Spatial Architecture of Myeloid and T Cells Orchestrates Immune Evasion and Clinical Outcome in Lung Cancer.

Understanding the role of the tumor microenvironment (TME) in lung cancer is critical to improving patient outcomes. We identified four histology-independent archetype TMEs in treatment-naïve early-stage lung cancer using imaging mass cytometry in the TRACERx study (n = 81 patients/198 samples/2.3 million cells). In immune-hot adenocarcinomas, spatial niches of T cells and macrophages increased with clonal neoantigen burden, whereas such an increase was observed for niches of plasma and B cells in immune-excluded squamous cell carcinomas (LUSC). Immune-low TMEs were associated with fibroblast barriers to immune infiltration. The fourth archetype, characterized by sparse lymphocytes and high tumor-associated neutrophil (TAN) infiltration, had tumor cells spatially separated from vasculature and exhibited low spatial intratumor heterogeneity. TAN-high LUSC had frequent PIK3CA mutations. TAN-high tumors harbored recently expanded and metastasis-seeding subclones and had a shorter disease-free survival independent of stage. These findings delineate genomic, immune, and physical barriers to immune surveillance and implicate neutrophil-rich TMEs in metastasis. SIGNIFICANCE: This study provides novel insights into the spatial organization of the lung cancer TME in the context of tumor immunogenicity, tumor heterogeneity, and cancer evolution. Pairing the tumor evolutionary history with the spatially resolved TME suggests mechanistic hypotheses for tumor progression and metastasis with implications for patient outcome and treatment. This article is featured in Selected Articles from This Issue, p. 897.

International urogynecological consultation chapter 4.1: definition of outcomes for pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: This manuscript of Chapter 4 of the International Urogynecological Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature and makes recommendations on the definition of success in the surgical treatment of pelvic organ prolapse. METHODS: An international group containing seven urogynecologists performed an exhaustive search of the literature using two PubMed searches and using PICO methodology. The first search was from 01/01/2012-06/12/2022. A second search from inception to 7/24/2022 was done to access older references. Publications were eliminated if not relevant to the clinical definition of surgical success for the treatment of POP. All abstracts were reviewed for inclusion and any disagreements were adjudicated by majority consensus of the writing group. The resulting list of articles were used to inform a comprehensive review and creation of the definition of success in the surgical treatment of POP. OUTCOMES: The original search yielded 12,161 references of which 45 were used by the writing group. Ultimately, 68 references are included in the manuscript. For research purposes, surgical success should be primarily defined by the absence of bothersome patient bulge symptoms or retreatment for POP and a time frame of at least 12 months follow-up should be used. Secondary outcomes, including anatomic measures of POP and related pelvic floor symptoms, should not contribute to a definition of success or failure. For clinical practice, surgical success should primarily be defined as the absence of bothersome patient bulge symptoms. Surgeons may consider using PASS (patient acceptable symptom state) or patient goal attainment assessments, and patients should be followed for a minimum of at least one encounter at 6-12 weeks post-operatively. For surgeries involving mesh longer-term follow-up is recommended.

Haemodynamic stability following adrenaline intracervical block for major haemorrhage during surgical management of late miscarriage: A case report.

The risk of heavy bleeding after a miscarriage is higher in women undergoing medical management compared with surgical. According to the literature, oxytocin receptor mRNA expression in the myometrium is not well formed during early gestation. Adrenaline may be considered in miscarriage which remains refractory to uterotonics and where bleeding from the placental bed may contribute to haemorrhage, before proceeding to surgical intervention. It is used in various settings to control bleeding in gynaecological procedures. A 34-year-old woman in her third pregnancy presented at 15 + 1 weeks of gestation with an open cervical os and bulging membrane. Within three hours of admission, she passed the fetus but failed to deliver the placenta and continued to bleed. She was taken to theatre for surgical management of miscarriage. The bleeding persisted following suction evacuation and despite the standard dose of oxytocin, and misoprostol uterotonics were given. Because the source of bleeding could be the placental bed, potentially low lying at this stage, a 4.4 ml prefix combination of 12.5 µg/ml adrenaline (1:80,000) and lidocaine (20 mg/ml) was administered as an intracervical block equally at four quadrants at the level of the cervical isthmus. This arrested the bleeding immediately and controlled the bleeding until discharge. This technique has not been described previously, which we believe causes vasoconstriction of the placental bed.

