Evaluating tissue-engineered repair material for pelvic floor dysfunction: a comparison of in vivo response to meshes implanted in rats.

INTRODUCTION AND HYPOTHESIS: Achieving better anatomic restoration and decreasing the associated complications are necessary for material repair of pelvic floor dysfunction (PFD). This study was aimed to investigate host response to tissue-engineered repair material (TERM) in rat models by comparing different materials and study the changes in biomechanical properties over time. METHODS: TERM was constructed by seeding adipose-derived stem cells (ADSCs) on electrospun poly(L-lactide)-trimethylene carbonate-glycolide (PLTG) terpolymers. The TERM, PLTG, porcine small intestine submucosa mesh (SIS), and polypropylene (PP) (n = 6 / group per time point) were implanted in rats for 7, 30, 60, and 90 days. Hematoxylin-eosin and Masson's trichrome staining were used to assess the host response, and mechanical testing was used to evaluate the changes in biomechanical properties. RESULTS: In vivo imaging showed that the ADSCs were confined to the abdominal wall and did not migrate to other organs or tissues. The TERM was encapsulated by a thicker layer of connective tissue and was associated with less reduced inflammatory scores compared with PLTG and PP over time. The vascularization of the TERM was greater than that with PP and PLTG over time (p < 0.05) and was greater than that with SIS on day 90. The ultimate tensile strain and Young's modulus of the PP group showed the greatest increases, and the TERM group followed on day 90. CONCLUSIONS: This TERM achieved better host integration in rat models and better biomechanical properties, and it may be an alternative material for PFD.

A biomechanical analysis of different meshes for reconstructions of the pelvic floor in the porcine model.

PURPOSE: Many different surgical approaches have been established for the repair of a pelvic organ prolapse. Especially in laparoscopic surgery, it is important to generate easy surgical techniques with similar stability. This study shall simplify the choice of mesh by evaluating three polypropylene meshes regarding their biomechanical properties. METHODS: Biomechanical testing was performed in the porcine model. The meshes are fixated on porcine fresh cadaver cervices after subtotal hysterectomy. The apical part of the mesh is fixated with parallel screw clamps at the testing frame. Forty-one trials were performed overall, subdivided into four subgroups. The groups differ in mesh type and fixation method. Maximum load, displacement at failure and stiffness parameters were evaluated with an Instron 5565® test frame. RESULTS: SERATEX® E11 PA (E11) showed the highest values for maximum load (199 ± 29N), failure displacement (71 ± 12 mm) and stiffness (3.93 ± 0.59 N/mm). There was no significant difference in all three evaluated parameters between SERATEX® B3 PA (B3) and SERATEX® SlimSling® with bilateral fixation (SSB). SERATEX® SlimSling® with unilateral fixation (SSU) had the lowest stiffness (0.91 ± 0.19 N/mm) and maximum load (30 ± 2 N) but no significant difference in displacement at failure. CONCLUSION: All meshes achieved a good tensile strength, but the results of maximum load show that the E11 is superior to the other meshes. Through a bilateral fixation of SERATEX® SlimSling®, a simple operating method is generated without a loss of stability.

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.

Impact of human umbilical cord-derived stem cells (HUMSCs) on host responses to a synthetic polypropylene mesh for pelvic floor reconstruction in a rat model.

In order to evaluate the effects of human umbilical cord-derived stem cells (HUMSCs) on the biocompatibility of and tissue response to a polypropylene (PP) mesh (Gynemesh™ PS) implanted in rat vaginas, HUMSCs were isolated and characterized in vitro and then combined with Gynemesh™ PS to create a tissue-engineered mesh. This tissue-engineered mesh and pure PP mesh were implanted in the submucosae of the posterior vaginal walls of rats. Mesh/tissue complexes were harvested at 1, 4 and 12 weeks after implantation. Histological evaluations including an assessment of the inflammatory reaction, neovascularization and fibrosis around the mesh fibers were performed and real-time quantitative polymerase chain reaction (RT-PCR) was used to analyze the mRNA expression of genes involved in wound healing at the tissue-mesh interface. After being seeded onto the PP mesh scaffold, HUMSCs grew and proliferated well in vitro culture. One week after implantation, the HUMSC-seeded mesh elicited a greater inflammatory response than the pure PP mesh (3.33 ± 0.21 vs. 2.63 ± 0.18, p = 0.026), while 4 and 12 weeks after implantation, the inflammatory response in the HUMSC-seeded mesh was lower than that in the unseeded mesh (p < 0.05). At 12 weeks, the HUMSC-seeded mesh induced a lower expression of matrix metalloproteinase (MMP)-1 and a higher expression of anti-inflammatory cytokine interleukin (IL)-4. HUMSCs may decrease the inflammatory response and improve the biocompatibility of a conventional synthetic mesh and may have the potential to reduce postoperative complications such as mesh exposure or erosion.

