Urogynecology Section of the Polish Society of Gynecologists and Obstetricians Guidelines on the management of recurrent pelvic organ prolapse.

OBJECTIVES: The aim of the publication was to present the Guideline of the Urogynecology Section of the Polish Society of Gynecologists and Obstetricians (PSGO) for the management of recurrent pelvic organ prolapse, based on the available literature, expert knowledge and opinion, as well as everyday practice. MATERIAL AND METHODS: In 2005, 2006 and 2010, the panel of PSGO experts published guidelines for the diagnosis and treatment of patients with lower urinary tract symptoms (LUTS). This publication presents an update of those recommendations and concerns recurrent POP treatment. MAIN CONCLUSION: The analysis of data revealed that sacrocolpopexy with the use of commercial sets or polypropylene hernia mesh is the method of choice for the surgical repair of recurrent vaginal vault prolapse. However, a significantly higher risk of surgical and postoperative complications after sacrocolpopexy, as compared to vaginal surgeries, should be considered when making treatment decisions. In other types of recurrent POP, the choice of surgery method should be tailored to the individual needs of each patient and may depend on the medical center.

The role of TVT position in relation to the pubic symphysis in eliminating the symptoms of stress urinary incontinence and urethral funneling.

The introduction of suburethral sling was a breakthrough in the treatment of stress urinary incontinence in women. The method is highly effective. However, the mechanism of action of a sling and the reasons for surgical failures are not fully understood. Aim: The aim of the study was to assess the impact of sling-pubic symphysis distance on eliminating the symptoms of stress urinary incontinence and urethral funneling. Materials and methods: The analysis included 106 patients who reported 3 to 6 months after sling placement for a follow-up visit encompassing clinical examination and standard ultrasonography. We evaluated the position of sling in relation to the pubic symphysis, urethral length, as well as urethral funneling length and width. Results: Cure criteria were met by 91 patients. Elimination of urethral funneling was achieved in 76.9% (n = 70) of cured patients. Urethral funneling was still present, yet shorter by a mean of 10.2 mm (p = 0.02) than before surgery in the remaining cured patients. There was a 32.5% reduction in the mean relative length of urethral funneling (p = 0.002). No significant differences were found in the pre- and postoperative funneling width. The tape-pubic symphysis distance was lower in cured women: 23.2 mm vs. 26.1 mm in failed women (p = 0.04). Similar observations were made for cured patients with persistent urethral funneling vs. failed patients (22.47 mm vs. 26.0 mm, p = 0.027). There were no differences between cured patients without urethral funneling and cured patients with persistent postoperative funneling (23.5 mm; 22.5 mm; p = 0.417). Conclusions: Tape position in relation to the pubic symphysis is important for the elimination of stress urinary incontinence. Sling location closer to the pubic symphysis reduces the length of urethral funneling, but has no effects on its width in cured patients with persistent postoperative funneling.

The influence of nebivolol on the activity of BRL 37344 - the ß3-adrenergic receptor agonist, in the animal model of detrusor overactivity.

AIMS: The cardiotoxic effects of antimuscarinics constitute a significant restriction in their application in elderly people. Overactive bladder syndrome pharmacotherapy using compounds with cardioprotective properties would seem an ideal solution. The main goal of the study was to assess the impacts of nebivolol (NEB) on the activity of BRL 37344 - ß3-adrenergic receptor (ß3AR) agonist, in the animal model of detrusor overactivity. As both these substances can impact on the cardiovascular system, their effect on the parameters of this system and diuresis was also examined. METHODS: Retinyl acetate (RA; 0.75%) solution was used to induce detrusor overactivity in female Wistar rats. BRL and/or NEB were administered intra-arterially during cystometry in a single dose (2.5 or 5, 0.05 or 0.1 mg/kg, respectively). In addition, a 24 hours measurement of heart rate, blood pressure, and urine production was carried out. RESULTS: NEB (0.05 mg/kg) and BRL (2.5 mg/kg) monotherapy proved to have no influence on the cystometric parameters of animals with RA-induced detrusor overactivity. NEB at 0.1 mg/kg resulted in a drop in the detrusor overactivity index, similarly to BRL at 5 mg/kg. Coadministration of NEB and BRL, both at ineffective doses, decreased the detrusor overactivity index and ameliorated the nonvoiding contractions. ß3AR stimulation proved to induce tachycardia and hypertension. NEB at 0.05 mg/kg proved to ameliorate detrusor overactivity and have preventive properties against adverse cardiovascular effects of the ß3AR agonist. CONCLUSIONS: The combined application of the ß3AR agonist and NEB may improve detrusor overactivity without affecting the heart rate, blood pressure, and urine production.

Blebbistatin reveals beneficial effects on the cystometric parameters in an animal model of detrusor overactivity.

