Obesity as an independent risk factor for poor long-term outcome after mid-urethral sling surgery.

INTRODUCTION: High body mass index (BMI) is a risk-factor for stress urinary incontinence (SUI). Mid-urethral sling (MUS) surgery is an effective treatment of SUI. The aim of this study was to investigate if there is an association between BMI at time of MUS-surgery and the long-term outcome at 10 years. MATERIAL AND METHODS: Women who went through MUS surgery in Sweden between 2006 and 2010 and had been registered in the Swedish National Quality Register of Gynecological Surgery were invited to participate in the 10-year follow-up. A questionnaire was sent out asking if they were currently suffering from SUI or not and their rated satisfaction, as well as current BMI. SUI at 10 years was correlated to BMI at the time of surgery. SUI at 1 year was assessed by the postoperative questionnaire sent out by the registry. The primary aim of the study was to investigate if there is an association between BMI at surgery and the long-term outcome, subjective SUI at 10 years after MUS surgery. Our secondary aims were to assess whether BMI at surgery is associated with subjective SUI at 1-year follow-up and satisfaction at 10-year follow-up. RESULTS: The subjective cure rate after 10 years was reported by 2108 out of 2157 women. Higher BMI at the time of surgery turned out to be a risk factor for SUI at long-term follow-up. Women with BMI <25 reported subjective SUI in 30%, those with BMI 25-<30 in 40%, those with BMI 30-<35 in 47% and those with BMI ≥35 in 59% (p < 0.001). Furthermore, subjective SUI at 1 year was reported higher by women with BMI ≥30, than among women with BMI <30 (33% vs. 20%, p < 0.001). Satisfaction at 10-year follow-up was 82% among women with BMI <30 vs 63% if BMI ≥30 (p < 0.001). CONCLUSIONS: We found that higher BMI at the time of MUS surgery is a risk factor for short- and long-term failure compared to normal BMI.

Dyspareunia and pelvic pain: comparison of mid-urethral sling methods 10 years after insertion.

INTRODUCTION AND HYPOTHESIS: The mid-urethral sling (MUS) has been used for more than 30 years to cure stress urinary incontinence. The objective of this study was to assess whether surgical technique affects the outcome after more than ten years, regarding dyspareunia and pelvic pain. METHODS: In this longitudinal cohort study we used the Swedish National Quality Register of Gynecological Surgery to identify women who underwent MUS surgery in the period 2006-2010. Out of 4348 eligible women, 2555 (59%) responded to the questionnaire sent out in 2020-2021. The two main surgical techniques, the retropubic and the obturatoric approach, were represented by 1562 and 859 women respectively. The Urogenital Distress Inventory-6 (UDI-6) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), as well as general questions concerning the MUS surgery, were sent out to the study population. Dyspareunia and pelvic pain were defined as primary outcomes. Secondary outcomes included PISQ-12, general satisfaction, and self-reported problems due to sling insertion. RESULTS: A total of 2421 women were included in the analysis. Among these, 71% responded to questions regarding dyspareunia and 77% responded to questions regarding pelvic pain. In a multivariate logistic regression analysis of the primary outcomes, we found no difference in reported dyspareunia (15% vs 17%, odds ratio (OR) 1.1, 95% CI 0.8-1.5) or in reported pelvic pain (17% vs 18%, OR 1.0, 95% CI 0.8-1.3) between the retropubic and obturatoric techniques among study responders. CONCLUSION: Dyspareunia and pelvic pain 10-14 years after insertion of a MUS do not differ with respect to surgical technique.

Retropubic slings are more efficient than transobturator at 10-year follow-up: a Swedish register-based study.