The in vivo biocompatibility of titanized polypropylene lightweight mesh is superior to that of conventional polypropylene mesh.

OBJECTIVE: To evaluate the histological response to and changes in the biomechanical properties of titanized polypropylene lightweight mesh and conventional polypropylene mesh at 1 and 12 weeks following implantation in the sheep vagina. METHODS: We compared a titanized polypropylene lightweight mesh (TiLOOP Mesh) to a conventional polypropylene mesh (Gynemesh PS) in a sheep vagina model. Explants were harvested after 1 and 12 weeks (n = 6/mesh type/time point) for histological observation. After 12 weeks, mesh-tissue complex specimens were biomechanically assessed by a uniaxial tension system. RESULTS: One week after implantation, there was no significant difference in the inflammatory response between the two groups. Twelve weeks after implantation, the TiLOOP light mesh elicited a lower inflammatory response than was observed for the Gynemesh PS (1.44 ± 0.61 vs 2.05 ± 0.80, P = .015). Twelve weeks after implantation, the collagen I/III ratio was lower in the TiLOOP light mesh group than in the Gynemesh PS group (9.41 ± 5.06 vs 15.21 ± 8.21, P = .019). The messenger RNA expression levels of the inflammatory factors interleukin 10 and tumor necrosis factor α were lower in the TiLOOP Mesh group than in the Gynemesh PS group at both 1 and 12 weeks (P < .05). There were no significant differences in any of the evaluated biomechanical characteristics between the two meshes (P > .05). CONCLUSION: Although the titanized polypropylene lightweight mesh induces slightly less tissue reactivity and has better in vivo biocompatibility, further studies should be conducted including the complications and the success rate of pelvic organ prolapse in patients before recommending it in pelvic floor reconstruction.

Percutaneous glue embolization as a primary treatment for visceral pseudoaneurysms.

Aim: To evaluate the feasibility and outcome of percutaneous glue embolisation as primary treatment for pseudoaneurysms in selective patients.Material and methods: A review of the pseudoaneurysm cases managed with percutaneous glue at our institute was analyzed in this study. A total of 21 patients over a period of last one year who were treated for pseudoaneurysm at varied sites primarily with percutaneous n-butyl cynoacrylate were retrospectively evaluated. Site of pseudoaneurysm was Pulmonary (seven cases), renal (four cases), pelvic (4four cases) and miscellaneous abdomen (six cases). Combined ultrasound and fluoroscopy approach was used in 17 cases, CT guidance in three cases and combined ultrasound and CT guidance in one case. Patients were evaluated for therapeutic response (radiological and clinical) and procedure related complications.Results: Complete occlusion of the pseudoaneurysm was seen in all patients. Two patients showed mild pneumothorax and one patient showed reflux into the intercostal artery. All the patients showed symptomatic improvement and discharged in stable condition.Conclusions: Percutaneous glue embolisation of the pseudoaneurysms as a primary treatment is feasible and can be safely carried out in select group of patients with good therapeutic response and minimal complications.

Tissue engineering for the pelvic floor.

PURPOSE OF REVIEW: To set in context the challenge of developing tissue-engineered constructs for use in the female pelvic floor compared with at least 30 years of research progress in tissue engineering for other tissues. RECENT FINDINGS: The relative lack of information on the mechanical requirements of the pelvic floor in women who have suffered damage to these tissues is a major challenge to designing tissue-engineered materials for use in this area. A few groups are now using autologous cells and biomaterials to develop constructs for repair and regeneration of the pelvic floor. Progress with these has reached early stage evaluation in small animal models. Meanwhile the regulatory challenge of introducing laboratory-expanded cell therapy into the clinic is prompting groups to look at alternatives, such as using lipoaspirate retrieved in theatre as a source of adult stem cells for a number of tissues. In our group, we have begun to look at lipoaspirate for repair of the pelvic floor. SUMMARY: There is a need for research to harvest the advances made over the last 30 years in developing tissue-engineered constructs for several tissues to now tackle the problems of the weakened pelvic floor. At present, there are relatively few groups engaged in this challenge despite the growing clinical need.

