Unilateral levator avulsion increases the risk of de novo stress urinary incontinence after cystocele repair.

INTRODUCTION: Patients without concurrent baseline stress urinary incontinence (SUI) can develop de novo SUI after transvaginal mesh surgery (TVM) for cystocele repair. Surgeons should be aware of de novo SUI risk factors after TVM. METHODS: A total of 1124 women who were underwent TVM surgeries were recruited and assessed for eligibility from January 1, 2012 to April 30, 2021. All data related to patients and surgeries was collected, which included general conditions, clinical examination, surgery records, and follow-up results. Patients were divided into three groups according to follow-up results and data were compared with each group. The relative risk (RR) of de novo SUI with levator avulsion was also calculated. RESULTS: Three hundred thirty-six patients were included in this study. They were divided into no complication group (n = 249), de novo SUI group (n = 68), and other complications group (n = 19). It seemed elder or obese women had a higher risk of de novo SUI after TVM (p < 0.05). In de novo SUI group, incidence of levator avulsion before surgery were higher than the other two groups (p = 0.001). TVM can significantly change a prolapse to point Aa and Ba on POP-Q quantification system (p < 0.05). RR ratios of de novo SUI with unilateral avulsion group is 2.60 (95% confidence interval [CI] 1.39-4.87), and 2.58 (95%CI 0.82-8.15) for bilateral group. CONCLUSION: Unilateral levator avulsion, instead of bilateral levator avulsion, is a risk factor of de novo SUI after cystocele repair surgery.

A serious consequence of pelvic organ prolapse: Hydroureteronephrosis.

INTRODUCTION AND HYPOTHESIS: We aimed to determine the association between pelvic organ prolapse (POP) and hydroureteronephrosis (HUN), risk factors for developing HUN and resolution of HUN after surgery. METHODS: A retrospective study was conducted on 528 patients diagnosed with uterine prolapse. RESULTS: All patients with or without HUN were compared in terms of risk factors. The 528 patients were divided into five groups according to the POP-Q classification. A significant relationship was found between POP stage and HUN. The other risk factors for developing HUN were age, rural life, parity, vaginal delivery, smoking, body mass index and increased comorbidity. The prevalence of POP was 12.2% and the prevalence of HUN was 65.3%. All patients with HUN underwent surgery. After surgery, HUN resolved in 292 (84.6%) patients. CONCLUSION: POP is a multifactorial herniation of pelvic organs out of the urogenital hiatus due to pelvic floor dysfunction. The main etiological factors in POP are older age, grand multiparity, vaginal delivery and obesity. The most important problem in patients with severe POP is HUN due to urethral kinking or urethral obstruction, which is a result of the cystocele squeezing the urethra under the pubic bone. In low-income countries, the main aim is to prevent the development of POP, which is the most common cause of HUN. It is important to increase the level of knowledge about contraception methods and to increase screening and training to reduce other risk factors. Women should be made aware of the importance of gynecological examination in the menopausal period.

Analysis of the anatomical and biomechanical characteristics of the pelvic floor in cystocele.

INTRODUCTION: Stress urinary incontinence (SUI) occurs due to disruption of the pelvic floor anatomy; however, the complexity of the pelvic floor support structures and individual patient differences make it difficult to identify the weak points in the pelvic floor support that cause SUI to occur, develop, and recur. This study aimed to analyze the pelvic floor anatomy, structural features, and biomechanics of cystoceles to develop more effective treatment plans with individualized and precise healthcare. MATERIAL AND METHODS: In this observational case-controlled study (clinical trial identifier BOJI201855L), 102 women with normal pelvic floor function and 273 patients diagnosed with cystocele degrees I-III were identified at Shanghai General Hospital from October 2016 to December 2019. We combined ultrasound and vaginal tactile imaging (VTI) to assess the anatomy and biomechanical functions of the anterior and posterior vaginal walls. Both examinations included relaxation and muscle tension tests. RESULTS: Of the 42 VTI parameters, 13 were associated with the degree of cystocele, six with an increase in the urethral rotation angle (pointing to the mobility of the urethra), and six with a decrease in the retrovesical angle (pointing to hypsokinesis and decrease in bladder position). According to these data, the strength of tissues, especially the muscles in both the anterior and posterior compartments, contributes to the stability of the pelvic floor structure. The strength of the levator ani muscle (LAM) is important for the degree of cystocele, mobility of the urethra, hypsokinesis, and decrease in bladder position. CONCLUSIONS: In general, the biomechanical status of the pelvic floor in patients with cystocele is complex and involves various muscles, ligaments, tendons, and fascia. Of these, repair and exercise of the LAM have not received much attention in the treatment of patients with cystoceles, which may be an important risk factor for the high recurrence rate.

