Long-term functional results of transvaginal anal sphincter repair for faecal incontinence; a retrospective case series.

INTRODUCTION AND HYPOTHESIS: We report our experience with a transvaginal approach with overlapping anal sphincter repair. The aim of this cohort study was to evaluate long-term functional outcomes. Women who had undergone transvaginal anal sphincteroplasty for anal incontinence from July 2005 to July 2020 and attended a multidisciplinary team of urogynaecologists and colorectal surgeons at the Mercy Hospital Perineal clinic were included. METHODS: One hundred seven women were included in the study with a median follow-up of 57.5 months. We analysed outcomes by comparing patient's St Mark's score difference before and after surgery. Meaningful clinical difference (MID) was set at 5 points; complications and patient demographics were recorded along with a question about whether they would recommend this treatment to a friend. RESULTS: An improvement was seen in 69.3% of women with a marked improvement in 46.5%. Furthermore, 70% said they would recommend the procedure to a friend, if they were in a similar situation. Wound infection or partial perineal breakdown was reported in 45% of women but did not have a significant impact on outcomes. CONCLUSION: Transvaginal anal sphincter repair is associated with significant improvements in patients' St. Mark's score. Our data show that the long-term success rate of transvaginal/perineal AS repair may be better than previously reported in the literature with 70% of women satisfied at 57 months. Another benefit of the transvaginal route is the possibility of performing a pelvic floor and perineal repair at the time of surgery.

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.

Delayed presentation of mons pubis abscess formation following MUS-case report and surgical video.

INTRODUCTION AND HYPOTHESIS: Mid-urethral sling (MUS) surgery for stress urinary incontinence (SUI) has relatively low complication rates. However, although rare, complications such as bladder wall, prepubic and thigh abscess occur. We present an unusual case of MUS vaginal mesh exposure followed by mons pubis abscess formation occurring 18 years postoperatively because of inadvertent prepubic insertion of the right arm. Our objectives were to raise awareness about such a rare complication and to describe the approach for sling removal. METHODS: A 75-year-old woman presented with gradual swelling on the mons pubis followed by pain with a past history of MUS insertion. Examination revealed a palpable, tender, non-fluctuant mass, extending about 10-15 cm from mons pubis to the right labia. There was a 2 × 2-cm vaginal mesh exposure. Following imaging, an examination under anaesthesia was performed with vaginal exploration and complete removal of the right arm of the MUS and closure of the vagina. RESULTS: Six months postoperatively, all surgical sites had healed well, and there was no recurrent SUI or persistent mesh exposure. CONCLUSIONS: Unusual long-term complications of MUS should be considered and recognized. Thorough evaluation is crucial for informed decision-making related to treatment strategies. The vaginal approach to mesh removal is safe and should be practised by experienced surgeons. Patients should be informed regarding the possibility of incontinence after sling removal.

Efficacy of Clorpactin in refractory bladder pain syndrome/interstitial cystitis: a randomized controlled trial.

INTRODUCTION: Clorpactin is an antibacterial agent with limited evidence for its use as instillation therapy in patients with bladder pain syndrome/interstitial cystitis (BPS/IC). This was a multi-centre, single-blinded randomized controlled trial to investigate whether Clorpactin instillation results in symptom improvement in patients with refractory BPS/IC. METHODS: Fifty women with refractory BPS/IC were randomized to undergo cystoscopy/hydrodistension (25) or instillation of Clorpactin 0.4% solution (25) under general anaesthesia. Primary outcome was based on Global Response Assessment (GRA) at 3 months; secondary outcomes were based on O'Leary Sant Symptom (OLSI) and Problem (OLPI) questionnaire scores, visual analogue scale (VAS) score for pain and bladder diary parameters. RESULTS: Complete follow-up data were available on 22 in the hydrodistension group and 16 in the Clorpactin group. GRA improvement was 4.5% for hydrodistension and 56% for Clorpactin (p = 0.001) at 3 months. Reduction in mean total scores for OLSI (14.1 to 9.1; p = 0.004) and OLPI (12.6 to 7.4; p = 0.001) was seen in the Clorpactin group only. VAS pain scores were reduced in the Clorpactin group only (7.4 to 3.3; p < 0.001). Post-treatment VAS pain scores did not differ between groups although 6/25 (24%) women in the Clorpactin group required admission for pain compared to 1/25 (4%) in the hydrodistension group. CONCLUSIONS: Clorpactin treatment results in significant improvement in BPS/IC symptoms, bother and pain based on the GRA, OLSI/OLPI and VAS pain scores at 3 months post-treatment compared to cystoscopy/hydrodistension. These conclusions are limited by the high loss to follow-up in both groups.

