Are older patients with prolapse likely to continue pessary use? A retrospective observational study.

INTRODUCTION AND HYPOTHESIS: To review the outcomes and complications of vaginal prolapse management with pessaries in women aged 75 years or older, to ascertain whether pessaries are providing satisfactory long-term outcomes for older women. METHODS: A retrospective observational study was performed on women aged 75 years or older presenting to a tertiary Urogynaecology service with vaginal prolapse who opted for management with a vaginal pessary. Demographic and clinical data were collected by reviewing clinical files. The primary outcome was the proportion of women who opted for pessary management who later required prolapse surgery. Secondary outcomes included pessary complications and risk factors for failure. Kaplan-Meier survival estimates were performed to analyse pessary failure. RESULTS: Of the 218 women who presented with prolapse, 78% opted for pessary management, and pessary fitting was successful in 84%. Sixty-nine percent of women who opted for initial pessary management underwent surgery later, with a mean time from pessary insertion to surgery of 21.6 months. Vaginal erosions were reported in 42% of pessary users. Risk factors for pessary failure were younger age and previous history of hysterectomy or prolapse surgery. CONCLUSIONS: Although vaginal pessary use was the preferred first-line management choice for vaginal prolapse in most older women, surgery for prolapse was ultimately required in two-thirds of those conservatively managed. As three-quarters of older women presenting with prolapse had surgery as either a primary or secondary procedure; patients need to be advised of the high chance of requiring surgery at a later stage if they opt for pessary management.

Long-term effectiveness and safety of open Burch colposuspension vs retropubic midurethral sling for stress urinary incontinence-results from a large comparative study.

BACKGROUND: There are few adequately powered long-term trials comparing midurethral sling and Burch colposuspension. Recent concerns about synthetic mesh with new stringent clinical and research governance support the need for evidence to facilitate shared decision making. OBJECTIVE: This study aimed to compare long-term outcomes of open Burch colposuspension with the retropubic midurethral sling. STUDY DESIGN: A matched cohort study of 1344 women with urodynamic stress incontinence (without intrinsic sphincter deficiency) who underwent surgery for stress urinary incontinence. Women had either open Burch colposuspension or the retropubic midurethral sling, from January 2000 to June 2018, in a tertiary center. Follow-up was by chart review and one-time phone follow-up until 2019, using a dedicated database. Primary outcomes were the presence or absence of stress urinary incontinence on follow-up, the success of index surgery based on response to validated questionnaires of patient-reported outcomes, and retreatment rates. Secondary outcomes are described below. Matching (1:3) was done at baseline to avoid confounding. RESULTS: The study included 1344 women who had either Burch colposuspension (336) or retropubic midurethral sling (1008). Mean follow-up was 13.1 years for Burch colposuspension and 10.1 years for retropubic midurethral sling. In the Burch colposuspension group, 83.0% of patients (279 of 336) reported no ongoing stress urinary incontinence at the time of the latest follow-up vs 85.0% (857 of 1008) in the retropubic midurethral sling group (P=.38). Success in terms of the latest reported International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (defined as International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form score of ≤6) where these data were available were similar within both groups: 76.0% (158 of 208 where this was available) in Burch colposuspension vs 72.1% (437 of 606 where this was available) in retropubic midurethral sling (P=.32). Where this information was available, success defined by a Patient Global Impression of Improvement of "very much improved" and "much improved" was similar between Burch colposuspension and retropubic midurethral sling groups (84.1% [243 of 289] vs 82.0% [651 of 794]; P=.88). Where data were available, 88.1% of women (178 of 202) in the Burch colposuspension group said they were very likely to recommend the surgery to family or a friend vs 85.0% (580 of 682) in retropubic midurethral sling (P=.30).Overall, 3.6% needed repeat incontinence procedures (13 in Burch colposuspension group [3.8%] vs 35 in retropubic midurethral sling group [3.5%]; P=.73). The incidence of mesh exposure was 1.0 %. Notably, 1 Burch colposuspension patient had a suture in the bladder during follow-up; 5 patients have reported long-standing pain across the study population. Overall, 51 women reported new-onset overactive bladder symptoms on follow-up: 10 of 336 (3.0%) had Burch colposuspension and 41 of 1008 (4.1%) had retropubic midurethral sling (P=.41). The need for future prolapse surgery per index procedure was 3.3% after Burch colposuspension vs 1.1% postretropubic midurethral sling (P=.01). Moreover, 9 of the 11 patients who needed a prolapse repair after Burch colposuspension required a posterior repair. The incidence of long-term severe voiding difficulty needing self-catheterization was similar in both groups (0.3% in Burch colposuspension and 0.5 % in retropubic midurethral sling group; P=1.00). CONCLUSION: This study shows no difference in success, patient satisfaction, or complications between Burch colposuspension and retropubic midurethral sling, although the risk of posterior compartment prolapse operations after Burch colposuspension is increased. Reoperation rates for incontinence were similar in both groups. Chronic pain was a rare outcome.