Investigation of predictive factors for the presence of voiding dysfunction after transvaginal mesh surgery-Can the flow curve shape on uroflowmetry be a predictor?

PURPOSE: This study established the prognostic significance of the uroflowmetry flow curve shape in the presence of voiding dysfunction following transvaginal mesh surgery. METHODS: This is a retrospective study of 439 symptomatic cystocele patients who underwent anterior wall repair with transvaginal mesh surgery. Uroflowmetry and postvoid residual were used to evaluate voiding function both preoperatively and 12 months postoperatively. The patients were divided into two groups: those with and without postoperative voiding dysfunction, and the predictors of postoperative voiding dysfunction were analyzed. The shape of the urine flow curve was analyzed for its influence on the presence of postoperative voiding dysfunction. RESULTS: Thirty-five participants were in the voiding dysfunction group, while 404 were in the nonvoiding dysfunction group. Multivariate analysis was conducted by adding an interrupted-shaped curve to age, Qmax, and postvoid residual, which showed significant differences in univariate analysis, found that age 68 years or older (odds ratio [OR]: 7.68, 95%CI 1.02-58, p = 0.048), postvoid residual ≥110 mL (OR: 2.8, 95%CI 1.25-6.29, p = 0.013) and interrupted-shaped curve (OR: 2.47, 95%CI 1.07-5.69, p = 0.034) were discovered to be independent risk factors for the presence of voiding dysfunction after transvaginal mesh surgery. CONCLUSIONS: Following transvaginal mesh surgery for cystocele, three variables were found to be predictive of voiding dysfunction: the old age, excessive postvoid residual, and an interrupted-shaped flow curve. The uroflowmetry flow curve shape has the potential to be a new predictor of postoperative voiding dysfunction.

Novel insight into the correlation between hernia orifice of cystocele and lower urinary tract function: a pilot study.

BACKGROUND: It has been hypothesized that women with significant pelvic organ prolapse (POP), particularly of the anterior vaginal wall, may have voiding dysfunction (VD). Although the VD mechanism due to cystocele is not fully understood, different vaginal compartments have rarely been closely examined. This study attempted to further elucidate the correlation between POP and VD through a new subgroup classification using cystoscopy. METHODS: This study reviewed clinical records of 49 women who underwent cystocele repair. All patients were scheduled for laparoscopic sacrocolpopexy, preoperatively underwent uroflowmetry and postvoid residual urine volume (PVR) measurement, and completed pelvic floor function questionnaires. Bladder examination by cystoscopy was additionally performed using the lithotomy position with the Valsalva maneuver. RESULTS: Subjects were divided into four groups according to hernia orifice presence determined by cystoscopy, which included the trigone type, posterior wall type, trigone and urethra type, and trigone and posterior wall type. The posterior wall type had statistically higher PVR values versus the trigone and posterior wall type (P = 0.013). The posterior wall type had statistically lower values for average urine flow rate versus the urethra and trigone type (P = 0.020). There were no significant differences noted in the pelvic floor function questionnaires among the four groups. CONCLUSIONS: A new bladder defect classification based upon hernia orifice location was associated with lower urinary tract function. Posterior wall hernia presence caused significant voiding function deterioration. This new subgroup classification, which can more clearly identify and indicate bladder function, is also comparable among patients.

Outcomes of a fixed skeletonised mini mesh implant for pelvic organ prolapse repair with uterine preservation.