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.

A prospective observational study of lower urinary tract symptoms before and after surgical removal of a large pelvic mass.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the impact of the surgical removal of a large pelvic mass on preexisting lower urinary tract symptoms (LUTS) and function. METHODS: This was a prospective study of planned surgical management of women with a large pelvic mass (uterine or ovarian mass ≥ 7 cm on pelvic ultrasound) who also reported bothersome LUTS (urinary frequency, urgency, incontinence and/or voiding dysfunction). Assessment included structured history and examination, completion of the short forms of the Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7), a 3-day bladder diary and multi-channel urodynamics (UDS) at baseline and 3 months postoperatively. The primary outcome was a reduction in the total mean scores of the UDI-6 and IIQ-7. Secondary outcomes were a change in bladder diary and UDS parameters. Univariate analysis and paired t test were used in the statistical analysis. RESULTS: Twenty-nine women underwent surgical management of a pelvic mass. The most common preoperative urinary symptom was urinary urgency. Two women had overt urinary retention that resolved completely postoperatively. All women completed pre- and postoperative UDI-6 and IIQ-7. The UDI-6 and IIQ-7 demonstrated a highly significant reduction in the mean total scores of 66%, signifying symptom and quality of life improvement. Bladder diary parameters showed significant reductions in daytime urinary frequency and stress incontinence episodes. Maximum and average voided volumes increased by a mean of 60 ml. Only 14 women underwent postoperative UDS. CONCLUSIONS: This study provides evidence that the majority of LUTS present preoperatively improve significantly or resolve completely following removal of a ≥ 7-cm pelvic mass.

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.

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.

Does pre-operative traction on the cervix approximate intra-operative uterine prolapse? A randomised controlled trial.

INTRODUCTION AND HYPOTHESIS: This study aims to compare pre-operative Pelvic Organ Prolapse Quantification (POP-Q) point C with and without cervical traction to that obtained intra-operatively in women undergoing pelvic organ prolapse surgery and to assess acceptability of examination with cervical traction without anaesthesia. METHODS: Eighty-one women were randomised to having pre-operative examination with or without cervical traction to measure point C. Visual analogue scale (VAS) pain scores were recorded for each pre-operative examination. Comparisons were made between pre-operative and intra-operative findings. RESULTS: The mean difference between pre-operative and intra-operative point C in the non-traction group was statistically higher than in the traction group (3.2 vs 1.6 cm, p = 0.0001). The level of agreement between pre-operative point C measurement with traction and intra-operative point C measurement was better than pre-operative point C measurement without traction and intra-operative point C measurement on Bland and Altman plots. Women having cervical traction reported significantly greater pain score on the VAS (3.4 vs. 1.2, p < 0.0001). CONCLUSIONS: Compared to routine pre-operative examination with Valsalva and cough manoeuvres only, pre-operative examination with cervical traction had better agreement with intra-operative point C findings. Although women reported greater pain score when examined with cervical traction, it was still a tolerable and acceptable examination without anaesthesia.

Sexual function following retropubic TVT and transobturator Monarc sling in women with intrinsic sphincter deficiency: a multicentre prospective study.

INTRODUCTION AND HYPOTHESIS: A prospective study comparing the effect of the tension-free vaginal tape (TVT) to the Monarc sling on sexual function in women with urodynamic stress incontinence (USI) and intrinsic sphincter deficiency (ISD) is presented. METHODS: Eighty-seven sexually active women with USI and ISD were enrolled. Sexual function was assessed pre-operatively and at 6 and 12 months post-operatively by history, PISQ-12, UDI-6 and IIQ-7 questionnaires. RESULTS: A significant increase was detected in PISQ-12 score following both TVT and Monarc insertion. This score was greater in the TVT group at 6 months but not at 12 months when compared to the Monarc group. A significant decrease in UDI-6 and IIQ-7 score was detected. Specifically, coital incontinence and fear of leakage were reduced in both groups, and no change in dyspareunia or orgasm intensity was found. CONCLUSIONS: Sexual function improves 6 months after TVT or Monarc sling, and this benefit is maintained at 12 months.