Extraperitoneal high vaginal cuff suspension at the time of vaginal hysterectomy for advanced uterovaginal prolapse: Results of a modified McCall technique from a longitudinal clinical study.

BACKGROUND: Women with high-grade uterovaginal prolapse have a greater risk of recurrent prolapse after pelvic organ prolapse surgery. Royal College of Obstetricians and Gynaecologists guidelines have recommended sacrospinous suspension (sacrospinous fixation) at the time of vaginal hysterectomy, whenever there is a marked uterovaginal prolapse. We have modified the McCall culdoplasty by placing sutures extraperitoneally, higher and more lateral into the uterosacral/cardinal ligaments to re-support the vaginal cuff at the time of a vaginal hysterectomy. AIMS: To evaluate the results of a modified technique of McCall high culdoplasty and native tissue repair at time of vaginal hysterectomy in women with advanced uterovaginal prolapse. MATERIAL AND METHODS: Longitudinal clinical follow-up conducted between 2000-2018, in a tertiary urogynaecology centre for patients presenting with stage 3-4 uterovaginal prolapse, who underwent vaginal hysterectomy and modified McCall vault suspension. RESULTS: There were 176 cases meeting the inclusion criteria. Mean follow-up was 19.35 months. There were 25 recurrences (14%) of ≥ stage 2 (76% not symptomatic). Twelve of these recurrences (48%) occurred in anterior compartment, six (25%) posterior, three (12%) combined anterior/posterior, two (8%) combined posterior/central and one case had recurrence in all compartments. Only six cases (3%) required another surgical procedure for symptomatic prolapse, all with an enterocele recurrence. CONCLUSIONS: Our described modified McCall technique incorporates high extraperitoneal approach to apical resuspension along with closure of any existing large hiatal defects of the levator plate at the time of vaginal hysterectomy for advanced uterine prolapse has excellent outcomes and extremely low complication rates and avoids the need for sacrospinous fixation.

Video of uterovaginal procidentia repair incorporating a high extraperitoneal uterosacral vault suspension.

INTRODUCTION AND HYPOTHESIS: Women with high-grade uterovaginal prolapse have a higher incidence of levator injury, larger levator hiatal defects, and are at a greater risk of recurrent prolapse after pelvic organ prolapse (POP) surgery. RCOG guidelines have recommended prophylactic sacrospinous suspension at the time of vaginal hysterectomy, whenever there is a marked uterovaginal prolapse. The aim of the video is to describe our surgical approach at the time of surgery for advanced POP, and describe the technique for modified McCall high extraperitoneal vault suspension. METHODS: We have modified the McCall culdoplasty by extending the dissection of the middle portion of the uterosacral/cardinal ligaments so that the sutures can be placed higher and more laterally extraperitoneally to re-support the vaginal cuff at the time of a vaginal hysterectomy. RESULTS: The video highlights the surgical technique used for apical support at the time of surgery for advanced POP. CONCLUSIONS: This video demonstrates our modified McCall technique for vault suspension at the time of vaginal surgery for advanced POP. This technique could be considered an alternative technique to other modes of apical support.

Does pelvic floor muscle maximum voluntary contraction improve after vaginal pelvic organ prolapse surgery? A prospective study.