INTRODUCTION AND HYPOTHESIS: Long-term performance of mid-urethral slings (MUS) and potential differences between the retropubic and the transobturator technique for insertion are scarcely studied. This study aims to evaluate the efficacy and safety 10 years after surgery and compare the two main surgical techniques used. METHODS: Women who underwent surgery with a MUS between 2006 and 2010 were identified using the Swedish National Quality Register of Gynecological Surgery and were invited 10 years after the operation to answer questionnaires regarding urinary incontinence and its impact on quality-of-life parameters (UDI-6, IIQ-7) and impression of improvement, as well as questions regarding possible sling-related complications and reoperation. RESULTS: The subjective cure rate reported by 2421 participating women was 63.3%. Improvement was reported by 79.2% of the participants. Women in the retropubic group reported higher cure rates, lower urgency urinary incontinence rates and lower UDI-6 scores. No difference was shown between the two methods regarding complications, reoperation due to complications or IIQ-7 scores. Persisting sling-related symptoms were reported by 17.7% of the participants, most commonly urinary retention. Mesh exposure was reported by 2.0%, reoperation because of the tape by 5.6% and repeated operation for incontinence by 6.9%, significantly more in the transobturator group (9.1% vs. 5.6%). Preoperative urinary retention was a strong predictor for impaired efficacy and safety at 10 years. CONCLUSIONS: Mid-urethral slings demonstrate good results for the treatment of stress urinary incontinence and tolerable complication profiles in a 10-year perspective. The retropubic approach displays higher efficacy than the transobturator, with no difference regarding safety.

Recurrent surgery in uterine prolapse: A nationwide register study.

INTRODUCTION: One in three women with pelvic organ prolapse (POP) undergoing surgery have a relapse. Currently, no optimal surgical treatment has been identified for correcting a uterine prolapse. This population-based register study aims to compare the relapse rate in patients with uterine prolapse undergoing hysterectomy with suspension or uterine-sparing surgical procedures. MATERIAL AND METHODS: All women with uterine prolapse undergoing prolapse surgery in Sweden from January 1, 2015 to December 31, 2018, were identified from the Gynecological Operation Register (GynOp). The primary outcome was the number of recurrent POP surgeries up to December 31, 2020. RESULTS: Sacrospinous hysteropexy (SSHP) without graft and sacrohysteropexy (SHP) were associated with a significantly higher rate of recurrent POP surgery (SSHP without graft: adjusted odds ratio [aOR] 2.6, 95% CI 2.0-3.5; SHP aOR 2.6, 95% CI 1.8-3.7) and patients describing a sense of globe (SSHP without graft, aOR 2.0, 95% CI 1.6-2.6; SHP, aOR 1.8, 95% CI 1.1-3.1) compared with cervical amputation with uterosacral ligament fixation (Manchester procedure). There was no difference in the reoperation rate or sense of a globe between SSHP with graft and Manchester procedure. Patients undergoing SSHP without graft had a higher frequency of 1-year postoperative complications compared with Manchester procedure (aOR 2.0, 95% CI 1.6-2.6) and SHP (aOR 2.4, 95% CI 1.4-3.9). Moreover, the frequency of 1-year postoperative complications was higher in SSHP with graft (aOR 1.6, 95% CI 1.1-2.2) than in Manchester procedure. CONCLUSIONS: The Manchester procedure was associated with a low rate of recurrent POP surgery, symptomatic recurrence and low surgical morbidity compared with other surgical methods in women with uterine prolapse.

Peri- and postoperative outcomes in patients with endometriosis undergoing hysterectomy.

OBJECTIVES: To assess whether hysterectomy in patients with endometriosis is associated with higher proportion of complications compared with patients without, and whether route of hysterectomy affects this outcome. STUDY DESIGN: This is a population-based retrospective cohort study. Data were prospectively obtained from three National Swedish Registers. Patients undergoing a benign hysterectomy between 2015 and 2017 in Sweden were included in the study and were grouped according to a histology-proven diagnosis of endometriosis. Different hysterectomy modes were compared in patients with endometriosis. Perioperative data and postoperative complications up to 1 year after surgery were collected and measured. RESULTS: In all, 8,747 patients underwent a benign hysterectomy, and 1,166 patients with endometriosis was compared with 7,581 patients without. Patients with endometriosis had higher proportion of complications (adjusted Odds ratio aOR 1.2, 95% CI 1.0-1.4), were more often converted to abdominal hysterectomy (aOR 1.7, 95% CI 1.1-2.6), had higher estimated blood loss (EBL) (200-500 ml; aOR 1.8, 95% CI 1.4-2.3, >500 ml; aOR 3.1, 95% CI 2.2-4.4) and a longer operative time (1-2 h; aOR 2.1, 95% CI 1.4-3.2, >2 h; aOR 4.3, 95% CI 2.7-6.6) than endometriosis-free patients. The conversion rate was 13.8 times higher in total laparoscopic hysterectomy (TLH) compared with robotic-assisted laparoscopic hysterectomy (RATLH) (aOR 13.8, 95% CI 3.6-52.4). CONCLUSION: Higher conversion rate, higher EBL and higher frequency of complications were seen in patients with endometriosis. RATLH was associated with lower conversion rate compared to TLH.