Designing new synthetic materials for use in the pelvic floor: what is the problem with the existing polypropylene materials?

PURPOSE OF REVIEW: This review identifies the clinical complications associated with the design of the current polyproplylene mesh materials used for the treatment of stress urinary incontinence and pelvic organ prolapse. Following on from this, new alternative materials under development for pelvic floor repair are reviewed. RECENT FINDINGS: It is well accepted that the textile properties of the current polypropylene surgical meshes are not suitable for the pelvic floor environment. This together with the chemical nature of the current mesh leads to complications whenever implanted in the pelvic floor of women. New alternative materials for the repair of the pelvic floor have been developed with properties designed to be more appropriate for the biomechanical requirements and implantation requirements for the pelvic floor to reduce these clinical complications. To support this, these newer materials are being rigorously tested using more appropriate in-vitro regimes and animal models. SUMMARY: This chapter summarizes developments in the design of new materials for pelvic floor repair. These are being subjected to preclinical testing to exclude materials, which might fail to work in this dynamic environment by either showing a poor mechanical match to the requirements of the tissue or by provoking sustained inflammation. The hope is that new materials will prove effective without causing the high incidence of unacceptable side-effects currently seen with polypropylene mesh implants.

Improving the biocompatibility of biomaterial constructs and constructs delivering cells for the pelvic floor.

PURPOSE OF REVIEW: Interactions between biomaterials and biomaterial-delivering cells and the host tissues are complexly affected by the material itself, the ultrastructure of the overall construct and cells and other bioactive factors involved. The aim of this review is to review the current understanding on the definitions of biocompatibility and current advances in improving biocompatability of tissue-engineered constructs. RECENT FINDINGS: Some synthetic materials are associated with more foreign body reactions compared with natural materials; however, they allow fabrication of materials with a great diversity of physical and mechanical properties. Material design strategies can be tailored to mimic the natural extracellular matrix topography. There are also advancements in the pharmacological functionalization of materials with improved angiogenic potential that can lead to better tissue response. Stem cells are also used to improve the tissue response of tissue-engineered materials; however, the recent regulations on regenerative medicine products necessitate significant regulatory approval processes for these. SUMMARY: The biggest challenge faced in translation of tissue-engineered constructs into clinical practice relates to their engraftment and poor tissue integration into the challenging wound bed of the pelvic floor. Biocompatibility of tissue engineered constructs can theoretically be improved by the incorporation of bioactive agents, such as vitamins C or oestradiol.

Use of a simple in vitro fatigue test to assess materials used in the surgical treatment of stress urinary incontinence and pelvic organ prolapse.

AIMS: Stress urinary incontinence and pelvic organ prolapse are very common conditions with a proportion of patients requiring implantation of synthetic materials for a durable repair. However increasing numbers of post-surgical complications have been reported related to the use of polypropylene meshes. One hypothesis for the adverse response is poor mechanical matching of the relatively stiff polypropylene mesh particularly as materials in the pelvic floor will need to cope with decades of distension as occurs with increase of intraabdominal pressure on coughing, laughing, or sneezing. METHODS: In this study we have undertaken a very simple fatigue testing regime to compare the mechanical abilities of six materials. Four commercial meshes in clinical use and two novel electrospun materials not yet evaluated in the clinic were assessed using a uniaxial tensile test. This was performed on six samples of each dry material and on another six samples of each material after just 3 days of fatigue conditions using a dynamic bioreactor. RESULTS: The four commercial materials showed permanent mechanical deformation after just 3 days of stretching these materials by 25% elongation on a regular dynamic cycle, whereas the two new materials presented more elastic properties without deformation. CONCLUSIONS: We suggest that a test as simple as this 3-day fatigue testing is sufficient to distinguish between materials which have already been found to cause complications clinically and newer materials yet to be tested clinically which will hopefully prove more mechanically appropriate for implantation in the pelvic floor.

[Questionnaire survey on the application of polypropylene mesh and sling in pelvic floor reconstruction surgery in Chinese IUGA members].