AIMS: to assess pelvic floor muscle maximum voluntary contraction (MVC) before and after surgical treatment for pelvic organ prolapse (POP). METHODS: This was a prospective observational study with women scheduled for surgical correction of POP. Assessments occurred 15 days before and 40 days after surgery. The primary outcome was pelvic floor muscle (PFM) MVC measured using the manometer Peritron™. The average strength of PFM contraction was also measured. Secondary outcomes were assessed using the Pelvic Organ Prolapse Quantification (POP-Q) score. The Student paired t-test was used for quantitative data. For the pre and postsurgery comparisons of PFM strength in relation to POP-Q value we used the nonparametric Kruskal-Wallis test for dependent variables. The level of significance adopted was P < 0.05. RESULTS: Sixty-seven women were recruited, 65 (97%) completed the study. The mean age of participants was 62 ± 10.2. There was no difference (1.9 cm H2 O ± 12.9; P = 0.22) between MVC before (27.1 cm H2 O ± 17.0) and after surgery (29 cm H2 O ± 17.8). The average contraction was higher after surgery (2.3 cmH2 O ± 8.6; P = 0.03). The higher the severity of pre and postsurgery POP, the worse the MVC. CONCLUSION: There was no difference in MVC pre and postsurgery, however we found an improvement in PFM average contraction strength postsurgery.

RCT of vaginal extraperitoneal uterosacral ligament suspension (VEULS) with anterior mesh versus sacrocolpopexy: 4-year outcome.

INTRODUCTION AND HYPOTHESIS: This study assessed the safety and efficacy of vaginal extraperitoneal uterosacral ligament suspension (VEULS) with anterior overlay mesh versus sacrocolpopexy (SCP) for posthysterectomy vault prolapse. METHODS: This was a multicenter randomized trial of women with posthysterectomy vault prolapse stage >2 according to the Pelvic Organ Prolapse Quantification (POP-Q) system. Primary outcome was a composite of no vaginal bulge symptoms, no anatomical recurrence in the anterior or apical compartment at or beyond the hymenal ring, and no surgical retreatment for prolapse 12 months postsurgery. Secondary outcomes were peri- and postoperative complications, changes in prolapse, and urogenital and sexual symptoms at 12, 24, and 48 months based on the Pelvic Floor Distress Inventory (PFDI)-20. RESULTS: Between 2006 and 2011, 82 eligible women were randomized: 39 received VEULS and 43 received SCP. Primary composite outcome at 12 months for success was 41% for VEULS and 65% for SCP [odds ratio (OR 2.68, p = 0.03)]. Perioperative complications were more common in the SCP group. C-point was higher for SCP (-6.0 VEULS vs -8.0 SCP, p = 0.005) and total vaginal length (TVL) was longer for SCP (8.0 VEULS vs 9.0 SCP, p = 0.05). Cumulative mesh exposure rate at 4 years was similar between the uterosacral [4/39 (10.3%)] and sacrocolpopexy [4/43 (9.3%)] groups, bearing in mind that not all patients were examined at 4 years. Subjective outcomes derived from three domains of the PFDI-20 were similar at 12, 24, 48 months. Postoperative Pelvic Organ Prolapse Distress Inventory (POPDI) score improved similarly for both groups at all timepoints, with the minimally important difference of at least 21 reached for both groups. CONCLUSIONS: Composite outcome of success was better for SCP at 12 months, but subjective outcomes for prolapse at all timepoints over 4 years for VEULS and SCP were not significantly different.

The Manchester repair: an instructional video.

