Effects of hypopressive exercises on pelvic floor and abdominal muscles in adult women: A systematic review of randomized clinical trials.

INTRODUCTION: Hypopressive exercises (HE) are postural and breathing exercises that activate deep muscles in the abdomen and pelvic floor. Despite this, there is still no consensus in the literature on its real effectiveness. The objective was to analyze the effects of HE on the abdominal and pelvic floor muscles in women with or without dysfunctions in these regions. METHODS: This is a systematic review of randomized clinical trials found in the PEDro, PubMed, Cochrane, LILACS, and Embase databases. We include studies that evaluate the effects of HE (with or without other techniques) on the pelvic floor and abdominal region for 8 weeks or more, in women over 18 years old, with or without dysfunction in these regions, with the presence of a control group (active or passive). RESULTS: HE were effective in improving strength, tone, and reducing symptoms of pelvic floor dysfunctions, in magnitude less than (in two studies) or equal (in one study) to the pelvic floor muscle training (PFMT). When HE were performed with PFMT in the same group, no additional benefits were found. Only one study evaluated abdominal muscles activation, where HE were effective in improving postural control and activation of the transversus abdominis muscle. CONCLUSIONS: The HE presented positive results to the evaluated parameters. However, the information is still preliminary and scarce. There are methodological divergences regarding the execution, follow-up and standardization of the method, which could affect the results. According to the existing information, HE cannot yet be reliably indicated for the treatment of the pelvic floor, despite pointing out relevant results in some studies. More randomized clinical trials and long-term studies are needed to analyze the effects of HE not only for pelvic floor, but also for other regions, such as abdominal muscles and related dysfunctions.

A randomized clinical trial comparing internal and external pessaries in the treatment of pelvic organ prolapse in postmenopausal women: A pilot study.

INTRODUCTION AND HYPOTHESIS: Internal vaginal pessary is among the leading treatments for pelvic organ prolapse (POP); however, it has a high adverse event rate. An external pessary was recently developed as an alternative. The study's objective was to compare the efficacy of external and internal pessaries in treating POP in postmenopausal women. METHODS: This parallel randomized (1:1 ratio) open-blind study included 40 symptomatic women with stage 2 or 3 POP. They were randomized into two groups: group 1 (internal pessary) and group 2 (external pessary) (n = 20 in each); and evaluated at the start of and 3 months after the treatment. Statistical analysis was performed to compare the results within and between the groups before and after the 3-month treatment. RESULTS: The groups were homogeneous, except for the variables previous pregnancies (p = 0.030) and POP-Q score of apical prolapse (p = 0.023) whose values were higher in group 2. A significant improvement in quality of life was observed in both groups after 3 months of follow-up; however, internal pessaries were found to be more effective (p < 0.001). In group 1 there were differences between the initial and final POP-Q scores of anterior (0.004) and apical prolapse (p = 0.005). The complication rate associated with internal pessary use was high (p = 0.044). CONCLUSIONS: The present data suggested that external pessaries have a similar effect to internal ones for the treatment of POP and improvement of the quality of life of postmenopausal women.

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice.

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines). PREOPERATIVE PATIENTS' INFORMATION: Each patient must be informed concerning the risks associated with POP surgery (EO). HEMORRHAGE, HEMATOMA: Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO). BLADDER INJURY: When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO). URETER INJURY: After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO). RECTAL INJURY: Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO). VAGINAL WALL INJURY: After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO). MESH INFECTION (ABSCESS, CELLULITIS, SPONDYLODISCITIS): Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient. BOWEL OCCLUSION RELATED TO NON-CLOSURE OF THE PERITONEUM: Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO). URINARY RETENTION: Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO). POSTOPERATIVE PAIN: Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO). POSTOPERATIVE DYSPAREUNIA: When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO). VAGINAL MESH EXPOSURE: To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO). SUTURE THREAD VAGINAL EXPOSURE: For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed. BLADDER AND URETERAL MESH EXPOSURE: When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).

Electrical stimulation plus biofeedback improves urination function, pelvic floor function, and distress after reconstructive surgery: a randomized controlled trial.