Mesh repair of pelvic organ prolapse (POP) is complicated, causing erosions, postoperative pain and surgical failure. We hypothesised that reducing the mesh size and fixating it would result in significant cure rates and reduce complication rates. Here, we present the effectiveness of mini mesh implants in POP reconstruction. Sixty women who underwent repair of stage III and IV apical prolapse with cystocele or rectocele using skeletonised mesh implant Seratom PA MR MN® were evaluated. Anatomical outcomes were assessed using modified POP-quantification (POP-Q) staging and functional outcomes were self-reported by patients - one and three months post-operatively. Apical support with anterior and/or posterior colporrhaphy was performed, resulting in 96.6% success rate. Follow-up conducted one and three months post-operatively revealed significant improvement on the modified POP-Q (p < .001) and no complaints of dyspareunia. Para-vesicular fixation using a skeletonised mini mesh implant is feasible and effective in POP repair and has low surgical complication risk.Impact StatementWhat is already known on this subject? Mesh repair for pelvic organ prolapse (POP) is currently under scrutiny as it may result in erosions, postoperative pain, and surgical failure.What do the results of this study add? The use of an apical support with mini-mesh implants resulted in a 96.6% (58/60) success rate and excellent outcomes at 1- and 3-month follow-up.What are the implications of these findings for clinical practice and/or further research? Reconstruction using skeletonised and fixated mini-mesh implants may be safe and effective for POP treatment.

[INVESTIGATION OF SURGICAL CORRECTION OF ANTERIOR APICAL PROLAPSE OF THE PELVIC ORGANS USING A COMBINED TECHNIQUE, MONOLATERAL CYRENE POSTERIOR IN COMBINATION WITH ANTERIOR COLPORRHAPHY].

Objective - to evaluate the results of surgical correction of anterior apical prolapse of the pelvic organs with a combined technique monolateral CYRENE posterior (using monofilament polypropylene tape CYRENE) in combination with anterior colporrhaphy. A prospective cohort study included 240 patients with urogenital prolapse. The subjects were followed up for three months, and the anatomical outcome according to the POP-Q System classification, intra- and postoperative complications, absence or presence of relapse, quality of life and sex life were assessed. A relapse was considered to be grade 3 or more anterior prolapse, grade 2 or more central prolapse. Quality of life and sex life were assessed using the PFDI-20, PFIQ-7 and PSIQ-12 questionnaires. The average age of women was 57.8 years. All 240 patients had grade 3 cystocele, prolapse of the anterior vaginal wall, and prolapse of the uterus. In 23 (9.6%) patients, de novo urinary incontinence developed, 8 patients had stress urinary incontinence before surgery, 6 of them persisted stress urinary incontinence after surgery, 2 of them stress urinary incontinence was arrested without the simultaneous use of a mid-urethral sling. According to questionnaires, the quality of life improved in 225 (96.9%) women according to PFDI-20 and in 210 (90.5%) according to PFIQ-7. There were no changes in the quality of sex life. Anatomically, 235 (96.9%) achieved the desired result (Ba≤ II, C≤ I according to the POPQ System). At the same time, in 36 (15%), 3 months after the operation, cystocele of the 2nd degree was revealed. In all cases, there was minimal blood loss, in 9 cases (3.75%) there was a hematoma of the anterior vaginal wall that did not require additional intervention, at discharge had signs of organization and was completely stopped 6 weeks after surgery; 3 (1.25%) patients had urinary retention after surgery. Dyspareunia was not identified in any patient. The study of the treatment of urogenital prolapse using a combined technique, monolateral CYRENE posterior in combination with anterior colporrhaphy, demonstrates high efficiency and relative safety. The technique showed excellent anatomical results for apical prolapse and good for anterior prolapse. A small number and low significance of postoperative complications were revealed. Longer postoperative follow-up is needed to assess long-term results and long-term prospects in order to form a more complete understanding of this technique.

Predictors of occult stress urinary incontinence.