OBJECTIVE: The Manchester repair, developed in the UK by Donald, described in 1908, and later modified by Fothergill, is a well-studied and proven surgical treatment for uterovaginal prolapse when uterine preservation is desired. This operation is currently not widely performed in parts of the world (USA) but is becoming increasing popular in Europe. The objective of this video is to demonstrate our surgical technique and recommendations for successful completion of the procedure. METHODS: This patient is a 39-year-old woman with two previous vaginal deliveries who presented with a 1-year history of vaginal protrusion. She had no urinary or bowel symptoms. On examination, she had a grade 2 cystocele and uterine descent. She desired surgical management of her uterovaginal prolapse but wished to retain her uterus. The procedure involves mobilizing the vagina and bladder off the cervix and uterosacral cardinal ligament complex anteriorly and laterally. The cervix is then amputated. The ligaments are clamped, cut, and ligated and attached to the anterior cervical remnant with an overlapping suture. This pulls the cervix backward into the pelvis and results in anteversion of the uterus. A posterior and then anterior Sturmdorf suture is used to reconstruct the cervix by covering the amputated cervix with vaginal mucosa. CONCLUSION: The Manchester repair is an operation worth considering in patients where preservation of the uterus is desired. It uses native tissue and has a low complication rate and good long-term results.

Technique of extraperitoneal uterosacral ligament suspension for apical suspension.

AIM OF THE VIDEO/INTRODUCTION: Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky-Navratil retractor. METHODS: This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension. CONCLUSIONS: This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.

Native tissue repair or transvaginal mesh for recurrent vaginal prolapse: what are the long-term outcomes?

INTRODUCTION AND HYPOTHESIS: The objective of this study was to assess outcomes in native tissue (NT) and transvaginal mesh (TVM) repair in women with recurrent prolapse. METHODS: A retrospective two-group observational study of 237 women who underwent prolapse repair after failed NT repair in two tertiary hospitals. A primary outcome of "success" was defined using a composite outcome of no vaginal bulge symptoms, no anatomical recurrence in the same compartment beyond the hymen (0 cm on POPQ) and no surgical re-treatment for prolapse in the same compartment. Secondary outcomes assessed included re-operation for prolapse in the same compartment, dyspareunia and mesh-related complications. RESULTS: Of a total of 336 repairs, 196 were performed in the anterior compartment and 140 in the posterior compartment. Compared with the TVM groups, women undergoing repeat NT repair were more likely to experience anatomical recurrence (anterior 40.9 % vs 25 %, p = 0.02, posterior 25.3 % vs 7.5 %, p = 0.01), report vaginal bulge (anterior 34.1 % vs 12 %, p < 0.01, posterior 24.1 % vs 7.5 %, p 0.02) and had a higher prolapse re-operation rate (anterior 23.9 % vs 7.4 %, p < 0.01, posterior 19.5 % vs 7.5 %, p = 0.08). Using composite outcomes, the success rate was higher with TVM repair in both compartments (anterior 34.2 % vs 13.6 %, p <0.01, posterior 56.6 % vs 23.0 %, p <0.01). Re-operations for mesh exposure were 9.3 % anteriorly and 15.1 % posteriorly. Although the number of women requiring a prolapse re-operation is lower in the TVM group, the overall re-operation rate was not significantly different when procedures to correct mesh complications were included. CONCLUSIONS: Although the success rate is better with the use of TVM for recurrent prolapse, the total re-operation rates are similar when mesh complication-related surgeries are included.

Failure of Expectations in Vaginal Surgery: Lack of Appropriate Consent, Goals and Expectations of Surgery.

INTRODUCTION AND BACKGROUND: Vaginal surgery for the treatment of urinary stress incontinence (USI) and pelvic organ prolapse (POP) using a synthetic polypropylene mesh is going through a time of unprecedented turmoil and debate. This review focuses on vaginal surgery for vaginal prolapse and looks at the current scientific literature on issues surrounding surgery including consent and expectations. SAFETY AND EFFECTIVENESS OF SURGICAL OPTIONS: Synthetic mesh has been used both abdominally and vaginally to improve the effectiveness of POP surgery. The relatively high incidence of mesh complications particularly with vaginal surgery has lead to repeat surgery, disappointment and litigation in some women. The benefits and risks of the various POP procedures are reviewed including native tissue repair, uterine conservation and obliterative vaginal surgery. CONCLUSION: Women with symptomatic pelvic organ prolapse and their doctors have many treatment options. The benefits and risks should be discussed as part of shared decision making.

Randomized trial of a single incision versus an outside-in transobturator midurethral sling in women with stress urinary incontinence: 12 month results.