Repeat synthetic mid urethral sling procedure for women with recurrent stress urinary incontinence.

PURPOSE: We reported and compared the outcomes of repeat mid urethral sling with primary mid urethral sling in women with stress urinary incontinence. MATERIALS AND METHODS: A total of 1,225 consecutive women with urodynamic stress incontinence underwent a synthetic mid urethral sling procedure (955 retropubic, 270 transobturator) at our institution between 1999 and 2007. Of the patients 91% (1,112) were interviewed via telephone call with a structured questionnaire and were included in the analysis. Mean +/- SD followup was 50 +/- 24 months (range 12 to 114). A comparison between repeat (77, mean age 62 +/- 12 years) and primary (1,035, mean age 60 +/- 13 years) mid urethral sling groups was performed. Repeat sling was placed without removal of the previous sling. RESULTS: The preoperative incidence of intrinsic sphincter deficiency was higher in patients who had a repeat mid urethral sling (31% vs 13%, p <0.001). The subjective stress incontinence cure rate was 86% and 62% in the primary and repeat group, respectively (p <0.001). The repeat retropubic approach was significantly more successful than the repeat transobturator approach (71% vs 48%, p = 0.04). The rates of sling related and general postoperative complications were similar between the primary and the repeat groups. However, de novo urgency (30% vs 14%, p <0.001) and de novo urge urinary incontinence (22% vs 5%, p <0.001) were more frequent in the repeat group compared with the primary group. CONCLUSIONS: A repeat synthetic mid urethral sling procedure has a significantly lower cure rate than a primary mid urethral sling procedure. The repeat retropubic approach has a higher success rate than the repeat transobturator approach. The incidence of de novo urgency and urge incontinence are significantly higher in repeat procedures.

Midurethral sling procedures for stress urinary incontinence in women over 80 years.

AIMS: To compare the safety and efficacy of midurethral sling surgery for management of urinary stress incontinence in women over 80 years versus younger women. METHODS: 1225 consecutive women with urodynamic stress incontinence had a synthetic midurethral sling (955 retropubic, 270 transobturator) at our institution between 1999 and 2007. Ninety one percent (n = 1112) of the patients were interviewed via phone call with a structured questionnaire and were included in the analysis. The mean follow-up was 50 ± 24 months (range 12-114). Comparison between elderly (≥80 years, n = 96) and younger patients (<80 years, n = 1016) was performed. RESULTS: The overall subjective cure rate was 85% (elderly 81%, younger 85%, = 0.32). There was no significant difference in cure rate between retropubic and transobturator sling in the elderly group (82% vs. 79.3%, P = 0.75). The bladder perforation rate was similar between the two groups (3%). The hospitalization time was significantly longer in the elderly (1.6 ± 1.7 days vs. 0.7 ± 1.1 days, P<0.001). However, major perioperative complications were uncommon (1%). Of the patients who had an isolated sling procedure, 37% of the elderly and 9% of the young patients failed their 1st trial of void (P < 0.001). However, the long-term rate of voiding difficulty was similar between the two groups (elderly 8% vs. young 6%, P = 0.21). The rate of de novo urge incontinence was similar between the two groups (7%). CONCLUSION: Retropubic and transobturator slings in women older than 80 years are effective and safe but are associated with an increased risk of transient postoperative voiding difficulty.

Risk factors of treatment failure of midurethral sling procedures for women with urinary stress incontinence.

INTRODUCTION AND HYPOTHESIS: Midurethral sling (MUS) is now the first line surgical treatment for female stress urinary incontinence. Our aim was to identify predictors for MUS failure. METHODS: A total of 1,225 consecutive women with urodynamic urinary stress incontinence had a synthetic MUS (955 retropubic and 270 transobturator) at our institution between 1999 and 2007. Multivariate analysis was performed in order to identify independent risk factors for failure. RESULTS AND CONCLUSIONS: At a mean follow-up of 50 +/- 24 months (range, 12-114), the subjective cure rate was 84.7%. Multivariate analysis revealed that BMI >25 (OR, 2.9), mixed incontinence (OR, 2.4), previous continence surgery (OR, 2.2), intrinsic sphincter deficiency (OR, 1.9), and diabetes mellitus (OR, 1.8) are significant independent predictors for MUS failure. Concomitant prolapse surgery decreased the likelihood of surgical failure after MUS (OR, 0.6). Patient's age and the type of the sling were not found to be risk factors for surgical failure.