Objective: To investigate the similarities and differences between Chinese International Urogynecological Association (IUGA) members and international IUGA members on the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) with polypropylene (PP) mesh and sling. Methods: Questionnaires were sent to Chinese IUGA members by Email. The contents of the questionnaires included POP mesh, SUI slings, abdominal sacrocolpopexy (ASC), complications, patients' awareness of rights protection, litigation and database use.Chi-square test was used to compare the proportion of Chinese IUGA members and international IUGA members to the problem alternatives. Results: A total of 31 Chinese IUGA members (100%, 31/31) responded to the questionnaire. All Chinese IUGA members (100%, 31/31) recognized and used PP sling to treat SUI, 98% (917/936) of international IUGA members had used and continued to use PP sling. For ASC surgery, 81% (25/31) of Chinese IUGA members and 82% (768/936) of international IUGA members agreed with and implemented the operation (P=0.841), while 94% (29/31) of Chinese IUGA members and 72% (674/936) of international IUGA members had the same or increased surgical volume as before (P=0.019). For the treatment of POP by transvaginal implantation of PP mesh, Chinese IUGA members had significant differences with international IUGA members in terms of whether they had used (P=0.002), were using (P<0.001), reasons for not using mesh (P<0.001), and indications of mesh implantation (P<0.001). Totally 81% (25/31) of Chinese IUGA members used various databases for monitoring and follow-up, while only 62% (580/936) of international IUGA members used databases, but there was no statistical difference (P=0.092). Conclusion: There are great differences in the concept and clinical application of transvaginal PP mesh implantation for POP between Chinese IUGA members and international IUGA members.

Biomimetic implants for pelvic floor repair.

BACKGROUND: Polypropylene implants are used for the reconstructive surgery of urogynaecological disorders like pelvic organ prolapse, but severe complications associated with their use have been reported. There is evidence that surface properties and a difference in mechanical stiffness between the implant and the host tissue contribute to these adverse events. Electrospinning is an innovative engineering alternative that provides a biomimetic microstructure for implants, resulting in a different mechano-biological performance. AIM: The main objective of this review is to inform about the potential of electrospun matrices as an alternative modality for pelvic floor repair. METHODS: Publications with the following studies of electrospun matrices were reviewed: (i) the technique; (ii) in vitro use for soft tissue engineering; (iii) in vivo use for reconstruction of soft tissues in animals; and (iv) clinical use in humans. RESULTS: Electrospun matrices provide a synthetic mimic of natural extracellular matrix (ECM), favoring cellular attachment, proliferation and matrix deposition, through which a proper, low-inflammatory tissue-implant interaction can be established. Electrospun sheets can also be created with sufficient mechanical strength and stiffness for usage in prolapse surgery. CONCLUSION: Electrospun matrices mimic the structural topography of the extracellular matrix and can be functionalized for better biological performance. As such, they have great potential for the next generation of urogynecological implants. However, their long-term safety and efficacy must still be established in vivo.

Demonstration of improved tissue integration and angiogenesis with an elastic, estradiol releasing polyurethane material designed for use in pelvic floor repair.

AIMS: Pelvic organ prolapse and stress urinary incontinence affect 40-50% of postmenopausal women worldwide. Polypropylene meshes have been extensively used for the surgical intervention of these disorders; however, these meshes can lead to severe complications in some patients. The need for synthetic materials more suited for use in pelvic floor repair is widely accepted. This study aims to develop an electrospun 17-ß-estradiol releasing polyurethane (PU) scaffold that not only provides the appropriate mechanical support but can also stimulate new extracellular matrix (ECM) production and angiogenesis. METHODS: PU scaffolds with and without 17-ß-estradiol (25 and 50 mg/g) were prepared by blend electrospinning. Mechanical properties of scaffolds were assessed by uniaxial cyclic and non-cyclic testing. The viability and ECM production of human adipose derived mesenchymal stem cells (hADMSCs) cultured on 17-ß-estradiol releasing PU scaffolds was evaluated. Angiogenic potential of estradiol releasing scaffolds was demonstrated by using an ex ovo chick chorioallantoic membrane (CAM) assay. RESULTS: The inclusion of estradiol in PU scaffolds did not change the ultrastructure but it significantly increased the ultimate tensile strength of scaffolds. hADMSCs on estradiol-releasing PU scaffolds showed more ECM production. The CAM assay revealed a significantly higher angiogenic potential of estradiol-releasing PU scaffolds with an additive effect seen when hADMSCs cultured on estradiol scaffolds. Histological examination of CAM tissue sections showed extensive cellular infiltration and a good tissue integration for all constructed scaffolds. CONCLUSIONS: This study shows the angiogenic potential of estradiol-releasing PU scaffolds with appropriate strength and elasticity desirable to support the pelvic floor.

[Clinical management of 110 cases of polypropylene mesh and sling exposure after reconstructive pelvic floor surgery].