Laser treatment for genitourinary syndrome of menopause: Scientific Impact Paper No. 72 (July 2022): Scientific Impact Paper No. 72 (July 2022).

Genitourinary syndrome of menopause (GSM) is the term used to describe the group of symptoms including vaginal pain, vaginal dryness, itching, pain during sexual intercourse and fragile vaginal tissues as well as urinary symptoms including urinary frequency, urgency, incontinence, blood in the urine (haematuria) and recurrent urinary tract infections that occur due to a lack of the hormone estrogen. These symptoms can have a significant negative impact on psychosexual issues, sexual function and quality of life in postmenopausal women. Traditionally women have been treated with vaginal lubricants, vaginal moisturisers or low-dose vaginal estrogens. Lasers have been used in the cosmetic industry for collagen remodelling and repair of the skin. Therefore, it has been suggested that laser therapy may be used on the vagina as an alternative treatment for GSM. A review of all the published studies assessing the safety and efficacy of laser therapy for GSM have shown promising beneficial results. The majority of studies to date have been small, short-term, observational studies. However, there are randomised controlled trials underway. Laser treatment may be beneficial for the symptoms of GSM but until more robust evidence is available it should not be adopted into widespread practice, and should be used as part of a research study only.

Characterisation of tumour microenvironment remodelling following oncogene inhibition in preclinical studies with imaging mass cytometry.

Mouse models are critical in pre-clinical studies of cancer therapy, allowing dissection of mechanisms through chemical and genetic manipulations that are not feasible in the clinical setting. In studies of the tumour microenvironment (TME), multiplexed imaging methods can provide a rich source of information. However, the application of such technologies in mouse tissues is still in its infancy. Here we present a workflow for studying the TME using imaging mass cytometry with a panel of 27 antibodies on frozen mouse tissues. We optimise and validate image segmentation strategies and automate the process in a Nextflow-based pipeline (imcyto) that is scalable and portable, allowing for parallelised segmentation of large multi-image datasets. With these methods we interrogate the remodelling of the TME induced by a KRAS G12C inhibitor in an immune competent mouse orthotopic lung cancer model, highlighting the infiltration and activation of antigen presenting cells and effector cells.

Functional antibody and T-cell immunity following SARS-CoV-2 infection, including by variants of concern, in patients with cancer: the CAPTURE study.

Patients with cancer have higher COVID-19 morbidity and mortality. Here we present the prospective CAPTURE study (NCT03226886) integrating longitudinal immune profiling with clinical annotation. Of 357 patients with cancer, 118 were SARS-CoV-2-positive, 94 were symptomatic and 2 patients died of COVID-19. In this cohort, 83% patients had S1-reactive antibodies, 82% had neutralizing antibodies against WT, whereas neutralizing antibody titers (NAbT) against the Alpha, Beta, and Delta variants were substantially reduced. Whereas S1-reactive antibody levels decreased in 13% of patients, NAbT remained stable up to 329 days. Patients also had detectable SARS-CoV-2-specific T cells and CD4+ responses correlating with S1-reactive antibody levels, although patients with hematological malignancies had impaired immune responses that were disease and treatment-specific, but presented compensatory cellular responses, further supported by clinical. Overall, these findings advance the understanding of the nature and duration of immune response to SARS-CoV-2 in patients with cancer.

Functional antibody and T cell immunity following SARS-CoV-2 infection, including by variants of concern, in patients with cancer: the CAPTURE study.

Patients with cancer have higher COVID-19 morbidity and mortality. Here we present the prospective CAPTURE study, integrating longitudinal immune profiling with clinical annotation. Of 357 patients with cancer, 118 were SARS-CoV-2 positive, 94 were symptomatic and 2 died of COVID-19. In this cohort, 83% patients had S1-reactive antibodies and 82% had neutralizing antibodies against wild type SARS-CoV-2, whereas neutralizing antibody titers against the Alpha, Beta and Delta variants were substantially reduced. S1-reactive antibody levels decreased in 13% of patients, whereas neutralizing antibody titers remained stable for up to 329 days. Patients also had detectable SARS-CoV-2-specific T cells and CD4+ responses correlating with S1-reactive antibody levels, although patients with hematological malignancies had impaired immune responses that were disease and treatment specific, but presented compensatory cellular responses, further supported by clinical recovery in all but one patient. Overall, these findings advance the understanding of the nature and duration of the immune response to SARS-CoV-2 in patients with cancer.