Vaginal vault prolapse and recurrent surgery: A nationwide observational cohort study.

INTRODUCTION: In surgical repair of pelvic organ prolapse the recurrence rate is about 30% and the importance of apical support was recently highlighted. In surgical randomized controlled studies, the external validity can be compromised because the surgical outcomes often depend on surgical volume. Therefore, we sought to study outcomes of surgical treatment in patients with vaginal vault prolapse in a nationwide setting with a variety of surgical volumes. MATERIAL AND METHODS: This is a nationwide cohort study. All patients with a vaginal vault prolapse undergoing surgery, between January 1, 2015 and December 31, 2018, were identified from the Swedish National Quality Register of Gynecological Surgery, GynOp. The primary outcome was the frequency of recurrent pelvic organ prolapse surgery within 2 years postoperatively. Secondary outcomes included patient-reported vaginal bulging, operative time, estimated blood loss and 1-year postoperative complications. RESULTS: In 1812 patients with vaginal vault prolapse, 538 (30%) had a sacrospinous ligament fixation (SSLF) with graft, 441 (24%) underwent SSLF without graft, and 200 (11%) underwent minimally invasive sacrocolpopexy (SCP) or sacrocervicopexy (SCerP). A significantly higher proportion of patients undergoing recurrent pelvic organ prolapse surgery was seen in SSLF without graft than in SSLF with graft (adjusted odds ratio [aOR] 2.2, 95% CI 1.4-3.6). Patient-reported sensation of vaginal bulging 1 year after surgery was higher in the SSLF group without graft than in the SSLF group with graft (aOR 1.9, 95% CI 1.3-2.8) and in the SCP/SCerP group (aOR 2.0, 95% CI 1.1-3.4). Finally, we found a significantly higher rate of complications 1 year after surgery in SSLF without graft (aOR 2.3, 95% CI 1.2-4.2) and in SSLF with graft (aOR 2.2, 95% CI 1.2-4.2) compared with SCP/SCerP. CONCLUSIONS: In patients with vaginal vault prolapse, SSLF without graft was associated with a higher frequency of recurrent pelvic organ prolapse surgery compared with SSLF with graft, and a higher subjective relapse rate compared with SCP/SCerP and SSLF with graft. Additionally, the complication rate 1 year after primary surgery was higher in SSLF both with and without graft than in SCP/SCerP.

Assessment of surgeon and hospital volume for robot-assisted and laparoscopic benign hysterectomy in Sweden.

INTRODUCTION: The study aims to analyze differences between robot-assisted total laparoscopic hysterectomy (RATLH) and total laparoscopic hysterectomy (TLH) in benign indications, emphasizing surgeon and hospital volume. MATERIAL AND METHODS: All women in Sweden undergoing a total hysterectomy for benign indications with or without a bilateral salpingo-oophorectomy from January 1, 2015 to December 31, 2017 (n = 12 386) were identified from three national Swedish registers. Operative time, blood loss, conversion rate, complications, readmission, reoperation, length of hospital stays, and time to daily life activity were evaluated by univariable and multivariable regression models in RATLH and TLH. Surgeon and hospital volume were obtained from the Swedish National Quality Register of Gynecological Surgery and divided into subclasses. RESULTS: TLH was associated with a higher rate of intraoperative complications (adjusted odds ratios [aOR] 2.8, 95% CI 1.3-5.8) and postoperative bleeding complications (aOR 1.8, 95% CI 1.2-2.9) compared with RATLH. Intraoperative data showed a higher conversion rate (aOR 13.5, 95% CI 7.2-25.4), a higher blood loss (200-500 mL aOR 3.5, 95% CI 2.7-4.7; > 500 mL aOR 7.6, 95% CI 4.0-14.6) and a longer operative time (1-2 h aOR 16.7 95% CI 10.2-27.5; >2 h aOR 47.6, 95% CI 27.9-81.1) in TLH compared with RATLH. The TLH group had a lower caseload per year than the RATLH group. Higher surgical volume was associated with lower median blood loss, shorter operative time, a lower conversion rate, and a lower perioperative complication rate. Differences in conversion rate or operative time in RATLH were not affected by surgeon volume when compared with TLH. One year after surgery, patient satisfaction was higher in RATLH than in TLH (aOR 0.6, 95% CI 0.4-0.9). CONCLUSIONS: RATLH led to better perioperative outcome and higher patient satisfaction 1 year after surgery. These outcome differences were slightly more pronounced in very low-volume surgeons but persisted across all surgeon volume groups.