Risk factors for trocar injury to the bladder during mid urethral sling procedures.

PURPOSE: We determined the incidence of and risk factors for bladder injury during mid urethral sling procedures for stress urinary incontinence. MATERIALS AND METHODS: At our institution 1,136 consecutive women underwent a mid urethral sling procedure (retropubic in 874 and transobturator in 262) and routine intraoperative cystoscopy between 1999 and 2007, and were followed to determine the clinical outcome. Statistical analysis was performed using the chi-square and independent t tests, and ANOVA to compare patients with and without bladder perforation by baseline characteristics and major risk factors. A total of 45 variables were included in analysis. Multivariate analysis to predict events was done with logistic regression models with stepwise forward selection. RESULTS: Bladder injury was noted in 34 patients (3%) and all except 1 were during a retropubic sling procedure (p <0.0001). Of the perforations 32 (94%) were associated with an inexperienced surgeon (p <0.0001). Multivariate analysis revealed that rectocele (OR 6.2), local anesthesia (OR 5.9), body mass index less than 30 kg/m(2) (OR 5.6), previous Cesarean section (OR 3.7) and previous colposuspension (OR 3.2) were significant independent risk factors for perforation. Urethral injury was detected intraoperatively in 2 women (0.2%) with a retropubic sling. CONCLUSIONS: Our results indicate that previous Cesarean section, colposuspension, body mass index less than 30 kg/m(2), rectocele and local anesthesia are independent risk factors for bladder perforation during mid urethral sling procedures. This occurs mainly during a retropubic sling procedure and when the surgeon is inexperienced.

Effectiveness of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial.

OBJECTIVE: To compare efficacy of transobturator tape with tension-free vaginal tape (TVT) in the treatment of stress urinary incontinence in women with intrinsic sphincter deficiency. METHODS: One hundred sixty-four women diagnosed with urodynamic stress incontinence and intrinsic sphincter deficiency with or without concomitant pelvic organ prolapse repair were randomized to receive TVT or transobturator tape. The primary outcome was the presence or absence of urodynamic stress incontinence at 6 months postoperatively. Secondary outcomes were the rate of operative complications, symptomatic stress incontinence requiring further surgery, and quality-of-life questionnaires. RESULTS: Of 180 women eligible to participate, 164 were enrolled and underwent surgery. Of the 138 patients assessed at 6 months with urodynamic studies, 14 of 67 (21%) had urodynamic stress incontinence in the TVT group compared with 32 of 71 (45%) in the transobturator tape group (P=.004), with nine women in the transobturator tape group having repeat sling surgery compared with none in the TVT group. In the intention-to-treat analysis, the incident rate difference for request of repeat surgery was 9.7% (95% confidence interval [CI] 0-19.9); repeat surgery would be requested in one of every six transobturator tape procedures compared with 1 of every 16 TVT procedures. The risk ratio of repeat surgery was 2.6 (95% CI 0.9-9.3) times higher in the transobturator tape group. CONCLUSION: Retropubic TVT is a more effective operation than the transobturator tape sling in women with urodynamic stress incontinence and intrinsic sphincter deficiency. CLINICAL TRIAL REGISTRATION: www.actr.org.au, Australian New Zealand Clinical Trials Registry, ACTRN12608000093381 LEVEL OF EVIDENCE: I.

Three-year follow-up of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency.