Objective: To explore the clinical management and outcomes of polypropylene mesh and sling exposure after reconstructive pelvic surgery (RPS) . Methods: A total of 110 cases of mesh and sling exposure after RPS were analyzed, who admitted between Jan. 2002 and Oct. 2017 in First Affiliated Hospital of PLA General Hospital, in which 3 cases were referred from other hospitals. Mesh and sling exposures were identified in the outpatient clinic and categorized and managed according to International Continence Society and International Urogynecology Association (ICS-IUGA) classification about category, time and site (CTS) of mesh complication. Outpatient management included observation, topical estrogen use and mesh removal. Management in hospital included surgical removal of exposed mesh and repair of the resulting defects under the anesthesia. Seventy-four cases were managed in the outpatient setting, and 36 cases required inpatient management. Follow-up was consecutively performed from 1 month to 10 years. Objective outcome included the surgeon's assessment of the healing state of the vaginal mucosa. Subjective outcome was evaluated with patient global impression of improvement questionnaire (PGI-I) . Results: One hundred and ten patients with mesh exposure were classified according to the different RPS underwent. There were 95 cases from transvaginal mesh surgery, 5 cases from anti-stress urinary incontinence sling surgery, and 10 cases from sacrocolpopxy. The outpatient group healed at an average of (3.0±1.8) months. Of the 36 patients who required inpatient management, 21 cases healed completely at an average of 7 days after one surgery. The remaining 8 cases required either two or three times surgeries or conservative management. In the outpatient group, the PGI-I scale very much better was found in 65 cases (87.8%) and much better in 9 cases (12.2%) . In the inpatient surgery group, the scale was very much better in 30 cases (83.3%) , and much better in 6 cases (16.7%) . Conclusions: Among patients with mesh exposure after mesh-augmented RPS, 2/3 of patients with a CTS classification 1-3 could be managed in the office, and remaining 1/3 with CTS classification 4-6 need operation under anesthesia in hospital. If the mesh and sling exposure could be scientifically classified, according to the size, site and accompany symptoms, as well as pain, most of the mesh complications after explosure could be resolved. Using the pelvic floor repair and polypropylene mesh sling, the majority of the patients could get a better outcome, without affecting the effect of the original operation.

Urethral bulking for recurrent stress urinary incontinence after midurethral sling failure.

AIMS: To assess the effectiveness of a polyacrylamide hydrogel (PAHG; Bulkamid®) in treating recurrent stress urinary incontinence (SUI) following a previous midurethral sling (MUS) implant. METHODS: This observational study, conducted since 2009, included 60 patients with recurrent SUI or mixed urinary incontinence (MUI) after a previous MUS and who chose to be treated with PAHG. Objective and subjective outcomes were assessed at 1, 6, and 12 months after the initial injection. Patients were classified as cured based on a negative cough test (supine and standing) and <2 g urine on 1-hr pad test and a VAS score improved by ≥90%. Improved were those with the loss of only a few drops of urine during the cough test and 2-10 g urine on 1-hr pad test or a reduction >50% compared with preoperative urine loss and a VAS score improved by ≥75%. RESULTS: The volume of PAHG injected in the current study ranged from 1-3 ml. Cured/improved rates were 93.3% (56/60), 88.3% (53/60), and 83.6% (46/55) at 1, 6, and 12 months, respectively. Patients with MUI had a cured urgency urinary incontinence rate of 36.8%, 47.4%, and 38.9%, respectively. Voiding dysfunction rates were 13.3% (8/60), 8.3% (5/60), and 1.8% (1/55) at 1, 6, and 12 months and urinary tract infection rates were 5% (3/60), 11.7% (7/60), and 3.6% (2/55), respectively. Other adverse events were short-term and/or observed in <4% of patients. CONCLUSIONS: PAHG can be used to treat recurrent SUI after MUS failure with good outcome and low complication rates. Neurourol. Urodynam. 36:722-726, 2017. © 2016 The Authors. Neurourology and Urodynamics published by Wiley Periodicals, Inc.

Treatment of total pelvic organ prolapse using a whole biological patch: A pilot study of 17 patients.

