Handheld vital microscopy for the identification of microcirculatory alterations in cervical intraepithelial neoplasia and cervical cancer.

BACKGROUND: Ninety percent of cervical cancer (CC) diagnoses and deaths occur in low and middle-income countries (LMICs). Especially in these countries, where human and material resources are limited, there is a need for real-time screening methods that enable immediate treatment decisions (i.e., 'see and treat'). OBJECTIVE: To evaluate whether handheld vital microscopy (HVM) enables real-time detection of microvascular alterations associated with cervical intraepithelial neoplasia (CIN) and CC. METHODS: A cross-sectional study was conducted in an oncologic hospital and outpatient clinic, and included ten healthy controls, ten women with CIN, and ten women with CC. The microvasculature was assessed in four quadrants of the uterine cervix using HVM. The primary outcome was the presence of abnormal angioarchitecture (AA). Secondary outcomes included capillary loop density (CD), total vessel density (TVD), functional capillary density (FCD), and the proportion of perfused vessels (PPV). RESULTS: 198 image sequences of the cervical microvasculature were recorded. Compared to healthy controls, significantly more abnormal image sequences were observed in women with high-grade CIN (11 % vs. 44 %, P < 0.001) and women with CC (11 % vs. 69 %, P < 0.001). TVD, FCD, and PPV were lower in women with CIN and CC. CONCLUSIONS: HVM enables easy, real-time, non-invasive assessment of cervical lesions through the detection of microvascular alterations. Thereby, HVM potentially provides an opportunity for point-of-care screening, which may enable immediate treatment decisions (see and treat) and reduce the number of unnecessary surgical interventions.

Vaginal Er:YAG laser application in the menopausal ewe model: a randomised estrogen and sham-controlled trial.

OBJECTIVE: To describe effects of non-ablative erbium-doped:yttrium-aluminium-garnet (Er:YAG) laser on vaginal atrophy induced by iatrogenic menopause in the ewe. DESIGN: Animal experimental, randomised, sham and estrogen-treatment controlled study with blinding for primary outcome. SETTING: KU Leuven, Belgium. SAMPLE: Twenty-four ewes. METHODS: Menopause was surgically induced, after which the ewes were randomised to three groups receiving vaginal Er:YAG laser application three times, with a 1-month interval; three sham manipulations with a 1-month interval; or estrogen replacement and sham manipulations. At given intervals, ewes were clinically examined and vaginal wall biopsies were taken. Vaginal compliance was determined by passive biomechanical testing from explants taken at autopsy. MAIN OUTCOME MEASURES: Vaginal epithelial thickness (primary), composition of the lamina propria (collagen, elastin, glycogen and vessel content), vaginal compliance, clinical signs. RESULTS: Animals exposed to Er:YAG laser application and sham manipulation, but not to estrogens, displayed a significant and comparable increase in vaginal epithelial thickness between baseline and 7 days after the third application (69% and 67%, respectively, both P < 0.0008). In laser-treated ewes, temporary vaginal discharge and limited thermal injury were observed. Estrogen-substituted ewes displayed a more prominent increase in epithelial thickness (202%; P < 0.0001) and higher vaginal compliance (P < 0.05). None of the interventions induced changes in the lamina propria. CONCLUSIONS: Vaginal Er:YAG laser has comparable effect to sham manipulation in menopausal ewes. TWEETABLE ABSTRACT: Vaginal Er:YAG laser has comparable effect to sham manipulation in menopausal ewes #LASER #GSM #RCT.

Is pelvic organ prolapse associated with altered microcirculation of the vaginal wall?