PURPOSE: This study is aimed at assessing the effect of postoperative electrical stimulation (ES) plus biofeedback therapy on patient rehabilitation after pelvic floor reconstructive surgery. METHODS: Patients with pelvic organ prolapse (POP) who had received pelvic floor reconstructive surgery were randomly allocated to the intervention group and the control group at a 1:1 ratio. Patients in the control group received routine postoperative nursing care. Patients in the intervention group underwent ES plus biofeedback therapy. The outcomes included the recovery of urination function, the improvement of pelvic floor muscle (PFM) strength, and the change of Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20) scores. The study outcomes were evaluated at pre-intervention (T0, 2 months after surgery), 3 months after surgery (T1), and 6 months after surgery (T2). RESULTS: A total of 60 patients with POP were included in this study. For the urination function evaluation, the intervention group had a higher recovered rate than the control group at the time point of T2 (p = 0.038). For the EMG results, the changes of flick-max and tonic-mean values from T0 to T2 were much higher in the intervention group comparing to the control group. Corresponding to the EMG results, digital palpation showed that intervention group had a much higher proportion of patients who had elevated PFM strength. Furthermore, the intervention group also had more significant PFDI-20 score improvements compared with control group. CONCLUSIONS: Postoperative ES plus biofeedback therapy could significantly improve urination function, PFM strength, and patient's reported QoL. TRIAL REGISTRATION: Clinical registration number: hiCTR2000032432.

Effectiveness of Laparoscopic Pectopexy for Pelvic Organ Prolapse Compared with Laparoscopic Sacrocolpopexy.

STUDY OBJECTIVE: To evaluate the clinical benefits of laparoscopic pectopexy vs laparoscopic sacrocolpopexy in women with pelvic organ prolapse (POP). DESIGN: Prospective cohort study. SETTING: A tertiary hospital. PATIENTS: We included 203 patients with POP. INTERVENTIONS: Laparoscopic pectopexy or laparoscopic sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: Anatomic effectiveness was measured using the POP Quantification system, both before and after operation. Functional recovery effectiveness was evaluated using complications and recurrence rates within 1 year. Quality of life was assessed by the Pelvic Floor Distress Inventory-20 and Incontinence Quality of Life questionnaires at enrollment and postoperative months 3, 6, and 12. Comparisons between groups were performed using t test, chi-square test, and mixed-effects model with repeated measures. The analysis included 203 eligible patients (sacrocolpopexy, 101; pectopexy, 102). The proportion of robotic-assisted surgeries was lower in the pectopexy group than in the sacrocolpopexy group (15.7% vs 41.6%, p <.001). The average operation time of pectopexy was shorter than that of sacrocolpopexy (174.2 vs 187.7 minutes) with a mean difference of 13.5 minutes (95% confidence interval, 3.9-23.0; p = .006). Differences of intraoperative blood loss, length of hospital stay, and postoperative 7-day complications between groups were not significant. Anatomic successes were obtained in both groups with similar improvement in POP Quantification scores. The rate of urinary symptoms recurrence was higher in the pectopexy group (13.7%) than in the sacrocolpopexy group (5.0%) at the 1-year follow-up (odds ratio, 3.1; 95% confidence interval, 1.1-8.8, p = .032). The Pelvic Floor Distress Inventory-20 and Incontinence Quality of Life scores were better improved at postoperative months 3, 6, and 12 for laparoscopic pectopexy than for sacrocolpopexy. CONCLUSION: Laparoscopic pectopexy revealed comparable anatomic success, shorter operation time, and better improvement in quality of life scores of prolapse, colorectal-anal, and urinary symptoms at 1-year follow-up, possibly being an alternative when sacrocolpopexy is not practicable. However, clinicians should pay more attention to the recurrence of urinary symptoms after pectopexy.

Can you breathe yourself to a better pelvic floor? A systematic review.