Making a decision about surgery for female urinary incontinence: a qualitative study of women's views.

INTRODUCTION AND HYPOTHESIS: This qualitative interview study explores aspects women with urinary incontinence(UI) reflect upon when considering whether or not to have surgery. Conducted prior to the recent mesh pause in the UK, the article provides insights for current and future approaches to shared decision-making. METHODS: Qualitative in-depth interviews of 28 patients referred to secondary care for stress and mixed UI who were considering UI surgery. Participants were recruited from four urogynaecology clinics in the Midlands and South England, UK. Interviews were conducted in clinics, in patient homes, and by telephone. Data analysis was based on the constant comparative method. RESULTS: Participants' accounts comprised three key concerns: their experience of symptoms, the extent to which these impacted a variety of social roles and demands, and overcoming embarrassment. Accounts drew on individual circumstances, values, and concerns rather than objective or measurable criteria. In combination, these dimensions constituted a personal assessment of the severity of their UI and hence framed the extent to which women prioritized addressing their condition. CONCLUSIONS: Acknowledging women's personal accounts of UI shifts the concept of 'severity' beyond a medical definition to include what is important to patients themselves. Decision-making around elective surgery must endeavour to link medical information with women's own experiences and personal criteria, which often change in priority over time. We propose that this research provides insight into how the controversy around the use of mesh in the UK emerged. This study also suggests ways in which facilitating shared decision-making should be conducted in future.

Minimum standards for reporting outcomes of surgery in urogynaecology.

INTRODUCTION AND HYPOTHESIS: The IUGA special interest group (SIG) identified a need for a minimum data set (MDS) to inform outcome measurements to be included and simplify data capture and standardise reporting for data collection systems. To define a minimum data set for urogynaecological surgical registries. METHODS: Existing registries provide an inventory of items. A modified Delphi approach was used to identify a MDS. At each stage reviewers ranked data points and used free text to comment. The rating used a scale of 0-10 at each review and a traffic light system rated the scores as desirable, highly desirable and mandatory. The scores were collated and reported back to clinicians prior to the further rounds. Outliers were highlighted and reviewers re-assessed prior to repeating the process. A comparison of the MDS was made with published outcomes. RESULTS: Reviewers were from the outcome SIG with emphasis on widespread representation. Fifteen clinicians from eight countries were involved. Four reviewers dissected the existing databases. Eighty data points were considered in four categories, background, preoperative, intraoperative and postoperative. Consensus was reached by the third round. Two points were added on review (date of surgery and urodynamics). Three background points, five preoperative points, seven intraoperative points and nine postoperative points were identified giving 24 minimum data points in the final recommendation. CONCLUSIONS: An MDS has been developed for urogynaecological surgical registries. These should be mandatory points which then allow larger varying points to be assessed. These points correspond well to data points used in published papers from established databases.

Variation in surgical treatment advice for women with stress urinary incontinence: a study using clinical case vignettes.

INTRODUCTION: The aim of this study was to determine how recommendations of gynaecologists on surgical treatment for stress urinary incontinence (SUI) were influenced by patient characteristics. METHODS: Two hundred forty-five gynaecologists in the UK fully responded to an online questionnaire including 18 vignettes describing 7 clinical characteristics of women with SUI (age, body mass index, SUI type, previous SUI surgery, frequency of leakage, bother, physical status). The gynaecologists scored recommendations for surgery ranging from 1 'certainly not' to 5 'certainly yes'. Mean scores were used to calculate the relative impact ('weight') of each clinical characteristic. Latent class analysis was used to distinguish groups of gynaecologists with a particular practice style because they responded to the patient characteristics captured in the case vignettes in a similar way. RESULTS: The gynaecologists' overall average recommendation score was 2.9 (interquartile range 2 to 4). All patient characteristics significantly influenced the recommendation scores (p always < 0.001) but their impact was relatively small. SUI type was most important (weight 23%), followed by previous SUI surgery (weight 21%). Latent class analysis identified five groups of gynaecologists with practice styles that differed mainly with respect to their mean recommendation score, ranging from 1.3 to 4.0. CONCLUSIONS: Surgical treatment advice in response to case vignettes was only minimally influenced by patient characteristics. There were five groups of gynaecologists whose inclination to recommend surgical treatment varied. This suggests that there is lack of consensus on the role of surgery as a treatment for SUI. A considerable number of gynaecologists were reluctant to recommend surgery.