BACKGROUND: Causes for occult stress urinary incontinence (SUI) are poorly recognised. AIMS: To explore the mechanisms behind occult SUI. We hypothesised that cystocele type affects the risk of occult SUI. MATERIALS AND METHODS: We conducted a retrospective, cross-sectional study on 878 consecutive women assessed at a tertiary urogynaecologic clinic between July 2016 and November 2018. The population of this study consisted of 424 women with urodynamic stress incontinence. Women with previous anti-incontinence surgery were excluded. All women underwent a standardised interview, clinical examination and urodynamic testing. Translabial ultrasound was used to categorise cystoceles into Green type II (cystocele with open retrovesical angle) and Green type III (cystocele with intact retrovesical angle). We compared women with overt SUI to those with occult SUI (defined as stress incontinence only observed after prolapse reduction) for demographic characteristics, urodynamic findings and functional anatomy. Predictors for occult SUI were identified with a multivariable logistic regression model. RESULTS: Of 424 women, 362 (85%) had overt, and 62 (15%) occult SUI. There were 136 (32%) women who had a significant cystocele on imaging; 57 (42%) were classified as type II and 79 (58%) as type III. On multivariable regression, age and cystocele type were significantly associated with occult SUI. Odds for occult SUI was 10.9 times higher with type III (cystocele with an intact retrovesical angle) than with type II cystocele (cystocele with an open retrovesical angle; 95% CI 1.3-90.9). CONCLUSIONS: Cystocele type affects the risk of occult SUI. Type III cystocele (intact retrovesical angle) associates with occult SUI.

Concomitant transobturator tape and anterior colporrhaphy versus transobturator subvesical mesh for cystocele-associated stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Stress urinary incontinence (SUI) and cystocele often occur concomitantly and thus may potentially be treated via a single surgical procedure. This study evaluated the efficacy and safety of concomitant transobturator tape (TOT) with anterior colporrhaphy versus subvesical transobturator mesh (TOM) for cystocele-associated SUI. METHODS: This prospective, clinical trial included women with cystocele-associated SUI. Patients were randomly allocated into either group I (anterior colporrhaphy with concomitant TOT "in-out" fixation) or group II (implantation of a subvesical four-armed TOM). All patients were followed up at 1, 3, 6, 9, and 12 months postoperatively. Statistical tests were performed to compare the group outcomes based on objective, subjective, and anatomical variables. RESULTS: There were 81 patients in group I and 83 in group II. Median follow-up duration was 12 months. The demographic data and baseline clinical characteristics of both groups were comparable. There were no significant differences between groups regarding the success rates of SUI and cystocele repair. Groups I and II had similar cure rates of SUI (82.9 and 88.4%, respectively; p = 0.369) and incidences of successful cystocele repair (85.4 and 97.7%, respectively; p = 0.055). No urethral or bladder injuries or mesh erosions were reported. Both groups had comparable postoperative complications, except the greater incidence of micturition difficulty in group I than group II, during the early follow-up (12.2% vs. 0.0%; p = 0.024). CONCLUSIONS: Transvaginal mesh was not superior to native tissue repair. Anterior colporrhaphy and TOT may be an appropriate alternative to four-armed TOM application for concomitant correction of SUI and cystocele.

Prevalence of detrusor underactivity and bladder outlet obstruction in women with cystocele and changes in voiding function after cystocele repair.