INTRODUCTION: Some authors suggest that breathing exercises should be recommended instead of or in combination with pelvic floor muscle training (PFMT) to prevent and treat urinary incontinence (UI) and pelvic organ prolapse (POP). AIMS: The primary aim of the present study was to investigate the evidence for breathing as an intervention alone or in addition to PFM contraction in treatment of UI and POP. MATERIALS & METHODS: This systematic review included short-term experimental studies and randomize controlled trials (RCTs) indexed on PubMed, EMBASE, and PEDro database. A form was used to extract data that was analyzed qualitatively due to the heterogeneity in interventions and outcome measures of the included studies. The individual methodological quality of RCTs was analyzed using the PEDro scale. RESULTS: A total of 18 studies were included, 374 participants from short-term experimental studies and 765 from nine RCTs. PEDro score varied from 4 to 8. Activation of the PFM during expiration was significantly less than during a PFM contraction. In general, the RCTs showed that training the PFM is significantly more effective to improve PFM variables and UI and POP than breathing exercises, and that adding breathing exercises to PFMT have no additional effect. CONCLUSION: This systematic review indicates that the evidence for incorporating breathing exercise in clinical practice in addition to or instead of PFMT is scant or non-existing, both based on short-term experimental studies and small RCTs.

Therapeutic effect of proprioception training combined with pelvic floor electrical stimulation biofeedback on postpartum pelvic floor dysfunction. / æœ¬ä½“æ„Ÿè§‰è®­ç»ƒè”åˆç›†åº•ç”µåˆºæ¿€ç”Ÿç‰©åé¦ˆå¯¹äº§åŽç›†åº•åŠŸèƒ½éšœç¢æ€§ç–¾ç— çš„æ²»ç–—æ•ˆæžœ.

OBJECTIVES: Pelvic floor tendons, fascia, and ligaments are rich in proprioceptors. Proprioceptive training can stimulate local proprioceptors to increase neuromuscular responses and promote the recovery of muscle and fascial ligament functions. This study aims to observe the therapeutic effect of proprioception training combined with pelvic floor electrical stimulation biofeedback on postpartum pelvic floor dysfunction (PFD), and to provide evidence for the treatment of postpartum PFD. METHODS: A total of 108 puerpera with postpartum PFD were selected and divided into a control group ( n =50) and an experimental group ( n =58). Puerpera in the control group received pelvic floor electrical stimulation biofeedback treatment. Puerpera in the experimental group received proprioception training combined with pelvic floor electrical stimulation biofeedback treatment. After one course of treatment, the pelvic floor muscle strength, muscle endurance, repetitive contraction ability, rapid contraction ability, percentage of normal vaginal posterior wall elevation, percentage of normal lower abdominal muscle synergistic contraction, percentage of normal reflex contraction during coughing, incidence of stress urinary incontinence (SUI), and staging of pelvic organ prolapse (POP) were compared before and after treatment between the 2 groups. RESULTS: After treatment, all indexes of the 2 groups were better than those before treatment; the pelvic floor muscle strength, muscular endurance, repetitive contraction ability, and rapid contraction ability of the experimental group were better than those of the control group (all P <0.05); the percentage of normal lower abdominal muscle synergistic contraction and percentage of normal reflex contraction during coughing of the experimental group were higher than those of the control group (both P <0.05); the incidence of SUI in the experimental group was lower than that in the control group ( P <0.05); the percentage of POP staging II in the experimental group was significantly lower than that in the control group ( P <0.05). There was no significant difference in the percentage of normal posterior vaginal wall elevation after treatment between the 2 groups ( P >0.05). CONCLUSIONS: Proprioception training combined with pelvic floor electrical stimulation biofeedback could improve the rehabilitation effect of postpartum pelvic floor dysfunction and promote the recovery of pelvic floor function, which possesses important clinical application value.

Postoperative pain and the need for intervention after sacrospinous ligament hysteropexy compared to colpopexy: a retrospective cohort study.

OBJECTIVES: To compare postoperative pain between patients undergoing sacrospinous ligament colpopexy (SSLF) and hysteropexy (SSLH). METHODS: This was a retrospective cohort study of all patients undergoing native tissue SSLF and SSLH between January 2013 and March 2020. The electronic medical record was queried for demographic and perioperative data until the postoperative visit. The primary outcome was a composite incidence of any of the following: telephone calls, urgent office visits, additional analgesic prescriptions and need for intervention for pain in the buttocks, posterior thigh or perirectal area. Secondary outcomes were the incidence of persistent pain at the postoperative visit and perioperative risk factors associated with reported pain. RESULTS: A total of 406 patients met inclusion criteria (308 SSLF, 98 SSLH). The composite pain outcome was seen in 99 patients (24.4%; 95% CI 20.5%-28.8%), and there was no statistical difference between cohorts. Persistent pain was seen in 15.6% and 13.3% of SSLF and SSLH patients at 6 weeks (p = 0.58). Twelve patients (3.0%) underwent interventions for pain, including physical therapy (2), trigger point injections (5) and suture release (5). Compared to SSLF patients, SSLH patients were more likely to need interventions (7 [7.1%] vs. 5 [1.6%], p = 0.005) and office visits (14 [14.3%] vs. 13 [4.2%], p = 0.0005) for pain. CONCLUSIONS: There was no difference in the overall incidence of postoperative pain between patients who underwent SSLF or SSLH. However, patients who underwent hysteropexy were more likely to need intervention and office evaluation for postoperative pain.