AIMS: Vascularisation of the vagina is necessary for optimal function and support of the surrounding organs. We evaluated whether vaginal microcirculation, as representative of vascularisation, differs between women with and without pelvic organ prolapse (POP). METHODS: In 17 women with POP-Q stage ≥2 and 10 women without POP measurements were performed using sidestream dark-field imaging (groups were not matched). POP and non-POP sites were compared in women with a single compartment prolapse (n = 7). Morphology of the microvessels was scored using the microcirculatory architecture and capillary tortuosity scores at four regions of the vaginal wall. Capillary density measurements were performed and microvascular flow was assessed according to the microvascular flow index (MFI) score. RESULTS: Architecture and tortuosity scores were similar for each anatomical region between women with and without POP and between the POP and non-POP site. A statistically significant difference in capillary density in the left vaginal wall between women with and without POP was observed (25.8 vs. 34.0, P = 0.049). No significant differences in capillary density were observed between the POP and non-POP site. Average MFI scores revealed a continuous flow for all four regions in patients with and without POP. CONCLUSIONS: Vaginal microcirculatory architecture, capillary density, and microvascular flow are similar in women with and without POP. Our method to assess the microcirculation of the vaginal wall is consistent in women with POP, which generates an opportunity to assess vaginal microcirculation in the (surgical) treatments of POP. Neurourol. Urodynam. 35:764-770, 2016. © 2015 Wiley Periodicals, Inc.

Comparison of translabial three-dimensional ultrasound with magnetic resonance imaging for measurement of levator hiatal biometry at rest.

OBJECTIVES: To compare translabial three-dimensional (3D) ultrasound with magnetic resonance imaging (MRI) for the measurement of levator hiatal biometry at rest in women with pelvic organ prolapse, and to determine the interobserver reliability between two independent observers for ultrasound and MRI measurements. METHODS: Data were derived from a multicenter prospective cohort study in which women scheduled for conventional anterior colporrhaphy underwent translabial 3D ultrasound and MRI prior to surgery. Intraclass correlation coefficients (ICCs) were calculated to estimate interobserver reliability between two independent observers and determine the agreement between ultrasound and MRI measurements. Bland-Altman plots were created to assess the agreement between ultrasound and MRI measurements. RESULTS: Data from 139 women from nine hospitals were included in the study. The interobserver reliability of ultrasound assessment at rest, during Valsalva maneuver and during contraction and of MRI assessment at rest were moderate or good. The agreement between ultrasound and MRI for the measurement of levator hiatal biometry at rest was moderate, with ICCs of 0.52 (95%CI, 0.32-0.66) for levator hiatal area, 0.44 (95%CI, 0.21-0.60) for anteroposterior diameter and 0.44 (95%CI, 0.22-0.60) for transverse diameter. Levator hiatal biometry measurements were statistically significantly larger on MRI than on translabial 3D ultrasound. CONCLUSIONS: The agreement between translabial 3D ultrasound and MRI for measurement of the levator hiatus at rest in women with pelvic organ prolapse was only moderate. The results of translabial 3D ultrasound and MRI should therefore not be used interchangeably in daily practice or in clinical research. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Intrauterine insemination or intracervical insemination with cryopreserved donor sperm in the natural cycle: a cohort study.