PURPOSE: To evaluate the prevalence of detrusor underactivity (DU) and bladder outlet obstruction (BOO) in women with high-grade cystocele and the impacts of cystocele repair. METHODS: Between November 2010 and September 2018, women with ≥stage II cystocele were included. DU (detrusor pressure at maximum flow rate (PdetQmax) < 20 cmH2O, maximum flow rate (Qmax) < 15 mL/s, and bladder voiding efficiency < 90%) and BOO (PdetQmax ≥ 40 cmH2O and Qmax < 12 mL/s) were diagnosed by urodynamic study (UDS). Women who underwent cystocele repair were further analyzed with preoperative and postoperative comparisons. RESULTS: A total of 623 women were included. Forty-four (7%) and 17 (3%) women were diagnosed with DU and BOO, respectively. Among the 314 operatively treated women, a significant increase in DU (7% vs. 15%, p = 0.0007), especially in those with stage III cystocele, and a slightly decreased rate of BOO were noted postoperatively. UDS revealed that the postvoid residual volume, functional profile length, maximum urethral closure pressure (MUCP), and pressure transmission ratio at the MUCP decreased significantly, as did the pad weight. Nearly all lower urinary tract symptoms (LUTS) improved significantly, except nocturnal enuresis. Among bladder diary parameters, nocturia episodes, daytime frequency, urgency episodes, and incontinence episodes decreased significantly after the operation. CONCLUSION: The prevalence rates of DU and BOO in women with high-grade cystocele were 7% and 3%, respectively. After cystocele repair, the rate of DU increased. Most LUTS improved subjectively on questionnaires and objectively on UDS and bladder diary parameters after operation.

Evolution of patients with and without preoperative stress urinary incontinence after surgical cystocele repair by mesh implantation using a vaginal approach.

INTRODUCTION: To review the short-term evolution of stress urinary incontinence (SUI) after Uphold™ LITE mesh implantation for genital prolapse repair. MATERIAL AND METHODS: Retrospective, descriptive, single centre study of women undergoing genital prolapse surgery with Uphold™ LITE mesh insertion between July 2016 and April 2019. Pre-, peri- and 1-year postoperative follow-up data were collected. RESULTS: Thirty-six women were included (mean age: 72±7years). Most patients (75%) had grade III cystocele and three (8.3%) had recurrent prolapse. Mean operative time was 41±12min. During surgery, no visceral injury or haemorrhagic complications were noted but there were three intraoperative bladder injuries (8.3%). Twelve patients (33.3%) had preoperative SUI, half of which (n=6; 50%) responded to prolapse repair. De novo SUI was noted in 6/24 (25%) patients. The risk of having persistent postoperative SUI was 50% in patients with preoperative SUI, and the risk of developing de novo postoperative SUI was 25% in patients without preoperative SUI. Thus, patients with preoperative SUI were twice as likely to have persistent postoperative SUI as those without preoperative SUI (RR=2.0 [95% CI: 0.8175-4.8928]; P=0.128). Five patients with de novo SUI and three patients with persistent postoperative SUI were subsequently treated with insertion of a mid-urethral sling (MUS). The other patients improved with physiotherapy. CONCLUSION: Risk of persistent SUI after implantation of an Uphold™ LITE mesh is higher in patients with preoperative SUI. Surgical correction with a MUS can be offered in cases of de novo SUI before or after physiotherapy. LEVEL OF EVIDENCE: 4.

Three-Dimensional Transperineal Ultrasonography for Diagnosis of Female Occult Stress Urinary Incontinence.

BACKGROUND We evaluated the utility of three-dimensional transperineal ultrasonography in detecting occult stress urinary incontinence in women undergoing anterior pelvic floor reconstruction surgery for severe cystocele. MATERIAL AND METHODS We enrolled 207 women with stage III-IV cystocele without urinary stress incontinence. One week before the operation, the patients underwent pelvic floor ultrasonography. We measured the vertical distance between the bladder neck and posterior margin of the pubic symphysis, the posterior vesicourethral angle, the urethral rotation angle, the formation of funnel shape, the hiatus area, and the length of the urethra and the funnel shape. Postoperatively, the patients were evaluated for symptoms of stress urinary incontinence and with the 20-minute pad test. RESULTS The posterior vesicourethral angle with Valsalva maneuver, the difference in the posterior vesicourethral angle between the resting state and with the Valsalva state, and the angle of the proximal urethra were larger in the incontinence-positive group than in the incontinence-negative group (P<0.05). Funnel shape urethra was longer in the incontinence-positive group than in the incontinence-negative group (P<0.05). The cutoff value was 137.5° for the posterior vesicourethral angle with Valsalva maneuver, 39.5° for the difference in the posterior vesicourethral angle, 44.5° for the angle of the proximal urethra, and 0.35 cm for the length of the funnel shape. Multivariate analysis revealed that the difference between the posterior vesicourethral angle in the resting state and with Valsalva, the angle of the proximal urethra, and the length of funnel shape were strongly correlated with occult stress urinary incontinence. CONCLUSIONS Ultrasonography is an effective method for identifying occult stress urinary incontinence.

