgico mais longo - MD 15,08 (0,48-29,67, p = 0,04), porém menor recorrência - OR 0,22 (0,13-0,38, p = 0,00001), não apresentando maior resolução dos sintomas - OR 1,93 (0,83-4,51, p = 0,15). Dispareunia e taxa de reoperação também não foram diferentes entre grupos. Qualidade de vida não apresentou diferença. Conclusões Cirurgia com tela para prolapso vaginal anterior apresenta melhor taxa de cura anatômica e menor recorrência, sem diferenças cura subjetiva, reoperação e qualidade de vida. Há maior tempo cirúrgico e perda sanguínea. Uso de telas deve ser individualizado.

The prevalence of fecal incontinence and associated risk factors in older adults participating in the SABE study.

AIMS: To assess the prevalence of fecal incontinence (FI) and associated factors in older adults. METHODS: The prevalence and factors associated with FI in older adults were studied by means the SABE study (Health, Well-being, and Aging). A group of 1,345 subjects were interviewed during the third wave of the SABE study performed in Sao Paulo, in 2010. The study included 64.3% females; the mean age of the participants was 70.4 years. The dependent variable was the positive answer for the question "In the last 12 months, have you ever lost control of bowel movements or stools?". Descriptive analysis and hierarchical logistic regression were performed. The independent variables were as follows: (a) demographics: gender, age and (b) clinical characteristics: self-reported chronic diseases, presence of cognitive and/or functional decline, depression and urinary incontinence symptoms, and nutritional status. RESULTS: The overall prevalence of FI was 11,7%, being 8.3% and 13.2% for males and females respectively. Among male subjects, the presence of malnutrition was associated with FI and thus presented a high relative risk index for its occurrence. Among female subjects, age group 70-74 years and some self-reported diseases or conditions such as mild depression, heart disease, urinary incontinence, and polypharmacy were associated with FI. For the first time in literature, polypharmacy appeared as an associated factor for FI for female older adults. CONCLUSIONS: The prevalence of FI in older adults was 11.7% and was mainly associated with advanced age and presence of heart disease, symptoms of depression, polypharmacy and urinary incontinence and malnutrition. Neurourol. Urodynam. 35:959-964, 2016. © 2015 Wiley Periodicals, Inc.

Oestrogen receptor alpha expression in neovaginal tissue of women following modified Abbé-McIndoe technique and in premenopausal women.

The aim of the study was to compare the expression of oestrogen receptor alpha (ERα) in neovaginal tissue of patients with vaginal agenesis following neovaginoplasty using regenerated, oxidised cellulose in premenopausal women. A prospective, observational case-control study was performed on eight patients with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty and 10 control premenopausal women following benign gynaecologic surgery. 6F11 monoclonal antibody was used to determine ERα expression in the vaginal mucosa. Quantitative and qualitative evaluations were performed, respectively, in vaginal epithelium and stroma. The thickness of the vaginal epithelium was determined as the vertical distance between the basal layer cells and the apical surface of the superficial layer. The percentage of ERα-expressing cells was higher in the control group, except in the superficial zone of the epithelium. In the stromal tissue, ERα was detected in only one patient from the neovagina group compared with nine women in the control group. The neovagina group had a statistically thinner epithelium. Our study suggests that women with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty using regenerated oxidised, cellulose experience relatively local hypo-oestrogenism in the first year after surgery, with repercussion in vaginal trophism.

A prospective, randomized, controlled trial of the treatment of anterior vaginal wall prolapse: medium term followup.

PURPOSE: We compared the efficacy and safety of anterior colporrhaphy with transvaginal polypropylene mesh insertion for anterior vaginal wall prolapse at medium term followup. MATERIALS AND METHODS: In this prospective, randomized, controlled trial 100 women with stage II or greater anterior vaginal wall prolapse assessed by POP-Q were randomized to anterior colporrhaphy (controls) or mesh insertion. Anatomical outcomes were assessed by POP-Q measurement and prolapse stage. Subjective outcomes and quality of life impact were evaluated by ICIQ questionnaires. We evaluated the procedure safety profile according to intraoperative complication rates throughout followup. RESULTS: In the mesh and control groups 42 and 50 women completed the 24-month followup. Point Ba did not significantly differ between the groups at baseline but at 24-month followup it had significantly improved in the mesh group compared to controls. However, no difference was found between the groups when considering 2 cure criteria on prolapse stage and subjective parameters. Asymptomatic mesh exposure developed on the anterior vaginal wall prolapse in 7 patients (16.4%) in the mesh group. Minor mesh related complications consisted of mesh exposure, prepubic ecchymosis and groin pain, of which most were treated conservatively. Urinary retention was treated surgically. CONCLUSIONS: Nazca TC™ and anterior colporrhaphy provided good overall anatomical outcomes during a minimum 24-month followup. Vaginal and urinary symptoms, and quality of life improved postoperatively in each group. From the patient perspective Nazca TC did not show superior overall outcomes compared to anterior colporrhaphy performed with or without a retropubic sling.