STUDY QUESTION: Does intrauterine insemination in the natural cycle lead to better pregnancy rates than intracervical insemination (ICI) in the natural cycle in women undergoing artificial insemination with cryopreserved donor sperm. SUMMARY ANSWER: In a large cohort of women undergoing artificial insemination with cryopreserved donor sperm, there was no substantial beneficial effect of IUI in the natural cycle over ICI in the natural cycle. WHAT IS KNOWN ALREADY: At present, there are no studies comparing IUI in the natural cycle versus ICI in the natural cycle in women undergoing artificial insemination with cryopreserved donor sperm. STUDY DESIGN, SIZE, DURATION: We performed a retrospective cohort study among all eight sperm banks in the Netherlands. We included all women who underwent artificial insemination with cryopreserved donor sperm in the natural cycle between January 2009 and December 2010. We compared time to ongoing pregnancy in the first six cycles of IUI and ICI, after which controlled ovarian stimulation was commenced. Ongoing pregnancy rates (OPRs) over time were compared using life tables. A Cox proportional hazard model was used to compare the chances of reaching an ongoing pregnancy after IUI or ICI adjusted for female age and indication. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included 1843 women; 1163 women underwent 4269 cycles of IUI and 680 women underwent 2345 cycles of ICI with cryopreserved donor sperm. MAIN RESULTS AND THE ROLE OF CHANCE: Baseline characteristics were equally distributed (mean age 34.0 years for the IUI group versus 33.8 years for the ICI group), while in the IUI group, there were more lesbian women than in the ICI group (40.6% for IUI compared with 31.8% for ICI). Cumulative OPRs up to six treatment cycles were 40.5% for IUI and 37.9% for ICI. This corresponds with a hazard rate ratio of 1.02 [95% confidence interval (CI) 0.84-1.23] after controlling for female age and indication. Increasing female age was associated with a lower OPR, in both the IUI and ICI groups with a hazard ratio for ongoing pregnancy of 0.94 per year (95% CI 0.93-0.97). LIMITATIONS, REASONS FOR CAUTION: This study is prone to selection bias due to its retrospective nature. As potential confounders such as parity and duration of subfertility were not registered, the effect of these potential confounders could not be evaluated. WIDER IMPLICATIONS OF THE FINDINGS: In women inseminated with cryopreserved donor sperm in the natural cycle, we found no substantial benefit of IUI over ICI. A randomized controlled trial with economic analysis alongside, it is needed to allow a more definitive conclusion on the cost-effectiveness of insemination with cryopreserved donor sperm. STUDY FUNDING/COMPETING INTERESTS: No funding was used and no conflicts of interest are declared.

Transvaginal prolapse repair with or without the addition of a midurethral sling in women with genital prolapse and stress urinary incontinence: a randomised trial.

OBJECTIVE: To compare transvaginal prolapse repair combined with midurethral sling (MUS) versus prolapse repair only. DESIGN: Multi-centre randomised trial. SETTING: Fourteen teaching hospitals in the Netherlands. POPULATION: Women with symptomatic stage two or greater pelvic organ prolapse (POP), and subjective or objective stress urinary incontinence (SUI) without prolapse reduction. METHODS: Women were randomly assigned to undergo vaginal prolapse repair with or without MUS. Analysis was according to intention to treat. MAIN OUTCOME MEASURES: The primary outcome at 12 months' follow-up was the absence of urinary incontinence (UI) assessed with the Urogenital Distress Inventory and treatment for SUI or overactive bladder. Secondary outcomes included complications. RESULTS: One hundred and thirty-four women were analysed at 12 months' follow-up (63 in MUS and 71 in control group). More women in the MUS group reported the absence of UI and SUI; respectively 62% versus 30% UI (relative risk [RR] 2.09; 95% confidence interval [CI] 1.39-3.15) and 78% versus 39% SUI (RR 1.97; 95% CI 1.44-2.71). Fewer women underwent treatment for postoperative SUI in the MUS group (10% versus 37%; RR 0.26; 95% CI 0.11-0.59). In the control group, 12 women (17%) underwent MUS after prolapse surgery versus none in the MUS group. Severe complications were more common in the MUS group, but the difference was not statistically significant (16% versus 6%; RR 2.82; 95% CI 0.93-8.54). CONCLUSIONS: Women with prolapse and co-existing SUI are less likely to have SUI after transvaginal prolapse repair with MUS compared with prolapse repair only. However, only 17% of the women undergoing POP surgery needed additional MUS. A well-informed decision balancing risks and benefits of both strategies should be tailored to individual women.

Levator hiatal area as a risk factor for cystocele recurrence after surgery: a prospective study.