Comparative evaluation of enema alone and in combination with oral polyethylene glycol for bowel preparation before transvaginal pelvic floor reconstruction in elderly patients: a retrospective cohort study.

The aim of this retrospective study was to assess the value of using an enema alone for mechanical bowel preparation (MBP) before transvaginal pelvic floor reconstruction (TPFR) in patients ≥65 years old. In total, 190 patients were included [81 in the enema group vs. 109 in the enema + polyethylene glycol (PEG) group]. The levels of serum potassium (p = .004) and calcium (p = .005) were higher in the enema group after surgery. The decrease in serum calcium was more significant in the enema + PEG group (p = .027). More patients in the enema + PEG group developed hypokalaemia (p = .035) or hypocalcaemia (p = .008) after surgery. The incidence of thrombus and surgical site infection was similar and earlier bowel movement was evident in the enema group (p = .000). Overall, the enema group used more laxatives (p = .026). Using enema alone before TPFR reduces the incidence of electrolyte disturbances with no increase in surgical complications in elderly patients.IMPACT STATEMENTWhat is already known on this subject? TPFR is an effective treatment for pelvic organ prolapse (POP) in elderly women. Bowel preparation performed before gynecological surgery can reduce surgical site infection, but increase discomfort and electrolyte disturbance.What do the results of this study add? The levels of serum potassium and calcium were lower in the enema + PEG group than in the enema group after surgery and more patients developed hypokalaemia or hypocalcaemia in the enema + PEG group. The incidence of thrombus and surgical site infection was similar between the two groups. Bowel movement was earlier in the enema group.What are the implications of these findings for clinical practice and/or future research? Using enema alone before TPFR reduces the incidence of electrolyte disturbance and does not increase surgical complications. This conclusion needs to be confirmed by random controlled trial studies in the future.

A novel bilateral anterior sacrospinous hysteropexy technique for apical pelvic organ prolapse repair via the vaginal route: a cohort study.

BACKGROUND: Uterine-preserving techniques are becoming increasingly popular in the last decade. This investigation evaluates a novel hysteropexy technique using a mesh in sling-alike configuration [Splentis (Promedon, Argentina)] which is attached anteriorly to the cervix and suspended to the sacrospinous ligaments bilaterally via the vaginal route in women undergoing surgery for uterine prolapse. METHODS: This was a single-center cohort study, evaluating women who underwent transvaginal hysteropexy with Splentis for primary uterine descent. Data have been collected prospectively as part of the quality assurance system. Primary endpoint was treatment success, defined as a combined endpoint including the absence of a vaginal bulge symptom and no retreatment of apical prolapse. A validated questionnaire to evaluate quality-of-life and prolapse symptoms was utilized. Descriptive analysis was applied. Wilcoxon signed-rank test was performed to compare paired samples. The significance level was set at 5%. RESULTS: A total of 103 women with a median age of 68.0 [IQR 11.5] years with a median apical POP-Q stage of 3 were included. The median surgery time was 22 [IQR 12] minutes and no intraoperative complication occurred. After a median follow-up time of 17 months, treatment success was achieved in 91 (89.2%) patients and quality of life and patient report outcomes improved significantly (p < 0.001). Mesh exposure occurred in 3 (2.9%) patients. Of these, two patients required surgical revision, and one patient was treated conservatively. One patient required partial mesh removal due to dyspareunia. CONCLUSION: Bilateral sacrospinous hysteropexy with Splentis offers an efficacious and safe alternative for apical compartment repair, incorporating the advantages of pelvic floor reconstruction via the vaginal route.