OBJECTIVE: The objective of the study was to evaluate objective and subjective outcomes of MiniArc and Monarc (American Medical Systems, Minnetonka, MN) midurethral sling (MUS) in women with stress incontinence at 12 months. STUDY DESIGN: A total of 225 women were randomized to receive MiniArc or Monarc. Women with intrinsic sphincter deficiency, previous MUS, or untreated detrusor overactivity were excluded. Objective cure was defined as negative cough stress test with a comfortably full bladder. Subjective cure was defined as no report of leakage with coughing or exercise on questionnaire. Validated questionnaires, together with urodynamic and clinical cough stress test, were used to evaluate the objective and subjective outcomes following surgery. Participants and clinicians were not masked to treatment allocation. Outcomes were compared with exact binomial tests (eg, Fisher exact test for dichotomous data) for categorical data and Student t tests or exact versions of Wilcoxon tests for numerical data as appropriate. RESULTS: There was no statistically significant difference in the subjective (92.2% vs 94.2%; P = .78; difference, 2.0%; 95% confidence interval, -2.7% to +6.7%) or objective (94.4% vs 96.7%; P = .50; difference, 2.3%; 95% confidence interval, -1.5% to +6.1%) cure rates between MiniArc and Monarc at 12 m, respectively, with a significant improvement in overactive bladder outcomes and incontinence impact from baseline in both arms. CONCLUSION: MiniArc outcomes are not inferior to Monarc MUS outcomes at 12 months' follow-up in women without intrinsic sphincter deficiency.

Does pelvic floor muscle training improve female sexual function? A systematic review.

INTRODUCTION AND HYPOTHESIS: We performed a review of the literature reporting on the effects of pelvic floor muscle training (PFMT) on female sexual function (SF). METHODS: Pubmed (from 1946 to December 2014), Ovid Medline (from 1946 to December 2014), CINAHL (from 1937 to December 2014), PsycINFO (from 1805 to December 2014), Scopus and Cochrane Central Register of Controlled Trials were searched by two independent reviewers. Randomised controlled trials (RCTs) investigating the impact of PFMT on women's SF published in English were included. Methodological quality was scored using the PEDro scale. Data were analysed qualitatively and interpreted. RESULTS: A total of 1341 women were included in the eight RCTs covered by this review. The studies were published between 1997 and 2014. Methodological scores were between 4 and 7. The sample included derived from heterogeneous populations of women. In only one study was SF the primary outcome measure. Pelvic floor dysfunction was an inclusion criterion in the majority of studies. Most studies reported a significant improvement in SF score after PFMT between control and intervention groups. CONCLUSIONS: Although most studies indicated an improvement of at least one sexual variable in women with pelvic floor dysfunction, and one study demonstrated an improvement in SF in postpartum women selected independently of their continence status, the results need to be interpreted with caution. High-quality RCTs specifically designed to investigate the impact of PFMT on women's SF are required.

Functional outcomes following surgical management of pain, exposure or extrusion following a suburethral tape insertion for urinary stress incontinence.

INTRODUCTION AND HYPOTHESIS: Surgical revision of a tape inserted for urinary stress incontinence may be indicated for pain, or tape exposure or extrusion. This study assesses the clinical outcomes of revision surgery. METHODS: A retrospective review of 47 consecutive women who underwent surgical revision for the indications of pain, tape exposure or tape extrusion. RESULTS: Forty-seven women underwent revision. 29 women (62 %) had initial tape placement at another institution. Mean interval between placement and revision was 30 months. 39 women (83 %) had an identifiable tape exposure or extrusion with or without pain, while 8 women (17 %) presented with pain alone. 11 (23 %) of the tapes were infected clinically and histologically at revision, 10 of the 11 (90 %) being of a multifilament type. In 23 (49 %) cases, the revision aimed to completely remove the tape. Partial excision 24 (51 %) was reserved for localised exposures or extrusions where infection was not suspected. A concomitant continence procedure was performed in 9(19 %) at the time of tape revision. None of these 9 women has experienced recurrent stress urinary incontinence (SUI) compared with 11 out of 38 women (29 %) requiring further stress incontinence surgery when no continence procedure was performed (Fisher's exact p = 0.092). Eight out of 47 underwent revision surgery for pain with no identifiable exposure or extrusion; pain subsequently resolved in all 8 women. CONCLUSIONS: Excision is an effective treatment for tape exposure and pain whether infection is present or not. Tapes of a multifilament type are strongly associated with infection. When infection is present, complete sling removal is necessary. A concomitant procedure to prevent recurrent SUI should be considered if tape excision is planned and infection is not suspected.