The aims of the study were to determine the effectiveness of blebbistatin (BLEB) on detrusor overactivity (DO) in an animal model induced by retinyl acetate (RA) and, because of potential urothelial permeability, to evaluate the degenerative impact of BLEB on the urothelium. Three days after RA instillation into the urinary bladder, BLEB was administered into the bladder and immediately after cystometric assessment was performed. Furthermore, Evans Blue extravasation into bladder tissue and urothelium thickness were measured. Sixty female Wistar rats were used and randomly assigned to one of four groups (n = 15 in each group): (1) control, (2) RA, (3) BLEB, and (4) RA + BLEB. RA administration induced changes in cystometric parameters reflecting DO, as previously reported. Treatment with BLEB did not significantly alter cystometric parameters in rats which did not receive RA. Administration of BLEB to rats pretreated with RA reversed changes in cystometric parameters induced by RA in basal pressure, threshold pressure, detrusor overactivity index, amplitude of nonvoiding contractions, frequency of nonvoiding contractions, voided volume, volume threshold, intercontraction interval, bladder compliance, and volume threshold to elicit nonvoiding contractions. There were no significant differences in Evans Blue extravasation into bladder tissue or urothelium thickness between the groups. The current research provides new data on the possible utility of blebbistatin in the pharmacotherapy of DO, which is an important feature of overactive bladder (OAB). Further studies in human patients with DO/OAB are warranted to confirm these preclinical results.

Blebbistatin, a Myosin II Inhibitor, Exerts Antidepressant-Like Activity and Suppresses Detrusor Overactivity in an Animal Model of Depression Coexisting with Overactive Bladder.

Overactive bladder (OAB) coexists with depression in women. Here, we assessed the effects of a 1-week treatment with blebbistatin, a myosin II inhibitor, on changes in behavior and detrusor overactivity (DO) symptoms induced by a 6-week administration of 13-cis-retinoic acid (13-cis-RA), with the aid of the forced swim test (FST), spontaneous locomotor activity test, and in vivo cystometric investigations in female Wistar rats. 13-cis-RA-induced depressive-like behavior and DO symptoms were associated with increased corticotropin-releasing factor (CRF) level in the plasma, prefrontal cortex (PFC), hippocampus (Hp), Barrington's nucleus (BN), and urinary bladder. Moreover, 13-cis-RA decreased brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) levels in plasma, PFC, Hp, and BN, while it increased BDNF and NGF levels in urinary bladder. Blebbistatin exerted antidepressant-like effect and attenuated changes in the cystometric parameters as well as the central and peripheral levels of CRF, BDNF, and NGF that were induced by 13-cis-RA, while it did not affect urine production, mean, systolic or diastolic blood pressure, or heart rate. The results point to blebbistatin as a potential treatment option for OAB coexisting with depression.

Transvaginal six-arm mesh OPUR in women with apical pelvic organ prolapse - analysis of short-term results, pelvic floor ultrasound evaluation.

OBJECTIVES: Analysis of feasibility, efficacy and short-term results after six-arm transvaginal mesh OPUR implantation in women with apical prolapse. MATERIAL AND METHODS: The same surgeon operated all of 39 women using mesh OPUR. Preoperatively patients had a standardized interview and clinical examination. Intraoperative and postoperative complications were analyzed. Postoperative evaluation included standardized interview, clinical examination and standardized pelvic floor ultrasound performed with 2D transvaginal probe and 4D abdominal probe. RESULTS: There was no complication that needed operative intervention. Hematomas in 3 patients resolved spontaneously. Transient voiding difficulties which lasted less than 7 days were observed in 5 patients. No erosion was observed. Comparison of pre- and postoperative results in 34 women revealed that in all 3 compartments improvement in POP-Q scale was statistically significant (p < 0.0000). One patient with malposition and rolled up mesh needed re-operation. During PFS-TV in 94.1% of patients urethra was normobile or hypermobile. In all of the patients urethral end of the mesh was positioned far enough from the middle part of the urethra (ultrasound) to implant suburethral sling without risk of collision. Sexually active women did not inform of any important discomfort or pain during intercourse. CONCLUSIONS: It seems that six-arm OPUR mesh, if implanted under strict surgical rules, gives low risk of complications and high chance to successfully reduce POP symptoms in short term after the operation. It seems that OPUR mesh should not have negative influence on the results after anti-incontinence suburethral sling.

The effectiveness of a pre-pubic four-arm NAZCA-TC mesh in treating cystocele and stress urinary incontinence simultaneously - results controlled with a pelvic floor ultrasound. A preliminary study.