Laparoscopic sacrocolpopexy versus pelvic organ prolapse suspension for surgical management of pelvic organ prolapse: a retrospective study.

This retrospective surgical clinical study compares clinical and functional effects of laparoscopic sacrocolpopexy (LSC) and laparoscopic pelvic organ prolapse suspension (L-POPS) for anterior and central prolapse correction. Thirty patients enrolled were affected by a symptomatic vaginal central compartment stage 2-3 prolapse and vaginal anterior compartment stage 1-3 prolapse without vaginal posterior compartment prolapse. A successful correction of anterior and central compartments prolapse without relapses were observed in both groups (LSC group versus L-POPS group). In patients who underwent L-POPS, a de novo posterior compartment prolapse was recorded. In this group, 7/15 patients complained more bowel symptoms and underwent vaginal colpoperineoplasty. In 20% (group LSC) and in 13.3% (group L-POPS) of cases, a condition of de novo urinary stress incontinence was described. LSC seems to remain the gold standard for pelvic organ prolapse correction, while further preventive strategies should be carried out in L-POPS to avoid a de novo posterior compartment prolapse.Impact StatementWhat is already known on this subject? Laparoscopic sacrocolpopexy is the gold standard technique for the correction of pelvic organ prolapse; however, laparoscopic pelvic organ prolapse suspension, based on the surgical technique of lateral suspension, is an innovative surgical method for the treatment of POP.What do the results of this study add? L-POPS could be considered a valid alternative to LSC for women with multiple comorbidities because of less operative time and reduced surgical risks. However, in the long follow-up period, some patients underwent L-POPS complained rectal discomfort and dysfunction on quality of life questionnaire and on clinical evaluation from six to twelve months after surgery probably due to the post-operative appearance of posterior compartment prolapse.What are the implications of these findings for clinical practice and/or further research? Considering the retrospective design and the small sample size the major limits of this study, larger, prospective, randomized studies could be encouraged to better compare a modified technique of L-POPS with posterior mesh apposition (preventing the post-operative appearance of posterior compartment prolapse) with the gold standard LSC for the correction of multi-compartment POP.

Transvaginal repair of anterior vaginal wall prolapse with polyvinylidene fluoride (PVDF) mesh: an alternative for previously restricted materials?

INTRODUCTION AND HYPOTHESIS: To study the mid-term safety and functional outcomes of transvaginal anterior vaginal wall prolapse repair using polyvinylidene fluoride (PVDF) mesh (DynaMesh®-PR4) by the double trans-obturator technique (TOT). METHODS: Between 2015 and 2020, we prospectively included women with symptomatic high-stage anterior vaginal wall prolapse with or without uterine prolapse or stress urinary incontinence (SUI) in the study. The patients underwent transvaginal repair of the prolapse using PVDF mesh in two medical centers. We followed all patients for at least 12 months. We recorded the characteristics of vaginal and sexual symptoms, urinary incontinence, and prolapse stage pre- and postoperatively using International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF), and Pelvic Organ Prolapse Quantification (POP-Q) system, respectively. RESULTS: One hundred eight women were included in the final analysis with a mean follow-up time of 34.5 ± 18.6 months. The anatomical success was achieved in 103 (95.4%) patients. There was a significant improvement in patients' vaginal symptoms, urinary incontinence, and quality of life scores postoperatively (p < 0.0001). Only six patients (5.5%) had mesh extrusion, five of whom were managed successfully. The total rates of complications and de novo urinary symptoms were 21.3% and 7.4%, respectively. Significant pain was reported in 17 cases (15.7%). CONCLUSION: Our findings show that using PVDF mesh in the double TOT technique for anterior vaginal wall prolapse repair is a safe procedure with high anatomic and functional success rates and acceptable complication rates in mid-term follow-up.

Postoperative Prevention of Urinary Tract Infections in Patients after Urogynecological Surgeries-Nonantibiotic Herbal (Canephron) versus Antibiotic Prophylaxis (Fosfomycin Trometamol): A Parallel-Group, Randomized, Noninferiority Experimental Trial.