Qual o índice de massa corporal de mulheres com disfunções dos músculos do assoalho pélvico que procuram tratamento fisioterapêutico? / What is the body mass index of women with pelvic floor muscles dysfunctions that seek for physiotherapy treatment?

Sobrepeso e obesidade são relatados como importantes fatores de risco para desenvolvimento de disfunções do assoalho pélvico (AP) feminino. Assim, objetivou-se averiguar o índice de massa corporal (IMC) de mulheres com disfunções do AP que procuraram tratamento fisioterapêutico, e comparar com as estatísticas nacionais. Trata-se de um estudo observacional. Foram avaliados os prontuários de mulheres com disfunções do AP atendidas pelo Setor de Fisioterapia no período de 2004 à 2010, e incluídas todas as mulheres com a presença de algum sintoma de disfunção do AP. Calculou-se o IMC de 312 mulheres com disfunção do AP. A média de IMC foi de 28,1 kg/m2. Dessas mulheres, cerca de 70% apresentavam sobrepeso ou obesidade, resultado maior do que o índice nacional de 59%. A base fisiopatológica da relação entre obesidade e disfunções do AP está na correlação entre o IMC e a pressão intra-abdominal. A identificação do sobrepeso e da obesidade deve fazer parte dos programas de reabilitação do AP, uma vez que a redução do peso corporal pode contribuir para redução da severidade da disfunção. Com o presente estudo observa-se que as mulheres que procuram tratamento fisioterapêutico para disfunções do AP apresentam índice de obesidade maior do que a população feminina nacional.

Overweight and obesity are reported as important risk factors for developing of female pelvic floor (PF) dysfunction. Thus, the objective was to verify the body mass index (BMI) of women with PF dysfunctions who sought physiotherapy treatment, and comparing it with national statistics. This is an observational study. There were evaluated the records of women with PF dysfunctions served by the Physiotherapy Service from 2004 to 2010, and included all women with the presence of any symptom of PF dysfunction. It was calculated the BMI of 312 women with PF dysfunction. The BMI mean was 28.1 kg/m2. Approximately 70% of these women were overweight or obese, a value higher than the national rate of 59%. The pathophysiological basis of the relationship between obesity and PF dysfunction is the correlation between BMI and intra-abdominal pressure. The identification of overweight and obesity should be part of the rehabilitation programs of the PF, since the reduction in body weight can contribute by reducing the severity of the disorder. With the present study it was observed that women seeking physiotherapy treatment for PF dysfunction have higher rates of obesity than the national female population.

Efeito da adição do biofeedback ao treinamento dos músculos do assoalho pélvico para tratamento da incontinência urinária de esforço / Effect the adding of biofeedback to the training of the pelvic floor muscles to treatment of stress urinary incontinence

OBJETIVO: Verificar o efeito da adição do biofeedback (BF) ao treinamento dos músculos do assoalho pélvico (TMAP) para o tratamento da incontinência urinária de esforço (IUE). MÉTODOS: Estudo piloto prospectivo, randomizado e controlado, com mulheres com IUE sem deficiência esfincteriana detectada ao estudo urodinâmico e que realizavam a correta contração dos MAP. Foram excluídas mulheres com doenças neuromusculares e com prolapso genital graus III e IV. Foram randomizadas 40 mulheres em Grupo Controle e Grupo BF. O protocolo de TMAP com equipamento de BF foi constituído de três séries de dez contrações lentas (tônicas), com tempo de manutenção de seis a oito segundos em cada contração, seguido de um período de repouso de mesmo valor. Após cada contração sustentada, eram realizadas de três a quatro contrações rápidas (fásicas) em decúbito dorsal e ortostatismo, duas vezes na semana, totalizando 12 sessões. Avaliou-se o efeito da adição do BF ao TMAP na qualidade de vida pelo King's Health Questionnaire (KHQ), nos sintomas urinários pelo diário miccional e na função dos músculos do assoalho pélvico (MAP) pela palpação digital. A avaliação foi realizada inicialmente e após as 12 sessões de tratamento. O resultado foi descrito em médias e desvios padrão. Para análise de homogeneidade e verificação das diferenças entre os grupos utilizou-se o teste de Mann-Whitney, e para diferenças entre os momentos de observação, o teste de Wilcoxon, com nível de significância de 0,05. RESULTADOS: Diminuição significativa nos escores dos domínios avaliados pelo KHQ na comparação entre os grupos, exceto para o domínio saúde geral (Grupo BF 32,8±26,9 versus Grupo Controle 48,4±29,5; p<0,13). Em concordância, observou-se melhora da função dos MAP após o tratamento no grupo BF, na power (4,3±0,8; p=0,001), endurance (6,0±2,2; p<0,001) e fast (9,3±1,9; p=0,001). Quando comparados os grupos, o Grupo BF destacou-se positivamente em relação ao power (Grupo BF 4,3±0,8 versus Grupo Controle 2,5±0,9; p<0,001), endurance (Grupo BF 6,0±2,2 versus Grupo Controle 2,7±1,9; p<0,001) e fast (Grupo BF 9,3±1,9 versus Grupo Controle 4,6±3,2; p<0,001). Redução da frequência urinária noturna (1,2±1,2 versus 0,7±0,9; p=0,02) e da perda de urina nos esforços (1,5±1,4 versus 0,6±0,8; p=0,001) foi observada no Grupo BF. CONCLUSÃO: A adição do BF ao TMAP para o tratamento da IUE, aplicado de acordo com o protocolo descrito, contribui para melhora da função dos MAP, redução dos sintomas urinários e melhora da qualidade de vida.