Effects of Obesity on Peri- and Postoperative Outcomes in Patients Undergoing Robotic versus Conventional Hysterectomy.

STUDY OBJECTIVE: To assess if women with obesity have increased complication rates compared with women with normal weight undergoing hysterectomy for benign reasons and if the mode of hysterectomy affects the outcomes. DESIGN: Cohort study. SETTING: Prospectively collected data from 3 Swedish population-based registers. PATIENTS: Women undergoing a total hysterectomy for benign indications in Sweden between January 1, 2015, and December 31, 2017. The patients were grouped according to the World Health Organization's classification of obesity. INTERVENTIONS: Intraoperative and postoperative data were retrieved from the surgical register up to 1 year after the hysterectomy. Different modes of hysterectomy in patients with obesity were compared, such as open abdominal hysterectomy (AH), traditional laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and robot-assisted laparoscopic hysterectomy (RTLH). MEASUREMENTS AND MAIN RESULTS: Out of 12,386 women who had a total hysterectomy during the study period, we identified 2787 women with normal weight and 1535 women with obesity (body mass index ≥30). One year after the hysterectomy, the frequency of complications was higher in women with obesity than in women with normal weight (adjusted odds ratio [aOR]) 1.4; 95% confidence interval [CI], 1.1-1.8). In women with obesity, AH was associated with a higher overall complication rate (aOR 1.8; 95% CI, 1.2-2.6) and VH had a slightly higher risk of intraoperative complications (aOR 4.4; 95% CI, 1.2-15.8), both in comparison with RTLH. Women with obesity had a higher rate of conversion to AH with conventional minimally invasive hysterectomy (TLH: aOR 28.2; 95% CI, 6.4-124.7 and VH: 17.1; 95% CI, 3.5-83.8, respectively) compared with RTLH. AH, TLH, and VH were associated with a higher risk of blood loss >500 mL than RTLH (aOR 11.8; 95% CI, 3.4-40.5; aOR 8.5; 95% CI, 2.5-29.5; and aOR 5.8; 95% CI, 1.5-22.8, respectively) in women with obesity. CONCLUSION: The use of RTLH may lower the risk of conversion rates and intraoperative bleeding in women who are obese compared with other modes of hysterectomy.

Risk-factors for continuous long-term use of prescription opioid drugs 3 years after hysterectomy: A nationwide cohort study.

INTRODUCTION: The widespread misuse of prescription pain medication, including opioids, has serious public health implications. Postoperative pain is a risk factor for persistent or chronic pain unless treated effectively. There are only a few studies that have assessed the use of opioid-containing drugs after gynecological surgery and most of these usually have a short follow-up period. The aim of this study was to identify risk-factors for long-term use of prescription opioid drugs following hysterectomy. MATERIAL AND METHODS: We performed a nationwide cohort study based on prospectively collected data. Information from two population-based registers, the Swedish National Quality Register of Gynecological Surgery and the Swedish National Drug Register, was linked. The study population consisted of women with benign disease undergoing a total hysterectomy from 1 January 2012 until 31 December 2015. To identify long-term changes in prescription of opioids, individual data were collected from 1 year prior to to 3 years after surgery between 2011 and 2018. Data analysis was performed using multivariable logistic regression models. RESULTS: The population included 17 385 women having had hysterectomy for benign disease. Of these women, 4233 (24.4%) were prescribed analgesics continuously for 3 years postoperatively and 1225 (7.1%) used opioids long term. Perioperative predictors of opioid use 3 years after surgery included a diagnosis of adenomyosis (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.2-2.7) and preoperative use of opioids (aOR 29.6, 95% CI 19.7-44.4), psycho- (aOR 3.5, 95% CI 2.4-5.0) and neuroactive drugs (aOR 1.8, 95% CI 1.0-3.1). For women with no opioid prescription preoperatively (n = 260, 1.5%), mild (aOR 2.8, 95% CI 1.1-7.3) and severe (3.0% vs 6.2%: aOR 6.4, 95% CI 1.4-20.0) postoperative complications and preoperative prescription of psychoactive drugs (aOR 4.6, 95% CI 1.9-10.7) were associated with long-term use of drugs containing opioids. CONCLUSIONS: Long-term use of prescription opioids after hysterectomy is common and is, among other risk factors, strongly associated with preoperative use of opioids, as well as psychoactive drugs and adenomyosis. To avoid opioid misuse disorders among women at risk for long-term opioid drug prescriptions after hysterectomy, further studies and strategies are needed.