INTRODUCTION AND HYPOTHESIS: Urinary tract infections (UTIs) are one of the most common complications of urogynecological surgeries. The risk of UTIs is increased by the catheterization of the bladder, intraoperative cystoscopy, and urine retention after the procedure. Due to increasing antibiotic resistance, there is a need to search for new methods of postoperative UTI prevention. Canephron is a mixture of century herbs, lovage roots, and rosemary leaves with diuretic, spasmolytic, anti-inflammatory, antibacterial, and nephroprotective properties. The aim of this study is to demonstrate the noninferiority of Canephron versus antibiotic prophylaxis with fosfomycin trometamol (FT), based on the collective results of postoperative urine culture analyses. METHODS: One hundred and twenty-five female patients were randomized into two groups before undergoing urogynecological surgeries, including a control group (n = 67), which received one dose of 3 g of FT the day after the procedure, and a study group (n = 58), which received Canephron three times a day for 14 days, starting the day after the procedure. All the patients were assessed using the Acute Cystitis Symptom Score (ACSS). RESULTS: UTIs were observed in 6.4% of the patients. There was no statistically significant difference between the use of FT and Canephron in terms of UTIs (Chi^2 N-1 = 0.8837; p = ns). Additional factors, such as menopausal status and the type of procedure performed, increased the risk of developing a UTI. Factors such as the body mass index (BMI) and parity had no correlation. CONCLUSIONS: Canephron is noninferior to FT in the prevention of postoperative UTIs. The use of such a phytotherapeutic drug may help to decrease antibiotic consumption, which is closely connected to the growing trend of antibiotic resistance.

Healthcare utilization following minimally invasive apical prolapse repair in a large integrated healthcare system.

INTRODUCTION AND HYPOTHESIS: We sought to describe healthcare utilization (HU) following minimally invasive apical prolapse repair (MIAR) and its association with duration of hospital stay, patient characteristics, and perioperative factors. METHODS: This retrospective study included women undergoing MIAR within a large managed care organization between January 1, 2011, and June 30, 2018, and aimed to quantify HU within 30 days of surgery. HU was dichotomized into two groups: normal and high, based on typical postoperative utilization of healthcare resources. The primary outcome was the rate of normal versus high HU overall and by duration of hospital stay [discharge home on day of surgery versus postoperative day (POD) 1-2]. Multivariable logistic regression was performed to identify factors predictive of high HU. A p value of < 0.05 was considered statistically significant. RESULTS: Of the 4208 patients in our final cohort, 17% had high HU, while 83% were normal utilizers. High utilizers were more likely to have multiple comorbidities (p < 0.01) and a diagnosis of chronic pelvic pain (p = 0.02) and were less likely to be discharged on day of surgery (p < 0.01). A higher burden of disease, a concurrent mid-urethral sling or posterior colporrhaphy, and discharge on POD 1-2 were independently predictive of high HU. Within the high HU cohort, the most common type of unanticipated healthcare encounter was emergency department visit for urinary retention or pain. CONCLUSIONS: Same-day discharge after MIAR does not result in increased HU, even after adjusting for relevant demographic and clinical characteristics. Pre-existing chronic pain diagnoses, multiple comorbidities, and concurrent mid-urethral sling are associated with high HU in this population.

Surgical management of pelvic organ prolapse in a high-volume resource-limited setting.

OBJECTIVE: To describe the care pathway of patients with pelvic organ prolapse in a high-volume resource-limited setting and characterize patients undergoing surgery. METHODS: The patient care pathway at a large referral hospital in eastern Democratic Republic of Congo was determined through interviews with key personnel. Patients with apical prolapse (with or without anterior/posterior prolapse) who underwent surgery between January and December 2018 were included. Demographics and outcomes were characterized. Data were presented as means (standard deviation [SD]), medians (interquartile range), or number (percentages). RESULTS: A holistic care model was described. During the study period, 772 patients underwent prolapse repairs, 235 met inclusion criteria. Mean age was 55 (±14) years, and 75% (176/235) were postmenopausal. Median parity was 7 (5-9). A majority (56%, 131/233) had body mass index <18.5 (calculated as weight in kilograms divided by the square of height in meters). Most were farmers (77%, 182/235) and had no formal education (76%, 178/235). Postmenopausal patients underwent hysterectomy, whereas premenopausal patients were treated with uterine-preserving techniques. Most repairs were performed vaginally (96%, 225/235), and 40% (94/234) had concurrent multicompartment repairs. Most common complications were hemorrhage (4%, 9/235, intraoperative) and urinary tract infection (5%, 11/235, postoperative). CONCLUSION: High-volume surgical services for treating prolapse can be integrated into existing healthcare delivery models. Our demographic of patients differs from studies in high-income countries. The degree to which these studies can be generalized to patients in settings similar to ours represents an opportunity for further research.