PURPOSE: To investigate the effect of adding biofeedback (BF) to the training of pelvic floor muscles (PFMT) for the treatment of stress urinary incontinence (SUI). METHODS: A prospective pilot study, randomized and controlled with women with SUI without sphincter deficiency, detected by urodynamic study and who performed the correct PFM contraction. Women with neuromuscular disorders and grade III and IV genital prolapse were excluded. Forty women were randomized into a Control Group and BF Group. The PFMT protocol with BF equipment consisted of three sets of ten slow contractions (tonic), with a holding time of six to eight seconds at each contraction followed by a rest period of equal duration. After each sustained contraction, they performed three to four fast contractions (phasic) in the supine and standing position twice a week, for a total of 12 sessions. We evaluated the effect of adding BF to PFMT on quality of life using King's Health Questionnaire (KHQ) regarding urinary symptoms based on a voiding diary and regarding the function of pelvic floor muscles by digital palpation. The evaluation was performed initially and after 12 treatment sessions. Data are reported as mean and standard deviation. The Mann-Whitney test was used for the analysis of homogeneity and to determine differences between groups, and the Wilcoxon test was used to determine possible differences between the times of observation, with the level of significance set at 0.05. RESULTS: A significant decrease in the scores of the domains assessed by the KHQ was observed in the comparison between groups, except for the general health domain (BF Group: 32.8±26.9 versus Control Group: 48.4±29.5, p<0.13). Accordingly, there was improvement in PFM function after treatment in the BF Group, regarding power (4.3±0.8, p= 0.001), endurance (6.0±2.2, p<0.001) and fast (9.3±1.9, p=0.001). When comparing the groups, the BF Group showed a positive result regarding power (BF Group 4.3±0.8 versus Control Group 2.5±0.9, p<0.001), endurance (6.0±2.2 BF Group versus Control Group 2.7±1.9, p<0.001) and fast (BF Group 9.3±1.9 versus Control Group 4.6 ± 3.2, p<0.001). Reduction of nocturnal urinary frequency (1.2±1.2 versus 0.7±0.9, p=0.02) and of effort urine loss (1.5±1.4 versus 0.6±0.8, p=0.001) was observed in the BF Group. CONCLUSION: The addition of BF to the PFMT for the treatment of SUI, applied according to the protocol described, improved PFM function, reduced urinary symptoms, and improved of the quality of life.

Sexual function after anterior vaginal wall prolapse surgery.

OBJECTIVE: The aim of this study was to compare female sexual function after surgical treatment of anterior vaginal prolapse with either small intestine submucosa grafting or traditional colporrhaphy. METHODS: Subjects were randomly assigned, preoperatively, to the small intestine submucosa graft (n = 29) or traditional colporrhaphy (n = 27) treatment group. Postoperative outcomes were analyzed at 12 months. The Female Sexual Function Index questionnaire was used to assess sexual function. Data were compared with independent samples or a paired Student's t-test. RESULTS: In the small intestine submucosa group, the total mean Female Sexual Function Index score increased from 15.5±7.2 to 24.4±7.5 (p<0.001). In the traditional colporrhaphy group, the total mean Female Sexual Function Index score increased from 15.3±6.8 to 24.2±7.0 (p<0.001). Improvements were noted in the domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. There were no differences between the two groups at the 12-month follow-up. CONCLUSIONS: Small intestine submucosa repair and traditional colporrhaphy both improved sexual function postoperatively. However, no differences were observed between the two techniques.

Sexual function after anterior vaginal wall prolapse surgery

OBJECTIVE: The aim of this study was to compare female sexual function after surgical treatment of anterior vaginal prolapse with either small intestine submucosa grafting or traditional colporrhaphy. METHODS: Subjects were randomly assigned, preoperatively, to the small intestine submucosa graft (n = 29) or traditional colporrhaphy (n = 27) treatment group. Postoperative outcomes were analyzed at 12 months. The Female Sexual Function Index questionnaire was used to assess sexual function. Data were compared with independent samples or a paired Student's t-test. RESULTS: In the small intestine submucosa group, the total mean Female Sexual Function Index score increased from 15.5±7.2 to 24.4±7.5 (p<0.001). In the traditional colporrhaphy group, the total mean Female Sexual Function Index score increased from 15.3±6.8 to 24.2±7.0 (p<0.001). Improvements were noted in the domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. There were no differences between the two groups at the 12-month follow-up. CONCLUSIONS: Small intestine submucosa repair and traditional colporrhaphy both improved sexual function postoperatively. However, no differences were observed between the two techniques.