OBJECTIVE: To compare the efficacy of tension-free vaginal tape (TVT) to transobturator tape in the treatment of women with stress urinary incontinence (SUI) and intrinsic sphincter deficiency at 3-year follow-up. METHODS: One hundred sixty-four women were randomized to either TVT or transobturator tape after diagnosis of urodynamic stress incontinence and intrinsic sphincter deficiency. Concomitant pelvic organ prolapse surgery was not an exclusion criterion. The primary outcome assessed at 3-year follow-up was symptomatic stress incontinence requiring repeat surgery. Secondary outcomes were quality-of-life parameters assessed by validated questionnaires and numerical success score. RESULTS: One hundred sixty-four women were enrolled in the study. At 3 years, 15 of the 75 (20%) women in the transobturator tape group underwent repeat surgery to correct SUI compared with one of the 72 (1.4%) in the TVT group. In other words, if TVT had been used exclusively, repeat surgery would have been avoided in one in six patients. The risk ratio of repeat surgery was 15 (95% confidence interval 2-113; P<.001) times greater in the transobturator tape group. In the transobturator tape group, the median time to repeat surgery was 15.6 months compared with 43.7 months for TVT (P<.001). The quality-of-life outcomes did show an improvement in both groups before and after surgery but no difference between the two slings in the Urogenital Distress Inventory short form, the Incontinence Impact Questionnaire short form, and a patient-rated numerical success score. CONCLUSION: The long-term cure rates for retropubic TVT are significantly greater than for transobturator tape in women with urodynamic stress incontinence and intrinsic sphincter deficiency. Urethral functions tests such as urethral closure pressure and Valsalva leak point pressures are of value in determining what surgery to perform. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, www.anzctr.org.au, ACTRN12608000093381. LEVEL OF EVIDENCE: I.

Anatomical study of the obturator foramen and dorsal nerve of the clitoris and their relationship to minimally invasive slings.

OBJECTIVES: The objective of the study is to clarify potential risks to the dorsal nerve of the clitoris (DNC) and obturator canal using different minimally invasive slings. STUDY DESIGN: Ten embalmed hemipelves were dissected to demonstrate the course of the DNC and the obturator canal. On each cadaver, tension-free vaginal tape (TVT), transobturator in-out (TVT-O) and transobturator out-in (Monarc) procedures were performed. Distances between the DNC and the obturator canal to the different devices were measured. RESULTS: The DNC passes beneath the pubic bone at a distance of 14.3 +/- 4.7 mm of the midline. The distances of the different devices to the DNC were similar. The distance to the obturator canal was significantly different, with TVT being the furthest (40.1 +/- 3.7 mm) and TVT-O the closest (19.3 +/- 3.1 mm; p < 0.0001). CONCLUSION: Given the course of the DNC along the medial aspect of the ischiopubic ramus, the out-in technique may be safer. The in-out technique is the closest to the obturator canal.

Pelvic floor trauma in childbirth - myth or reality?

The issue of traumatic damage to the pelvic floor in childbirth is attracting more and more attention amongst obstetric caregivers and laypersons alike. This is partly due to the fact that elective Caesarean section, as a potentially preventative intervention, is increasingly available and perceived as safe. As there are a multitude of emotive issues involved, including health economics and the relative roles of healthcare providers, the discussion surrounding pelvic floor trauma in childbirth has not always been completely rational. However, after 25 years of urogynaecological research in this field it should be possible to determine whether pelvic floor trauma in childbirth is myth or reality. On reviewing the available evidence, it appears that there are sufficient grounds to assume that vaginal delivery (or even the attempt at vaginal delivery) can cause damage to the pudendal nerve, the caudal aspects of the levator ani muscle, fascial pelvic organ supports and the external and internal anal sphincter. Risk factors for such damage have been defined and variously include operative vaginal delivery, a long second stage, and macrosomia. It is much less clear, however, whether such trauma is clinically relevant, and how important it is in the aetiology of pelvic floor morbidity later in life.

Risk factors for mesh erosion after transvaginal surgery using polypropylene (Atrium) or composite polypropylene/polyglactin 910 (Vypro II) mesh.

The objective of this study was to identify the risk factors associated with the occurrence of mesh erosion (ME) during the first 6 post-operative months in patients having undergone transvaginal repair of pelvic organ prolapse (POP) with Atrium or Vypro II mesh. We retrospectively reviewed the records of 198 consecutive patients who underwent vaginal reconstructive surgery reinforced either by Atrium or Vypro II mesh between February 1999 and July 2003. Univariable and multivariable logistic regression was performed to assess associations between measured covariates and ME. Fourteen patients [7.1%, 95% confidence interval (CI): 3.9-11.6] developed vaginal ME. We found that, in the Vypro II mesh patients, the surgeon experienced in the technique had less erosions than less experienced surgeons (2.9 vs 15.6%, p=0.02). There was no statistically significant difference between the monofilament polypropylene (Atrium) and the composite polypropylene/polyglactin 910 (Vypro II) mesh (7.2 vs 6.9%, p=0.41) when adjusted for surgeon experience and patient age. There was no association between mesh type (Atrium or Vypro II) and vaginal ME following transvaginal repair of POP. Surgeon experience and patient age were associated with ME.