OBJECTIVE: To investigate whether increased levator hiatal area, measured preoperatively, was independently associated with anatom-ical cystocele recurrence 12 months after anterior colporrhaphy. DESIGN: Multicentre prospective cohort study. SETTING: Nine teaching hospitals in the Netherlands. POPULATION: Women planned for conventional anterior colporrhaphy without mesh. METHODS: Women underwent physical examination, translabial three-dimensional (3D) ultrasound and magnetic resonance imaging (MRI) prior to surgery. At 12 months after surgery the physical examination was repeated. MAIN OUTCOME MEASURES: Women with and without anatomical cystocele recurrence were compared to assess the association with levator hiatal area on 3D ultrasound, levator hiatal area on MRI, and potential confounding factors. The receiver operating characteristic (ROC) curve was created to quantify the discriminative ability of using levator hiatal area to predict anatomical cystocele recurrence. RESULTS: Of 139 included women, 76 (54.7%) had anatomical cystocele recurrence. Preoperative stage 3 or 4 and increased levator hiatal area during Valsalva on ultrasound were significantly associated with cystocele recurrence, with odds ratios of 3.47 (95% confidence interval, 95% CI 1.66-7.28) and 1.06 (95% CI 1.01-1.11) respectively. The area under the ROC curve was 0.60 (95% CI 0.51-0.70) for levator hiatal area during Valsalva on ultrasound, and 0.65 (95% CI 0.55-0.71) for preoperative Pelvic Organ Prolapse Quantification (POP-Q) stage. CONCLUSIONS: Increased levator hiatal area during Valsalva on ultrasound prior to surgery and preoperative stage 3 or 4 are independent risk factors for anatomical cystocele recurrence after anterior colporrhaphy; however, increased levator hiatal area as the sole factor for predicting anatomical cystocele recurrence after surgery shows poor test characteristics.

Assessment of vaginal atrophy: a review.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to provide an evidence-based definition of vaginal atrophy (VA) and present an overview of subjective and objective measurements of VA applicable in clinical practice and research. METHODS: A systematic literature search was performed in MEDLINE and EMBASE to identify studies reporting on measurement properties of diagnostic instruments for VA. Additional searches in MEDLINE aimed to document the definitions, diagnostic criteria, and outcome measures of VA. Studies reporting on definitions, diagnosis, outcome measurements, and measurement properties of diagnostic instruments of VA were selected. RESULTS: Specific symptoms for VA that were consistently described could be identified to suggest an evidence-based definition of VA. As subjective outcome measurements, seven scoring systems to assess the signs of VA during physical examination were identified. The most bothersome symptom (MBS) approach is most useful in clinical practice and research as it focuses on the most common symptoms of VA. As objective outcome measurements, numerous ways to assess vaginal cytology and vaginal pH were identified. CONCLUSIONS: At the moment, there is no consensus on the definition and assessment of VA. We propose to define VA as a common manifestation of estrogen decline associated with specific symptoms of which the most common are: vaginal dryness, itching or irritation, and dyspareunia. In both clinical and research settings, subjective assessment (the MBS approach) and objective assessments of VA (measurement of vaginal maturation index and vaginal pH) should be combined.

Prolapse surgery with or without stress incontinence surgery for pelvic organ prolapse: a systematic review and meta-analysis of randomised trials.