Geographical variation in rates of surgical treatment for female stress urinary incontinence in England: a national cohort study.

OBJECTIVE: To examine geographic variation in use of surgery for female stress urinary incontinence (SUI), mainly midurethral mesh tape insertions, in the English National Health Service (NHS). DESIGN: National cohort study. SETTING: NHS hospitals. PARTICIPANTS: 27 997 women aged 20 years or older who had a first SUI surgery in an English NHS Hospital between April 2013 and March 2016 and a diagnosis of SUI at the same time as the procedure. METHODS: Multilevel Poisson regression was used to adjust for geographic differences in age, ethnicity, prevalence of long-term illness and socioeconomic deprivation. PRIMARY OUTCOME MEASURE: Rate of surgery for SUI per 100 000 women/year at two geographic levels: Clinical Commissioning Group (CCG; n=209) and Sustainability and Transformation Partnership (STP; n=44). RESULTS: The rate of surgery for SUI was 40 procedures per 100 000 women/year. Risk-adjusted rates ranged from 20 to 106 procedures per 100 000 women/year across CCGs and 24 to 69 procedures per 100 000 women/year across the STP areas. These regional differences were only partially explained by demographic characteristics as adjustment reduced variance of surgery rates by 16% among the CCGs and 35% among the STPs. CONCLUSIONS: Substantial geographic variation exists in the use of surgery for female SUI in the English NHS, suggesting that women in some areas are more likely to be treated compared with women with the same condition in other areas. The variation reflects differences in how national guidelines are being interpreted in the context of the ongoing debate about the safety of SUI surgery.

Managing pain after synthetic mesh implants in pelvic surgery.

Pelvic mesh surgery has courted controversy with around 10% of patients experiencing complications. This article concentrates on the factors around pain, its presentation and management. Immediate pain is related to insertion and immediate removal recommended. With later presentation excision of the mesh relieves pain in up to 80% of women. Infection may be contributory but in refractory cases other factors maybe involved. Idiosyncratic reaction to mesh without risk factors appears to be relatively rare.

The effect of body mass index on retropubic midurethral slings.

BACKGROUND: Analyzing surgical databases uses "real-life" outcomes rather than highly selected cases from randomized controlled trials. Retropubic midurethral slings are a highly effective surgical treatment for stress urinary incontinence; however, if modifiable patient characteristics alter outcomes, thereby rendering treatments less effective, patients should be informed and given the opportunity to change that characteristic. OBJECTIVE: The aim of this study was to evaluate the effect of body mass index on patient-reported outcome measures by analyzing midurethral slings from the British Society of Urogynaecology database. MATERIALS AND METHODS: The British Society of Urogynaecology approved analysis of 11,859 anonymized midurethral slings from 2007 to 2016. The primary outcome of this retrospective cohort study was to assess how body mass index affects patient-reported outcome measures. Outcomes were assessed at 6 weeks, 3 months, 6 months, or 12 months after surgery, depending on local arrangements. Outcomes were compared by body mass index groups using χ2 tests. RESULTS: As BMI increased, Patient Global Impression of Improvement (PGI-I) scores declined. Women with a normal body mass index (18 to <25) reported feeling better in 91.6% of cases compared to lower rates in BMI groups >30 (87.7-72%) (P < .001). Patient-reported outcome measures for stress urinary incontinence inversely correlated with body mass index, with 97% of women with normal body mass index stating that they were cured/improved compared to women in higher body mass index groups (84-94%) reporting lower rates (P < .005). Patient-reported outcome measures for overactive bladder show that as body mass index increases, patients reported higher rates of worsening symptoms (P < .05). There were higher rates of perforation at the low and high extremes of body mass index. CONCLUSION: Our results suggest increased body mass index is associated with poorer outcomes after midurethral sling surgery, and that patients should be given the opportunity to change their body mass index. These data could help to develop a model to predict personalized success and complication rates, which may improve shared decision making and give an impetus to modify characteristics to improve outcomes.

miR-29b directly targets activation-induced cytidine deaminase in human B cells and can limit its inappropriate expression in naïve B cells.