Transperineal Ultrasound Assessment of a Cystocele's Impact on the Bladder Neck Mobility in Women with Stress Urinary Incontinence.

Background and objectives: As pelvic floor disorders are often difficult to assess thoroughly based on clinical examination alone, the use of imaging as a complementary technique is helpful. This study's aim was to investigate by transperineal ultrasound (US) if there was any significant difference in the mobility of the bladder neck in women with stress urinary incontinence (SUI) without a cystocele and in those with SUI and an associated cystocele. The study also investigated whether the number of vaginal births and/or the heaviest newborn's birth weight was correlated with the bladder neck mobility. Materials and Methods: A total of 71 women suffering from SUI were included in the study and divided into two groups based on the presence of a cystocele. Their bladder neck mobility was evaluated by transperineal US, calculating the distance from the inferior margin of the symphysis pubis to the bladder neck (SPBN), and the dorsocaudal linear movement (DLM), term used to illustrate the displacement of the bladder neck by subtracting rest and Valsalva values. GraphPad Prism 8 was used for statistical analysis. Results: Within both study groups, the SPBN values were significantly higher and the DLM values were significantly lower at rest as compared to Valsalva maneuver (p < 0.05). No significant difference between the groups regarding SPBN and DLM values at rest, Valsalva, or subtraction was demonstrated. A significant positive correlation was found between the bladder neck mobility and the heaviest newborn's birth weight, regardless of the presence of a cystocele (p = 0.042). Conclusions: The presence of a cystocele had no significant impact on the bladder neck mobility measurements in patients with SUI. The heaviest newborn's birth weight positively correlated with bladder neck hypermobility, as quantified by SPBN.

Anterior colporrhaphy plus inside-out tension-free vaginal tape for associated stress urinary incontinence and cystocele: 10-year follow up results.

AIMS: We report the success rate and complications rate of combined ultralateral anterior Colporrhaphy plus Tension-free Vaginal Tape (TVT-O) in a long-term (10 year) follow-up prospective survey. METHODS: Patients previously treated for associated stress urinary incontinence (SUI) and cystocele were subjected to annual follow-up for 10 year with a complete urogynecologic evaluation. Furthermore, an urodynamic assessment and a quality of life questionnaire (ICIQ-UI SF) were recorded at the 5th and 10th year of follow up. RESULTS: Fifty patients treated between June 2004 and May 2006 were included in the analysis. Five patients did not return to 5-yr follow-up: two patients developed a median tape erosion and three patients withdraw. At 10-yr follow-up two more patients withdraw for a total of seven patients lost to follow-up. After 10 years patients objectively cured from cystocele were 41 (95%) while patients objectively cured from SUI were 39 (91%). At 10th year follow-up 38 patients (89%) result cured from both SUI and cystocele, 3 (7%) patients result cured only from prolapse, 1 (2%) patient only from SUI, and 1 (2%) patient result objectively failed for both SUI and cystocele. The ICIQ-UI SF scores at 10th year follow-up was 6.2 ± 3.7. The late complication rate at 10th year follow-up was 32% (OAB symptoms 20%; Mixed incontinence 2%; Bladder outlet obstruction 0%; Dyspareunia 6%; Chronic pelvic pain 0%; Vaginal tape erosion 4%; Detrusor hyperactivity 0%). CONCLUSIONS: The combined procedures shown proved to be an effective and safe procedure to treat concomitant SUI and cystocele.