Pelvic floor reconstructive surgery under local anesthesia: A systematic review and meta-analysis.

AIMS: The decision on the appropriate type of anesthesia for pelvic floor repair depends on a variety of factors including patients' age, performance status, comorbidities, cost-effectiveness and personal preferences. We aim to review the literature on urogynecological procedures performed under local anesthesia (LA). METHODS: A systematic search of four electronic databases was conducted for articles published up to May 2020. Studies reporting outcomes of women who underwent pelvic floor reconstructive surgery under LA with or without sedation, were considered eligible. RESULTS: Nineteen studies (14 noncomparative and 5 comparative), including 1626 cases of urogynecological procedures under LA were recruited. Meta-analysis revealed significantly lower mean pain scores in LA group compared to general-regional anesthesia one (GA/RA) at both 4-6 h and 8-18 h postoperatively (160 patients; mean difference [MD], -1.70; 95% confidence interval [CI]: -3.12, -0.28; p = 0.02 and 160 patients; MD, -0.72; 95% CI: -1.17, 0.27; p = 0.002, respectively). Pain scores at >24 h did not differ among the two groups (160 patients; MD, -0.28; 95% CI: -0.60-0.05; p = 0.10). Intra- and postoperatively morphine use was not different among patients who received LA and GA during prolapse surgery while nausea rates were significantly lower in LA group compared to RA group 8 h postoperatively. CONCLUSIONS: LA with or without sedation represents a safe and efficient alternative anesthetic technique for urogynecological procedures with improved pain scores in up to 18 h postoperatively especially in patients who underwent surgery for SUI. LA is feasible and could be offered to patients undergoing pelvic floor surgery allowing a prompt postoperative recovery.

Extending the limits of vaginal hysterectomy under local anesthesia and conscious sedation.

INTRODUCTION AND HYPOTHESIS: In this video we present the surgical management of a 58-year-old woman presenting with a large prolapsed myomatous uterus treated with vaginal hysterectomy (VH) and pelvic floor repair (PFR) (uterosacral ligament suspension and posterior colporraphy) under local anesthesia and conscious sedation. METHODS: The patient underwent VH and PFR by using an infiltration of a local anesthetic solution of lidocaine, ropivacaine and adrenaline in combination with intravenous (iv) conscious sedation. Debulking techniques, such as intramyometrial coring, uterine bisection, myomectomy and wedge resection, were used to facilitate VH. The final weight of the removed uterus was 870 g. RESULTS: This video demonstrates that performing a surgically challenging VH under local anesthesia is feasible. CONCLUSIONS: Vaginal uterine morcellation can be performed to debulk the enlarged uterus so that hysterectomy can be accomplished under local anesthesia. The use of local anesthesia may safely be offered as an alternative to patients undergoing a complex vaginal hysterectomy and reconstructive surgery.

Laparoscopic Pectopexy: An Effective Procedure for Pelvic Organ Prolapse with an Evident Improvement on Quality of Life.

It has been stated that the effectiveness of pectopexy method for the treatment of pelvic organ prolapse (POP) is similar to sacrocolpopexy. We aimed to search the effects of pectopexy method to the quality of life, sexual function and urinary incontinence. Thirty-one patients who were operated for POP with the technique of laparoscopic pectouteropexy/pectocolpopexy between January 2016 and November 2017 were included the study. Exclusion criteria were pelvic inflammatory disease, suspect of malignancy, pregnancy, prior POP or continence surgery. Quality of life inventories were (P-QOL, PISQ-12, UDI-6, IIQ-7) recorded preoperatively and at the postoperative third month. Results were compared statistically. The percentage of patients with menopause was 67.7% (n=21) and with reproductive term was 32.3% (n=10). Mean prolapse related quality of life inventory (P-QOL) score was 83.45 ± 8.7 (64-98) preoperatively and 8.61 ± 6.4 (0-23) postoperatively (p<0.05). The preoperative and postoperative score of quality of life inventories for urinary symptoms were 20 (15-21) and 2 (0-9) for IIQ-7 and 13 (3-18) and 4 (0-11) for UDI-6, respectively (p<0.05). The mean PISQ-12 sexual quality of life inventory score was 29.61 ± 4.8 (14-38) preoperatively and 7.1 ± 3.2 (1-13) postoperatively. According to our results laparoscopic pectopexy offers a feasible, safe and comfortable alternative for apical prolapse surgery.