Perineorrhaphy Compared With Pelvic Floor Muscle Therapy in Women With Late Consequences of a Poorly Healed Second-Degree Perineal Tear: A Randomized Controlled Trial.

OBJECTIVE: To evaluate outcomes after pelvic floor muscle therapy, as compared with perineorrhaphy and distal posterior colporrhaphy, in the treatment of women with a poorly healed second-degree obstetric injury diagnosed at least 6 months postpartum. METHODS: We performed a single center, open-label, randomized controlled trial. After informed consent, patients with a poorly healed second-degree perineal tear at minimum 6 months postpartum were randomized to either surgery or physical therapy. The primary outcome was treatment success, as defined by Patient Global Impression of Improvement, at 6 months. Secondary outcomes included the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the Hospital Anxiety and Depression Scale. Assuming a 60% treatment success in the surgery group and 20% in the physical therapy group, plus anticipating a 20% loss to follow-up, a total of 70 patients needed to be recruited. RESULTS: From October 2015 to June 2018, 70 of 109 eligible patients were randomized, half into surgery and half into tutored pelvic floor muscle therapy. The median age of the study group was 35 years, and the median duration postpartum at enrollment in the study was 10 months. There were three dropouts in the surgery group postrandomization. In an intention-to-treat analysis, with worst case imputation of missing outcomes, subjective global improvement was reported by 25 of 35 patients (71%) in the surgery group compared with 4 of 35 patients (11%) in the physical therapy group (treatment effect in percentage points 60% [95% CI 42-78%], odds ratio 19 [95% CI 5-69]). The surgery group was superior to physical therapy regarding all secondary endpoints. CONCLUSION: Surgical treatment is effective and superior to pelvic floor muscle training in relieving symptoms related to a poorly healed second-degree perineal tear in women presenting at least 6 months postpartum. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02545218.

Associations Between Childbirth and Urinary Incontinence After Midurethral Sling Surgery.

OBJECTIVE: To assess whether subsequent childbirths affect the outcomes of midurethral sling surgery with regard to stress urinary incontinence (SUI). METHODS: In this population-based cohort study, we used the validated Swedish nationwide health care registers (the Patient Register and the Medical Birth Register) to identify women with a delivery after midurethral sling surgery (n=207, study group). From the same registers we then randomly identified a control group who had no deliveries after their midurethral sling procedure (n=521, control group). The women in the control group were matched to the women in the study group by age and year of surgery. The Urogenital Distress Inventory and the Incontinence Impact Questionnaire were sent out to the study population. Symptomatic SUI was defined as the primary outcome. Secondary outcomes included the total Urogenital Distress Inventory score, Urogenital Distress Inventory subscale scores, and Incontinence Impact Questionnaire scores. RESULTS: A total of 728 women were eligible for the study. The response rate was 74%; 163 in the study group (64 with vaginal delivery and 95 with cesarean delivery) and 374 women in the control group were included in the analysis. The rate of SUI (primary outcome) was 36 of 163 (22%) in the study group and 63 of 374 (17%) in the control group. In a multivariate regression analysis of the primary outcome, we found no significant difference between the groups (odds ratio [OR] 1.2, 95% CI 0.7-2.0). Vaginal childbirth after midurethral sling surgery did not increase the risk of SUI compared with cesarean delivery (22% vs 22%, OR 0.6, 95% CI 0.2-1.4). There were no significant differences in Urogenital Distress Inventory and Incontinence Impact Questionnaire scores between any of the groups. CONCLUSION: Childbirth after a midurethral sling procedure is not associated with an increased risk of patient-reported SUI, and continence status is not affected by the mode of a subsequent delivery.