Class-switch recombination (CSR) is an essential B cell process that alters the isotype of antibody produced by the B cell, tailoring the immune response to the nature of the invading pathogen. CSR requires the activity of the mutagenic enzyme AID (encoded by AICDA) to generate chromosomal lesions within the immunoglobulin genes that initiate the class switching recombination event. These AID-mediated mutations also participate in somatic-hypermutation of the immunoglobulin variable region, driving affinity maturation. As such, AID poses a significant oncogenic threat if it functions outside of the immunoglobulin locus. We found that expression of the microRNA, miR-29b, was repressed in B cells isolated from tonsil tissue, relative to circulating naïve B cells. Further investigation revealed that miR-29b was able to directly initiate the degradation of AID mRNA. Enforced overexpression of miR-29b in human B cells precipitated a reduction in overall AID protein and a corresponding diminution in CSR to IgE. Given miR-29b's ability to potently target AID, a mutagenic molecule that can initiate chromosomal translocations and "off-target" mutations, we propose that miR-29b acts to silence premature AID expression in naïve B cells, thus reducing the likelihood of inappropriate and potentially dangerous deamination activity.

What can we learn from large data sets? An analysis of 19,000 retropubic tapes.

INTRODUCTION AND HYPOTHESIS: Retropubic tapes are successful for treating stress urinary incontinence (SUI), but there is controversy around risk profiles. The British Society of Urogynaecology (BSUG) database allows analysis of surgery for patient safety, surveillance and benchmarking. Objectives of this study were to establish success and complication rates in routine practice, determine complication rates for trainees and consultants, explore reasons for outliers and assess perforation as a surrogacy of quality. METHODS: Approval was obtained from BSUG to use data on retropubic tapes. Data was anonymised, and patients gave prior consent. Analysis was done using the χ2 test, and a funnel plot of bladder perforation rate was calculated. RESULTS: There were 18,763 procedures recorded: 14,156 were performed by consultants, 64 by associate specialists (64), 1140 by subspecialty trainees, 2549 by registrars, 201 staff grades and 377 other. We found a 3.5 % bladder perforation rate, which was statistically higher for trainees than consultants (p < 0.05). The rate of other "standard" complications were low: 95.8 % of patients felt better on the Patient Global Impression of Improvement of Incontinence (PGI) scale. There was a significant difference (p < 0.05) in PGI and SUI outcome between patients who did and did not experience perforation. CONCLUSIONS: Success rates with retropubic tapes are high, with low complication rates. Bladder perforation in "real", not "trial" data was 3.5 %, which is lower than reported by the Cochrane review (4.5 %). Trainees have a higher perforation rate (p < 0.05) because of learning curves. Outliers are easily identified, and reasons for this should be explored, including proportion of trainees doing the surgery. This analysis confirms that bladder perforation is a valid surrogate for quality with a small but measurable difference. We have a responsibility to analyse data to improve patient care and encourage colleagues to support the International Urogynaecology Association (IUGA) database initiative.

Does age affect the outcome of suburethral tape surgery? The importance of national registries in answering bigger questions.

INTRODUCTION AND HYPOTHESIS: The objective of this article was to use the British Society of Urogynaecology (BSUG) database to assess the impact of age on success rates and insertion complications of suburethral tapes for primary procedures using the Patient Global Impression of Improvement (PGII) as the primary endpoint. METHODS: We carried out a retrospective analysis of data at a national level (BSUG database) using PGII as the primary outcome measure. Secondary outcomes included improvement in stress incontinence and complications from surgery. All episodes of suburethral tapes on the database were extracted and analysis was by decade of life. RESULTS: A total of 7,600 cases were identified on the database, of which 757 were in women over 70 years of age, with 119 in women over 80. Just over 80 % of the cases on the database involved retropubic and just under 20 % transobturator tapes. Short-term follow-up was available for 54 % of the cases. The PGII remained high in all age groups, but did decrease slightly with age, with more than 90 % of women under 50 scoring highly, which reduced to 70 % in those over 80. Improvement in stress incontinence was globally high, with 98 % scoring highly in the women aged under 50 and 85 % in the 80+ group. This suggests that the suburethral tapes worked well in treating stress incontinence. Reassuringly, complications did not increase with age, although short-term voiding difficulties were higher with increasing age. CONCLUSION: Contributing to national databases gives useful information that may be difficult to ascertain from RCTs. Suburethral tapes appear to have good efficacy and low complications with increasing age.