Pelvic organ prolapse surgery with and without tension-free vaginal tape in women with occult or asymptomatic urodynamic stress incontinence: a randomised controlled trial.

INTRODUCTION: We set out to determine if insertion of a retropubic tension-free vaginal tape (TVT) sling at the time of pelvic organ prolapse surgery improves continence outcomes in women with pre-operative occult stress incontinence (OSI) or asymptomatic urodynamic stress incontinence (USI). METHODS: We conducted a randomised controlled study of prolapse surgery with or without a TVT midurethral sling. The pre- and post-operative assessment at 6 months included history, physical examination and urodynamic testing. Quality of life (QOL) and treatment success was assessed with the UDI-6 SF, IIQ-7 SF and a numerical success score. The primary outcome was symptomatic stress urinary incontinence (SUI) requiring continence surgery (TVT) at 6 months. Long-term follow-up continued to a minimum of 24 months. Secondary outcomes were quality of life parameters. RESULTS: Eighty women received prolapse surgery alone (n = 43) or prolapse surgery with concurrent TVT (n = 37). Six months following prolapse surgery 3 out of 43 (7 %) patients in the no TVT group requested sling surgery compared with 0 out of 37 (0 %) in the TVT group (ARR 7 % [95 %CI: 3 to 19 %], p = 0.11). After 24 months there was one further participant in the no TVT group who received a TVT for treatment of SUI compared with none in the TVT group (4 out of 43, 9.3 % versus 0 out of 37; ARR 9.3 % [95 %CI: -1 to 22 %], p = 0.06). Both groups showed improvement in QOL difference scores for within-group analysis, without difference between groups. CONCLUSION: These results support a policy that routine insertion of a sling in women with OSI at the time of prolapse repair is questionable and should be subject to shared decision-making between clinician and patient.

Which women develop urgency or urgency urinary incontinence following midurethral slings?

INTRODUCTION AND HYPOTHESIS: De novo urgency has a negative impact on women after midurethral sling (MUS). We aimed to identify risk factors for de novo urgency (dU) and urgency urinary incontinence (dUUI) following MUS, using multivariate analysis. METHODS: We investigated 358 consecutive women with only stress urinary incontinence (SUI) [or urodynamic stress incontinence (USI)] and 598 women with both SUI (or USI) and urgency (but not UUI) who underwent MUS with a mean follow-up of 50 months. Women who developed dU or dUUI at long-term follow-up were compared to those who did not. RESULTS: dU occurred in 27.7 % (99/358) and dUUI occurred in 13.7 % (82/598) of women at long-term follow-up after midurethral sling. Intrinsic sphincter deficiency {odds ratio (OR) dU 3.94 [95 % confidence interval (CI) 1.50-10.38]; OR dUUI 2.5 (1.31-4.80)}, previous stress incontinence surgery [sling: OR dU 3.69 (1.45-9.37); colposuspension: OR dUUI 2.5 (1.23-5.07)], previous prolapse surgery [OR dU 2.45 (1.18-5.10)], preexisting detrusor overactivity [OR dU 1.99 (1.15-3.48); OR dUUI 1.85 (1.31-2.60)] increased the risk, whereas performing concomitant apical prolapse surgery [OR dU 0.5 (0.41-0.81); OR dUUI 0.29 (0.087-0.97)] significantly decreased the risk. Women are more likely to not recommend surgery when they experienced dU (18.2 vs 0.8 %, p < 0.0001) or dUUI (20.7 vs 2.1 %, p < 0.0001). CONCLUSIONS: Urodynamic parameters, history of prior incontinence or prolapse surgery and concomitant apical prolapse operation were important predictors of dU or dUUI following MUS.

Counseling for stress urinary incontinence in the era of adverse publicity around mesh usage: Results from a large-sample global survey.