Vaginal cystocele repair and hysteropexy in women with anterior and central compartment prolapse: efficacy and safety after 30 months of follow-up.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the safety and efficacy of vaginal native tissue repair and uterine suspension after a follow-up of at least 1 year. METHODS: We included all consecutive women with an anterior vaginal prolapse of stage II or higher and a concomitant uterine prolapse of stage II who underwent this surgical procedure. We considered women with a descensus with maximum point of less than -1 in any compartment as objectively cured. Overall success was defined as no prolapse symptoms, together with a Patient Global Impression of Improvement (PGI-I) score of 2 or less, prolapse of stage lower than II, and no need for other surgery. RESULTS: A total of 102 patients underwent this surgical procedure during the study period and met all the inclusion criteria for statistical analysis. The mean follow-up was 31 ± 8.2 months; no patient was lost to follow-up. Five patients (4.9%) showed postoperative complications. In terms of subjective outcomes, at the last available follow-up, failure of this surgical procedure was seen in 2% of patients. The objective cure rate and the overall cure rate were the 95.1%. No significant deterioration in objective cure rates was observed over time (p = 0.6). CONCLUSIONS: Vaginal repair and hysteropexy appear to be an effective and safe option for women with advanced uterovaginal prolapse.

The hybrid technique of pelvic organ prolapse treatment: apical sling and subfascial colporrhaphy.

INTRODUCTION AND HYPOTHESIS: The majority of patients with cystocele undergoing reconstructive surgery have combined defects of pubocervical fascia and uterosacral/cardinal ligament complex. In this regard, the simultaneous correction of both defects is rational. Furthermore, decreasing the use of synthetic materials in pelvic floor surgery is an important goal. The aim was to evaluate the objective and subjective cure rate of a hybrid technique: bilateral sacrospinous fixation using modern monofilament synthetic tape (apical sling) combined with the original technique of subfascial colporrhaphy. MATERIALS AND METHODS: This prospective study involved 148 women suffering from cystocele combined with apical prolapse. We used the following criteria to evaluate the results of surgical treatment: results of the vaginal examination (POP-Q system), urodynamic tests, bladder ultrasound, special questionnaires (Pelvic Floor Distress Inventory [PFDI-20], Pelvic Floor Impact Questionnaire [PFIQ-7], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire [PISQ-12], International Consultation on Incontinence Modular Questionnaire Short Form [ICIQ-SF]). All listed parameters were determined before the surgery and at control examinations at 1, 6, and 12 months after the treatment. RESULTS: At the 1-year follow-up, the objective cure rate for prolapse was 97.8%. The rate of anatomical recurrence was 2.2% (3 out of 138). The following long-term complications were noted: de novo urgency and stress urinary incontinence de novo in 2 (1.4%) and 4 (2.9%) patients, respectively. Comparison of the scores by the questionnaires also revealed a significant improvement in the quality of life in the postoperative period. Patient satisfaction rate was 97.1%. CONCLUSION: The hybrid technique is an effective and safe uterus-sparing method for patients with advanced forms of cystocele combined with apical prolapse. This technique improves voiding function, quality of life, and provides a high satisfaction rate.

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.

Cystocele Repair by Autologous Rectus Fascia Graft: the Pubovaginal Cystocele Sling.

PURPOSE: The autologous rectus fascia pubovaginal sling has been a safe and effective means of correcting stress urinary incontinence. We tested the feasibility of using a larger graft to correct cystocele with or without stress urinary incontinence. MATERIALS AND METHODS: Between January 2006 and October 2010, 30 patients with symptomatic cystocele underwent the pubovaginal cystocele sling procedure, including 14 with and 16 without concomitant stress urinary incontinence. The technique is a modification of the standard pubovaginal sling procedure. A large trapezoidal (major base 6 cm, minor base 4 cm and height 5 cm) rectus fascia graft is used with 4 instead of 2 sutures to suspend the graft corners. The 2 sutures at the level of the mid urethra are tied above the rectus muscles in a tension-free manner while the 2 sutures at the level of the cervical fold are tied with tension. Data on anatomical outcomes (Baden-Walker classification), functional outcomes (PFIQ-7), post-void residual urine volume and urinary tract infection were prospectively collected. RESULTS: At a mean followup of 62.6 months (range 46 to 98) there was no recurrence in the anterior compartment. There was 1 recurrence involving the apical and posterior compartments. All patients reported a statistically significant improvement in PFIQ-7 score. When present preoperatively, post-void residual urine volume, urinary tract infection and stress urinary incontinence ceased in all cases. The only complication was donor site wound dehiscence without fascial involvement. CONCLUSIONS: The autologous pubovaginal cystocele sling seems to be a safe, effective technique to correct cystocele with or without stress urinary incontinence.