Cervical amputation versus vaginal hysterectomy: a population-based register study.

INTRODUCTION AND HYPOTHESIS: Surgical management of uterine prolapse varies greatly and recently uterus-preserving techniques have been gaining popularity. The aim of this study was to compare patient-reported outcomes after cervical amputation versus vaginal hysterectomy, with or without concomitant anterior colporrhaphy, in women suffering from pelvic organ prolapse. METHOD: We carried out a population-based longitudinal cohort study with data from the Swedish National Quality Register for Gynecological Surgery. Between 2006 and 2013, a total of 3,174 patients with uterine prolapse were identified, who had undergone primary surgery with either cervical amputation or vaginal hysterectomy, with or without concomitant anterior colporrhaphy. Pre- and postoperative prolapse-related symptoms and patient satisfaction were assessed, in addition to complications and adverse events. Between-group comparisons were performed using univariate and multivariate logistic regression. RESULTS: There were no differences between the two groups in neither symptom relief nor patient satisfaction. In both groups a total of 81 % of the women reported the absence of vaginal bulging 1 year after surgery and a total of 89 % were satisfied with the result of the operation. The vaginal hysterectomy group had a higher rate of severe complications than the cervical amputation group, 1.9 % vs 0.2 % (p < 0.001). The vaginal hysterectomy group also had a longer duration of surgery and greater perioperative blood loss, in addition to longer hospitalization. CONCLUSIONS: Cervical amputation seems to perform equally well in comparison to vaginal hysterectomy in the treatment of uterine prolapse, but with less morbidity and a lower rate of severe complications.

Does the choice of suture material matter in anterior and posterior colporrhaphy?

INTRODUCTION AND HYPOTHESIS: The optimal suture material in traditional prolapse surgery is still controversial. Our aim was to investigate the effect of using sutures with rapid (RA) or slow (SA) absorption, on symptomatic recurrence after anterior and posterior colporrhaphy. METHODS: A population-based longitudinal cohort study with data from the Swedish National Quality Register for Gynecological Surgery. A total of 1,107 women who underwent primary anterior colporrhaphy and 577 women who underwent primary posterior colporrhaphy between September 2012 and September 2013 were included. Two groups in each cohort were created based on which suture material was used. Pre- and postoperative prolapse-related symptoms and patient satisfaction were assessed. RESULTS: We found a significantly lower rate of symptomatic recurrence 1 year after anterior colporrhaphy in the SA suture group compared with the RA suture group, 50 out of 230 (22 %) vs 152 out of 501 (30 %), odds ratio 1.6 (CI 1.1-2.3; p = 0.01). The SA group also had a significantly higher patient satisfaction rate, 83 % vs 75 %, odds ratio 1.6 (CI 1.04-2.4), (p = 0.03). Urgency improved significantly more in the RA suture group (p < 0.001). In the posterior colporrhaphy cohort there was no significant difference between the suture materials. CONCLUSIONS: This study indicates that the use of slowly absorbable sutures decreases the odds of having a symptomatic recurrence after an anterior colporrhaphy compared with the use of rapidly absorbable sutures. However, the use of RA sutures may result in less urgency 1 year postoperatively. In posterior colporrhaphy the choice of suture material does not affect postoperative symptoms.

Clinical efficacy of a trocar-guided mesh kit for repairing lateral defects.