OBJECTIVES: It is controversial whether pelvic organ prolapse and stress urinary incontinence (SUI) should be treated simultaneously with a single surgery or separately with two procedures. The pre-pubic four-arm NAZCA-TC® mesh was invented to treat cystocele and SUI with a single procedure. The objective of this study is to analyze short-term results after the implantation of NAZCA-TC mesh. MATERIAL AND METHODS: A total of 18 women underwent the evaluation of results of mesh implantation within a 24 to 36 months follow-up. Pre-operatively, patients were examined under standardized conditions. Postoperatively we analyzed the following: standardized interview and examination as well as pelvic floor ultrasound: 2D with a transvaginal probe and 4D with an abdominal probe. RESULTS: There was one case of intraoperative bladder damage noticed and repaired followed with NAZCA implantation. In 2 cases vaginal erosion was found that healed successfully after re-operation. In 3 cases hematomas were observed but resolved spontaneously. After the surgery there was a statistically significant improvement of prolapse in anterior (p < 0.0003) and in central (p < 0.001) compartment. Six women (33.3%) had no stress urinary incontinence symptoms during the control visit but we did not find a statistically significant improvement in SUI symptoms after the procedure. We recorded no case of hypomobile urethra after the surgery. The mesh covered > 50% of the urethral length in all of the patients. CONCLUSIONS: Mid-term results showed that implantation of NAZCA TC mesh allows to achieve statistically significant im-provement in reducing cystocele coexisting with enterocele in over 65% of patients. A complete cure from stress urinary incontinence was confirmed in 1/3 of patients. NAZCA-TC covered more than 50% of the urethral length, which can possibly have a negative influence on the effectiveness of the suburethral tape.

Can we predict urinary stress incontinence by using demographic, clinical, imaging and urodynamic data?

OBJECTIVE: It has been claimed that urethral hypermobility and resting urethral pressure can largely explain stress incontinence in women. In this study we tried to replicate these findings in an unselected cohort of women seen for urodynamic testing, including as many potential confounders as possible. STUDY DESIGN: This study is a retrospective analysis of data obtained from 341 women. They attended for urodynamic testing due to symptoms of pelvic floor dysfunction. We excluded from the analysis women with a history of previous anti-incontinence and prolapse surgery. All patients had a standardised clinical assessment, 4D transperineal pelvic floor ultrasound and multichannel urodynamic testing. Urodynamic stress incontinence (USI) was diagnosed by multichannel urodynamic testing. Its severity was subjectively graded as mild, moderate and severe. Candidate variables were: age, BMI, symptoms of prolapse, vaginal parity, significant prolapse (compartment-specific), levator avulsion, levator hiatal area, Oxford grading, midurethral mobility, maximum urethral pressure (MUP), maximum cough pressure and maximum Valsalva pressure reached. RESULTS: On binary logistic regression, the following parameters were statistically significant in predicting urodynamic stress incontinence: age (P=0.03), significant rectocele (P=0.02), max. abdominal pressure reached (negatively, P<0.0001), midurethral mobility (P=0.0004) and MUP (negatively, P<0.0001). On multivariate analysis, accounting for multiple interdependencies, the following predictors remained significant: max. abdominal pressure reached (negatively, P<0.0001), cough pressure (P=0.006), midurethral mobility (P=0.003) and MUP (negatively, P<0.0001), giving an R(2) of 0.24. CONCLUSIONS: Mid-urethral mobility and MUP are the main predictors of USI. Demographic and clinical data are at best weak predictors. Our results suggest the presence of major unrecognised confounders.

[Evaluation of cyclin E expression in endometrial hyperplasia and cancer in postmenopausal women]. / Ocena ekspresji cykliny E w rozrostach i raku blony sluzowej trzonu macicy u kobiet po menopauzie.

OBJECTIVES: The aim of present study was to determine expression of cyclin E in endometrial hyperplasia without atypia, atypical endometrial hyperplasia and endometrial cancers in comparison with expression of cyclin E in atrophic endometrium of postmenopausal women. We have also estimated relationship between cyclin E expression and prognostic factors for endometrial cancer such as: histological type, cancer stage and histological grade. MATERIAL AND METHODS: 154 women were enrolled into study Women were divided into 4 groups. The first group consist of 38 women with endometrial hyperplasia without atypia, the second group consist of 18 women with atypical endometrial hyperplasia. The third group comprise 62 women with endometrial cancer and the forth 36 women with atrophic endometrium. Cyclin E expression was estimated in formalin-fixed, paraffin-embedded tissues obtained from enrolled women with the use of immunohistochemical techniques. We estimated labelling index (LI) - the number of cells that stained for cyclin E in relation to all cells at the certain field of view. RESULTS: Medians of labelling indices of cyclin E in atrophic endometrium, endometrial hyperplasia with atypia, atypical endometrial hyperplasia end endometrial cancer were 13.7%, 34.7%, 62%, 72.2% respectively These differences were statistically significant. In our study we haven't found relationship between cyclin E expression and histological type of tumour (p = 0.186), cancer stage (p = 0.186) and histological grade (p = 0.539) CONCLUSIONS: In the carcinogenesis of endometrial tumours in postmenopausal women there is a progressive disorder in mechanisms regulating cell cycle. It seems impossible to use cyclin E as prognostic factor for endometrial cancer.