OBJECTIVE: To investigate doctors' opinions of the use of synthetic mesh for the treatment of stress urinary incontinence (SUI) and the effect on patient's attitude following recent adverse publicity and legal findings. METHODS: Electronic survey approved by International Urogynecological Association (IUGA) and American Urogynecologic Society (AUGS), distributed to their members. RESULTS: A total of 593 respondents completed the survey. The preferred initial surgical treatment for SUI was retropubic midurethral sling (MUS) (62%), followed by trans-obturator MUS (19%), mini-slings (10%), and then bulking agents (5%). Despite prolongation of consultation, most respondents (87%) believed that clinicians should provide a patient information leaflet (PIL) for their patients. However, only 70% of respondents were doing this. Most participants would use either the IUGA PIL or their institution PIL (61%). Only 8% felt that patients have a positive preconception of synthetic mesh for SUI. Eighty-three per cent of respondents had not changed their recommendations for treatment and the consent process. A logistic regression model identified preferences of certain geographic areas as predictors of consenting practices. CONCLUSION: Despite the negative publicity and the current medicolegal litigation involving MUS for SUI treatment, the majority of respondents still prefer this as the initial surgical treatment. Most clinicians value PIL in the surgical consent process.

Predictors of Surgical Failure of Open Burch Colposuspension Versus Retropubic Midurethral Sling for Stress Urinary Incontinence.

OBJECTIVE: To identify and compare long-term predictors for 'surgical failures' in matched groups of Midurethral sling (MUS) and Burch colposuspension (BC). METHODS: A secondary analysis of patients with urodynamic stress incontinence who were treated either by open BC or retropubic MUS. The study had a cohort of 1344 women with a ratio of 1:3 (BC: MUS). We defined surgical success or failure by combining Patient Reported Outcome Measures and the need for repeat surgery. Risk factors for failure identified by multivariate analysis. RESULTS: Of the 1344 women included, 336 had BC, and 1008 had MUS. Patients were followed-up for 13.1 and 10.1 years, and the rate of failure was 22% and 20%, for BC and MUS, respectively (P = 0.35). Significant predictors for MUS failure were Body mass index (BMI) > 30, preoperative anticholinergic medication use, smoking, diabetes, and previous surgery for incontinence (Hazard ratio 3.6, 2.6, 2.5, 1.8, 2.3, respectively). BMI > 25, preoperative use of anticholinergic medication, age > 60, previous surgery for incontinence, and loss of follow-up>5 years (Hazard ratio: 3.2, 2.8, 2.6, 2.5, 2.1, respectively), were significant predictors of BC failure. CONCLUSION: This study shows similar predictors for surgical failure for BC and MUS, with high BMI, mixed urinary incontinence, and previous continence procedures being the most important.

International Urogynecological Association (IUGA)/International Continence Society (ICS) joint terminology and classification of the complications related to native tissue female pelvic floor surgery.

INTRODUCTION AND HYPOTHESIS: A terminology and standardized classification has yet to be developed for those complications related to native tissue female pelvic floor surgery. METHODS: This report on the terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many external referees. A process of rounds of internal and external review took place with decision-making by collective opinion (consensus). RESULTS: A terminology and classification of complications related to native tissue female pelvic floor surgery has been developed, with the classification based on category (C), time (T), and site (S) classes and divisions, that should encompass all conceivable scenarios for describing operative complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, color charts, and online aids (www.icsoffice.org/ntcomplication). CONCLUSIONS: A consensus-based terminology and classification report for complications in native tissue female pelvic floor surgery has been produced. It is aimed at being a significant aid to clinical practice and particularly to research.

Women with occult stress incontinence should not routinely have a mid-urethral sling with prolapse surgery.

The risk of postoperative stress incontinence (SI) is increased in women with occult stress incontinence (OSI) but the majority of patients will not develop troublesome SI postoperatively or need further SI surgery. This risk reported in current studies does not warrant a mid-urethral sling at the time of surgery for pelvic organ prolapse in women with OSI. However, if performed, the risks as well as the benefits need to be discussed with the patient.