INTRODUCTION AND HYPOTHESIS: The optimal surgery for lateral defects is not well defined. Our objective was to assess the effects of anterior trocar-guided transvaginal mesh repair versus anterior colporrhaphy in women with lateral defects. METHODS: This subanalysis from a randomized controlled trial of mesh kit versus anterior colporrhaphy assessed 99 patient diagnosed at baseline with lateral defects in the anterior vaginal wall. Thirty-nine patients underwent anterior colporrhaphy and 60 anterior trocar-guided transvaginal mesh surgery. RESULTS: One year after surgery, a persistent lateral defect was significantly more common after colporrhaphy compared with transvaginal mesh [11/32 (34.4 %) vs 1/42 (2.4 %), risk ratio (RR) 14.4, 95 % confidence interval (CI) 2.0-106.1; P < 0.001)] However, there were no significant differences between treatment groups with regard to subjective symptoms as reflected by the overall Urogenital Distress Inventory scores, with mean difference from baseline 37.3 ± 50.6 in the colporrhaphy group vs 39.0 ± 45.8 in the mesh group (p = 0.61). CONCLUSIONS: Use of a transvaginal mesh kit increases the odds for anatomical correction of lateral defects compared with anterior colporrhaphy but does not necessarily improve lower urinary tract symptoms.

Risk factors for mesh complications after trocar guided transvaginal mesh kit repair of anterior vaginal wall prolapse.

AIMS: To identify risk factors for mesh exposures after anterior pelvic organ prolapse repair using a standardized trocar guided polypropylene mesh kit. METHODS: A secondary risk analysis combining patients from two prospective multicenter studies. Main outcome was clinical host-vs-implant reactions one year after surgery using a macroscopic inflammatory scale. RESULTS: 353 patients were included in the study. Mean age at surgery was 65.3 (± 9.6 SD) years and surgery was performed as a primary procedure in 224/353 (63.5%) patients. Mesh exposures, of which the majority were mild-moderate, occurred in a total of 30/349 patients (8.6%). Multivariate logistic regression showed increased odds for mesh exposures for women who smoked before surgery (OR 3.48, 95% CI 1.18-10.28), who had given birth to more than two children (OR 2.64, 95% CI 1.07-6.51) and those with somatic inflammatory disease (OR 5.11, 95% CI 1.17-22.23). Age, body mass index, and menopausal status showed no significant association with clinical mesh exposures. CONCLUSIONS: Smoking, multiple childbirth, and somatic inflammatory disease are possible risk factors for mesh exposure after trocar guided mesh kit surgery for anterior pelvic organ prolapse. Preoperative smoking cessation may decrease the risk for exposures.

Effects of anterior trocar guided transvaginal mesh surgery on lower urinary tract symptoms.

AIMS: To assess the effects of trocar guided transvaginal mesh on lower urinary tract symptoms after anterior vaginal wall prolapse repair. METHODS: One hundred twenty-one patients undergoing anterior transvaginal mesh surgery was prospectively evaluated at baseline and 1 year after surgery using the urogenital distress inventory (UDI). RESULTS: Overall UDI scores declined from 91 before surgery to 31 one year after surgery (P < 0.001). UDI subscales for obstructive and irritative symptoms improved 1 year after surgery (P < 0.001 for both) while stress symptoms did not (P = 0.11). CONCLUSION: Trocar guided transvaginal mesh surgery for anterior vaginal wall prolapse was associated with an overall resolution of most symptoms associated with overactive bladder syndrome and bladder outlet obstruction. These beneficial effects should be weighed against an increased risk for stress urinary incontinence related to the procedure.

Urodynamic assessment of anterior vaginal wall surgery: a randomized comparison between colporraphy and transvaginal mesh.

AIMS: To investigate the urodynamic effects of anterior vaginal wall prolapse surgery using either trocar guided transvaginal mesh or colporraphy. METHODS: A prospective, randomized multicenter trial enrolling 50 patients: 27 underwent anterior colporrhaphy and 23 anterior trocar guided transvaginal mesh. Urodynamic assessment was performed pre- and two months postoperatively. RESULTS: De novo stress urinary incontinence was significantly more common after trocar guided transvaginal mesh surgery compared to colporraphy. In comparison to baseline urodynamics, transvaginal mesh surgery resulted in a significant decrease in maximal urethral closing pressures (MUCP) whereas conventional anterior colporraphy had no significant effect on urodynamic parameters. CONCLUSION: Trocar guided transvaginal mesh of anterior vaginal wall prolapse results in a lowering of MUCPs and increases the risk for de novo stress urinary incontinence compared to colporraphy.