The role of ambulatory urodynamics in investigation of female urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Lower urinary tract symptoms (LUTS) impact upon quality of life and occur in women of all ages. The National Institute for Clinical Excellence states that ambulatory urodynamic monitoring (AUM) should be used as a second-line investigational modality; however, its use is becoming more frequent. AUM provides a valid second line to conventional urodynamic methods that may be more widely used. METHOD: A literature review was undertaken to assess evidence for the use of AUM alongside a retrospective review of patients undergoing AUM at a tertiary care centre and symptom reporting at a follow-up visit. Both these methods included evidence for pathology detection, technical ease of use, recreation of symptoms and patient experience, allowing comparison of literature results to those experienced in day-to-day use. RESULTS: The literature shows AUM to have sensitivity superior to that of other urodynamic investigations. However, evidence suggests this correlates less well with clinical effectiveness. Patients felt AUM was superior in recreating their symptoms, and they tolerated the procedure well. The increased technical demands of AUMs, however, meant that traces were more commonly harder to interpret than with conventional urodynamics. Our experience correlates well with the existing literature, suggesting increased symptom diagnosis; 63.2 % of diagnoses correlated well with symptoms. CONCLUSION: AUM remains an important urodynamic method to supplement conventional urodynamics. Evidence suggests it is superior in LUTS diagnosis, but its technical difficulty can affect results.

Does vaginal estrogen treatment with support pessaries in vaginal prolapse reduce complications?

OBJECTIVE: Pelvic organ prolapse is often co-existant with atrophy of the genital tract in older women who tend to prefer vaginal pessaries for prolapse. Vaginal estrogen therapy is used by some along with a support pessary for prolapse with no robust evidence to back this practice. We aimed to evaluate differences in complications of support pessaries for vaginal prolapse in postmenopausal women, with and without vaginal estrogen use. STUDY DESIGN: We prospectively assessed postmenopausal women attending the urogynaecology clinic for a pessary change. We asked them about the level of discomfort during pessary change (visual analogue scale for pain), discharge, bleeding and infection. Ethics approval was not required as this was a service evaluation project. Statistical analysis for relative risk was performed, including sub-group analysis for 'ring pessary' and 'non-ring group' (Shelf, Gellhorn, Shaatz). RESULTS: Between July 2013 and December 2014, we assessed 120 postmenopausal women using support pessaries for prolapse. The mean age was 70 years; 45% of the patients used vaginal estrogen. There were no statistically significant differences in complications with or without vaginal estrogen use, although the trend was higher amongst non-users. The 'non-ring' sub-group not using vaginal estrogen had a higher risk of vaginal ulceration, bleeding and discharge. CONCLUSION: Postmenopausal women may have lesser complications when using vaginal estrogen with a support pessary for prolapse, particularly with pessaries other than the ring. An adequately powered randomised controlled trial is needed to assess conclusively whether vaginal estrogen enhances comfort and reduces complications of support pessaries for prolapse.

What is the best surgical intervention for stress urinary incontinence in the very young and very old? An International Consultation on Incontinence Research Society update.

An increasing number of continence procedures are being performed in women of all ages. An overview of the existing literature and consensus regarding surgery for stress urinary incontinence (SUI) in the young and the old was presented and discussed at the International Consultation on Incontinence Research Society Think Tank. This manuscript reflects the Think Tank's summary and opinion. Despite the increasing number of continence procedures, there are relatively few data to guide management in the very young and the very old. When considering continence surgery in the young, long-term efficacy and safety are paramount, and the future effects of pregnancy and childbirth need to be carefully considered. Conversely, in the elderly, minimally invasive procedures with low morbidity are important, especially in the frail elderly who may have significant co-morbidities. Further research including prospective randomised trials, cohort studies and national registries, should help guide our management in these two challenging groups of patients.

Management of prolapse in older women.

Pelvic organ prolapse (POP) is a common problem affecting 37% of women over the age of 80. Review by a specialist with the aid of a validated quality of life questionnaire will help assess bother, as well as the frequency and severity of urinary, bowel and sexual symptoms. Pelvic examination should be carried out to assess the extent of any prolapse and the compartments affected. The main aim of the treatment is to improve the woman's quality of life. Treatment options may be conservative with lifestyle modifications and pelvic floor muscle therapy, use of a pessary or surgery. Treatment has previously been incorrectly limited in the elderly with the misconception that surgery should be avoided. Her current state of health and expectations are most important. Regardless of age, each patient should be assessed individually with a holistic multi-compartment approach and the risk benefit ratios of every treatment considered.