[The effects of operative SUI treatment established using Burch colposuspension and IVS tape and evaluated through various urogynecologic tests]. / Efekty leczenia operacyjnego wysilkowego mietrzymania moczu (wnm) za pomoca kolpopsuspensji sposobem Burcha oraz tasmy IVS oceniane przy uzyciu róznych badan uroginekologicznych.

OBJECTIVES: Numerous diagnostic instruments have been used in modern urogynecology; alas, sufficient comparative analysis between most of them has not been carried out in world literature. DESIGN: The aim of the study was to compare the results of selected urogynecology tests, used to analyze the effectiveness of SUI treatment, using Burch colposuspension and IVS tape. MATERIAL: The study was conducted among 76 patients selected for operative treatment of SUI II and III degree, using of Burch colposuspension (I group, n=47) and IVS tape, Tyco (II group, n=29). METHODS: The following investigations: urogynecologic anamnesis and examination with cough test, miction diary, pad test, urodynamic exam and UDI-6 questionnaire, have been used to evaluate SUI symptoms before and half a year after the operation. RESULTS: The percentage of the cured, depending on the adopted urogynecology investigation, oscillated in group I between 56.8% to 91.5%, and 56.5% to 86.2% in group II. The best results were obtained in anamnesis and cough test. CONCLUSIONS: 1. The analyzed methods of urogynecology tests correlate with anamnesis as far as SUI symptoms after operative treatment are concerned. 2. There are relevant differences between several tests, in case of the estimation of SUI cure rate after colposuspension, as well as when using IVS tape.

[Abdominal sacrocolpopexy in the enterocoele treatment--analysis of the surgical technique and the course of the initial procedures]. / Brzuszna sakrokolpopeksja w leczeniu enterocele--omówienie techniki operacyjnej oraz analiza przebiegu pierwszych operacji.

OBJECTIVES: Abdominal sacrocolpopexy is one of the most effective treatments of enterocoele. Alas, little is known about complications resulting from the procedure. DESIGN: The aim of the study was to analyze the course of the operation, the perioperative period and the outcome of abdominal sacrocolpopexy. MATERIALS AND METHODS: 8 women, aged 60-75, have undergone the operation. The sacrocolpopexy procedure has been performed through abdominal access on patients with considerable enterocele (III and IV degree on POP-Q scale). Polypropylene multifilament tape Surgipro (Tyco) has been applied in all cases. RESULTS: All of the procedures have run without any complications. The patients did not complain about any major ailments during postoperative period and have been released from the hospital according to schedule. One month after the operation, the check-up proved the outcome was good. After six months, III degree POP has been diagnosed again in two patients with previously performed Richter operation and, additionally, vaginal erosion has been found in one of them. CONCLUSIONS: Abdominal sacrocolpopexy procedure involves a low risk of complications. Detailed evaluation will only be possible after assessing higher number of procedures and estimating the results after a longer period of time.

[Sacrospinous colposacrofixation in the treatment of female pelvic organ prolapse (POP)--analysis of the operation course and complications]. / Kolpopeksja krzyzowo-kolcowa w leczeniu zaburzen statyki narzadu plciowego u kobiet--analiza przebiegu operacji oraz powiklan na podstawie doswiadczen wlasnych.

OBJECTIVES: Richter operation is used for the enterocele and high rectocoele treatment. There are many modifications of the procedure. Alas, not much data concerning complications and the learning curve of Richter operation is currently at our disposal. DESIGN: The aim of the study is to analyze the course of sacrospinous colposacrofixation and the postoperative period of time in order to optimize surgical technique. MATERIAL AND METHODS: The first 200 procedures, performed by two surgeons, have been investigated. Women with II, III and IV degree of pelvic organ prolapse, according to POP-Q scale, recommended by ICS, have undergone the operation. In accordance with the protocol, we have analyzed the course of the operation and postoperative period of time during the patients' stay in the hospital, as well as the first month after their leaving the hospital. RESULTS: Difficulties in reaching the sacrospinous ligament have occurred during the initial procedures. The incidence of the problem has been gradually reducing with the increasing number of performed operations. None of the patients was in need of blood transfusion. Granulation in the vagina, resulting in the necessity of its, and parts of sutures, evacuation, occurred in case of 6 (3%) patients. CONCLUSIONS: Sacrospinous colposacrofixation equals a low risk of complications, even during the initial procedures. With the rise of the number of performed operations and better ability recognition of anatomic properties of the operating area, technical problems decrease significantly.