Outcomes of two different incision techniques for surgical treatment of stress urinary incontinence with concomitant anterior vaginal wall prolapse.

PURPOSE: To assess the outcomes of two different incision techniques used in the surgical treatment of stress urinary incontinence (SUI) with concomitant anterior vaginal wall prolapse and to identify possible associated risk factors with a medium-term follow-up in patients who underwent TOT procedure. METHODS: We conducted a retrospective cohort study of 233 women who underwent transobturator tape procedure with cystocele repair. The women were divided into two groups according to two different incision techniques. The outcomes were analyzed considering five postoperative parameters: objective cure, subjective cure, patient satisfaction, resolution of urgency urinary incontinence and complications. The mean follow-up period was 43.6 months (range 12-85). RESULTS: A total of 226 women were documented in this study: 79 women in single-incision technique (group 1) and 147 women in double-incision technique (group 2). The objective and subjective cure and patient satisfaction (visual analog scale score ≥80) rates were 89.8, 73.4, 84.8 % and 90.4, 74.1, 86.4 % in group 1 and group 2, respectively. Complications reported according to the Clavien-Dindo classification were grade I 5.2 %, grade II 42.1 %, grade IIIa 47.3 %, and grade IIIb 5.2 %, and grade I 22.2 %, grade II 77.7 %, grade IIIa 0 % and grade IIIb 0 % in group 1 and group 2, respectively. The mean operative time was significantly shorter in group 1 compared to group 2 (p = 0.001). CONCLUSIONS: Both incision techniques have satisfactory outcomes in the surgical treatment of SUI with cystocele; nevertheless, the postoperative complications favor the double-incision technique.

Apical support at the time of hysterectomy for uterovaginal prolapse.

INTRODUCTION AND HYPOTHESIS: The aim was to determine factors associated with performing concurrent apical support procedures in hysterectomies carried out for uterovaginal prolapse. METHODS: Hysterectomies performed for uterovaginal prolapse from 2000 to 2010 were identified by ICD-9 codes. Uterovaginal prolapse was a proxy for apical descent. Primary outcome was the rate of concurrent apical procedures. Secondary outcomes included concurrent surgeries, complications, and surgeon training. Chi-squared tests compared categorical variables. Logistic regression determined factors associated with concurrent apical support. RESULTS: A total of 2,465 hysterectomies were performed for uterovaginal prolapse. In only 1,358 cases (55.1%) were concurrent apical support procedures carried out. Cases without apical procedures were more likely to undergo cystocele repair (23.8% vs 9.4%, p < 0.001), but less likely to have rectocele (3.4% vs 12.2%, p < 0.001) or combined cystocele/rectocele repair (16.4% vs 25.6%, p < 0.001). Of those without apical procedures, 95.7% were performed by generalists. Urogynecologists and minimally invasive gynecologists were more likely to perform apical procedures (97.1% and 88.8% vs 23.6%, p < 0.001). Older patients (>75 years) were more likely to undergo apical procedures (OR 5.096, 95% CI 3.127-8.304). Surgeons practicing for 10-14 years and >20 years were less likely to perform apical procedures than those practicing <5 years (p < 0.001 vs. p = 0.01). CONCLUSIONS: At a tertiary hospital, a significant proportion of hysterectomies are carried out for uterovaginal prolapse without concurrent apical support procedures, with the majority performed by generalists. Urogynecologists and minimally invasive gynecologists are more likely to perform an apical suspension at the time of hysterectomy for uterovaginal prolapse than generalists. This supports the need for continued education about apical support to appropriately manage uterovaginal prolapse.