[Influence of complex rehabilitation programs on the uterine blood flow in patients of different age after plastic surgery for rectocele]. / Vliyanie reabilitatsionnykh kompleksnykh programm na pokazateli matochnogo krovotoka po dannym 3D-ekhodopplerografii u patsientok raznykh vozrastnykh grupp posle plasticheskoi operatsii po povodu rektotsele.

OBJECTIVE: To develop the optimized complex programs, including general magnetotherapy, fractional microablative therapy with a CO2 laser, electromyostimulation with biofeedback of the pelvic floor muscles, and a special exercise therapy complex in late rehabilitation programs for women of different age after reconstructive plastic surgery for rectocele. MATERIAL AND METHODS: There were 200 women of childbearing, peri- and menopausal age with rectocele grade II-III and 20 healthy women of comparable age. All patients were divided into 4 groups by 50 womes: main group, two comparison groups and control group. Surgical treatment of rectocele was followed by long-term postoperative rehabilitation including symptomatic therapy, general magnetotherapy, and electromyostimulation with biofeedback of the pelvic floor muscles, intra-vaginal fractional microablative therapy with a CO2 laser and special complex of therapeutic physical education. RESULTS: General magnetotherapy in early (1 day) postoperative period and complex rehabilitation in long-term postoperative period (within a month after surgery) including 2 procedures of intra-vaginal microablative fractional therapy with carbon dioxide laser, electromyostimulation with biological connection of the pelvic floor muscles and special complex of therapeutic physical education ensured more significant improvement of uterine blood flow regardless age and baseline disorders in the uterine arteries in patients with rectocele. In our opinion, this is primarily due to vasoactive effects of general magnetotherapy, recovery of circulation via relief of spasm in the arteries and arterioles, improved vein contractility and venous outflow. These processes combined with electrical stimulation and therapeutic exercises of pelvic floor muscle followed by their reinforcement, as well as fractional microablative therapy ensured significant vascular effect.

An alternative technique in surgical correction of anterior compartment prolapse; Iliococcygeal fixation of the pubocervical fascia by native tissue repair.

AIM: To present 'bilateral iliococcygeal fixation of the pubocervical fascia' as an alternative vaginal surgical technique for anterior compartment repair with native tissue and the surgical outcomes of 30 cases. MATERIALS-METHODS: The consecutive 30 cases who admitted to urogynecology clinic with anterior vaginal prolapse/cystocele and underwent anterior compartment repair by bilateral iliococcgeal fixation of the pubocervical fascia by native tissue were included to the study. All cases attended to the postoperative follow-up visits at the sixth and the twelfth months. RESULTS: There were no major or minor intraoperative complications. Overall, in 28 (93.3 %) patients surgical success was achieved at the postoperative 12th month when it was defined as the maximum descent of the anterior segment was proximal to the hymen. During the study period, none of the patients requested or admitted for re-treatment for anterior compartment prolapse. Subjective cure that was assessed by the absence of bulge symptoms was achieved in 29 cases (96.7 %) at first year follow-up. Lower urinary tract symptoms (LUTS) were found to be significantly lower at the first-year postoperative visit compared to pre-operative evaluation. A clinically significant improvement in the quality of life parameters were also noted (mean PFIQ-7 scores = 8.5, 5.6 and 50.8, respectively). CONCLUSION: Bilateral iliococcygeal fixation of the pubocervical fascia seems to be effective in surgical correction of anterior vaginal prolapse according to our post-operative follow-up results. It is an easy to learn procedure with low complication rates and associated with high patient satisfaction.