AIM: A complete and non-splice porcine small-intestine submucosa (SIS) patch was used for total pelvic anatomical repair of organ prolapse. METHODS: This study included a total of 17 patients with severe total pelvic organ prolapse, including five patients with combined stress urinary incontinence (SUI). Panhysterectomy was performed, and then a porcine SIS patch was placed on the anterior (posterior) vaginal wall. The top of the vaginal wall was moved to the corresponding side of the vaginal wall, and the patch was sutured to bilateral uterosacral ligaments, the sacrospinous ligament, and arcus tendineus fasciae pelvis. SUI was addressed at the same time. 'Failure' was defined as anterior or posterior wall prolapse beyond the hymen. RESULTS: The mean follow-up duration was 11.6 ± 7.45 months (2-24 months). No symptom recurrence was observed in the five patients with combined SUI. One patient who underwent porcine SIS patch placement on the posterior wall experienced stage II anterior vaginal wall prolapse after surgery. The vaginal wall and fornix of the remaining patients with patches were restored to stable anatomical positions (92.85%). No organ damage, infection, erosion, or rejection was observed, and no blood transfusion was necessary. CONCLUSION: This study is the first to implement total pelvic anatomical repair using a complete and non-splice SIS. Our results suggest that this new surgical method is safe and can achieve satisfactory therapeutic effects, especially for patients with combined SUI.

[Management of recurrent stress urinary incontinence after anti-incontinence surgery]. / Management recidivující stresové inkontinence moci po selhání efektu anti-inkontinentních operací.

OBJECTIVE: The review article describes the possibilities of procedures for failed anti-incontinence surgery - sling procedure or "bulking agent"? DESIGN: Review article. SETTING: Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty, Charles University, Prague. MATERIALS AND METHODS: The correct choice of procedure type to treat persistent SUI (Stress Urinary Incontinence) which persists or soon reoccurs after anti-incontinence surgery is often problematic. The procedures that treat SUI decrease excessive mobility of the urethra by partially compressing it. If the excessive mobility of the urethra and BN (bladder neck) persist and MUCP (Maximal Urethral Closure Pressure) is within normal range, then we choose a new sling operation to treat the persistent SUI. What type of sling procedure is preferable in this situatitons: transobturator, retropubic or possibly SISs (Single Incision Slings)? SISs are not adequately fixed to the surrounding structures after implantation and are often not of the correct size - especially regarding length - with poor compliance (elasticity). For mentioned reasons we do not use them in reoperations. In this cases we choose such a sling which is properly fixed to the surrounding structures, is of sufficient length, and of appropriate elasticity. When choosing the right type of procedure we also have to consider previous operations: for example, whether reconstructive surgery of pelvic floor defects using mesh has been carried out, where the mesh has been placed, and whether it might be an obstacle to the newly implanted sling. If there is a low urethral mobility after the unsuccessful incontinence operation and a low MUCP is observed on urodynamic examination, then we prefer either a retropubic sling or the application of a bulking agent. The decision of which method to choose also depends on other circumstances, such as whether the patient has undergone radiation treatment or more than on previous surgery to treat SUI. The results of urodynamic, ultrasound and other examinations are very important. CONCLUSIONS: The choice of the right type of surgery to treat SUI after a previous failed procedure depends on information and findings from complex examination of the patient. Case history, examination results, imaging and the experience of the surgeon in individual procedures are therefore most important.

Pelvic floor dysfunction in female Sjögren's syndrome: an 8-year audit.

INTRODUCTION AND HYPOTHESIS: The classic triad of dry eyes, mouth and vagina is known to most gynaecologists as pathognomonic of Sjögren's syndrome, but rheumatologists seldom consider vaginal symptoms. Our hypothesis was that women with Sjögren's syndrome would have an increased likelihood of postoperative voiding dysfunction, severe vaginal stenosis or poor response to anticholinergics compared with the general urogynaecology patient. METHODS: All patients with Sjögren's syndrome were prospectively recorded from July 2007 to June 2015. Presenting complaint, pelvic examination findings, previous/subsequent pelvic surgery, voiding dysfunction and response to anticholinergics were noted. The denominator, all new urogynaecology patients, was prospectively recorded. RESULTS: Fifteen patients were identified over 8 years (0.5 % of 2794 new presentations). Of the seven patients who had previously undergone surgery elsewhere, all had demonstrable pelvic tissue fibrosis; five had such severe fibrosis that no speculum could be passed. Anticholinergic medications were completely intolerable in 10/11 (91 %) women, and severe postoperative voiding dysfunction occurred in 6/9 (67 %) women. Only 2/15 (13 %) women were unaffected by fibrosis, postoperative voiding dysfunction or intolerance to anticholinergics. CONCLUSIONS: This audit demonstrates a substantial risk of vaginal stenosis, postoperative voiding dysfunction or severe intolerance to anticholinergics in women with Sjögren's syndrome.