OBJECTIVES: The combination of prolapse surgery with an incontinence procedure can reduce the incidence of stress urinary incontinence (SUI) after surgery, but may increase adverse events. We compared the effectiveness and safety of prolapse surgery versus combined prolapse and incontinence surgery in women with pelvic organ prolapse. DESIGN AND SETTING: Pubmed, EMBASE, DARE, the Cochrane Library and the register of Current Controlled Trials were searched for randomised trials (restricted to Burch colposuspension and midurethral sling as incontinence procedure) from 1995 to 2013 limited to the English literature. METHODS: Two reviewers selected eligible articles and extracted the data. Pooling for SUI was based on three patient groups: (1) women with coexisting SUI; (2) women asymptomatic for SUI; and (3) women with occult SUI. For adverse events, pooling was based on incontinence procedure. MAIN OUTCOME MEASURES: The primary outcome was SUI. The secondary outcomes were treatment for SUI, bladder storage symptoms, obstructive voiding and adverse events. RESULTS: Seven trials were included. Pooling for women with coexisting SUI was possible for objective SUI with two studies and showed no difference. Statistical (I(2) = 95%) and clinical heterogeneity was, however, high. The largest study showed a lower incidence of persisting SUI (5% versus 23%) and treatment for this (0% versus 57%) in women who underwent prolapse repair with a midurethral sling. The second study did not find a difference in women undergoing a sacrocolpopexy with or without Burch colposuspension. In asymptomatic women, combination surgery resulted in a lower incidence of de novo subjective SUI (two studies; 24% versus 41%; relative risk [RR], 0.6; 95% confidence interval [CI], 0.3-0.9; I(2) = 36%) and the need for subsequent anti-incontinence surgery (three studies; 2% versus 7%; RR, 0.4; 95% CI, 0.2-0.8; I(2) = 13%). For the outcome objective SUI, pooling was possible for five studies, but statistical heterogeneity was high (I(2) = 82%) and the difference was not statistically significant. In the subgroup of women with occult stress incontinence, we found a lower incidence of objective SUI after combination surgery (two studies; 22% versus 52%; RR, 0.4; 95% CI, 0.3-0.8; I(2) = 32%). There were no differences in bladder storage symptoms, urgency incontinence or long-term obstructive voiding symptoms. Adverse events (two studies; 15% versus 10%; RR, 1.6; 95% CI, 1.0-2.5; I(2) = 0%) and prolonged catheterisation (three studies; 6% versus 1%; RR, 4.5; 95% CI, 1.5-13.3; I(2) = 0%) were more frequent after vaginal prolapse repair with a midurethral sling. CONCLUSIONS: Combination surgery reduces the risk of postoperative stress incontinence, but short-term voiding difficulties and adverse events were more frequent after combination surgery with a midurethral sling.

Four-defect repair in women with symptomatic anterior compartment prolapse: a large cohort study.

INTRODUCTION AND HYPOTHESIS: We aimed to collect long-term follow-up data and report on both objective and subjective outcome, including morbidity, reinterventions, and sexual function following four-defect repair (FDR) as surgical correction of symptomatic anterior vaginal wall prolapse with or without stress urinary incontinence (SUI). METHODS: Consecutive patients who underwent FDR between 1999 and 2005 were included in this study. We performed a retrospective analysis to evaluate anatomical and functional outcome by reviewing medical charts and sending validated questionnaires (Urogenital Distress Inventory and Defecatory Distress Inventory) to all patients. We also sent a self-developed, nonvalidated questionnaire to assess sexual function and inform the patient about reinterventions for pelvic floor dysfunction. RESULTS: Two hundred and twenty-nine (60 %) of the 381 patients who underwent FDR participated. At a median follow-up of 40 months (range 5-88), 21 % of patients reported bothersome prolapse symptoms, and 11 % reported bothersome SUI. Temporary postoperative urinary retention occurred in 23 %. During follow-up, posterior vaginal wall prolapse was observed in 14 % of patients. Overall surgical reintervention rates were 15 % and 4 % for (all types of) pelvic organ prolapse and SUI, respectively; dyspareunia was reported by 30 %. CONCLUSIONS: Functional cure rates of FDR as surgical treatment for anterior vaginal wall prolapse with or without SUI are satisfying. Nevertheless, given the negative side effects of FDR (urinary retention, high reintervention rate for posterior vaginal wall prolapse, high risk of sexual dysfunction), we question the superiority of FDR over standard anterior colporrhaphy in patients with anterior vaginal wall prolapse only.

Postpartum urinary retention: a systematic review of adverse effects and management.

INTRODUCTION AND HYPOTHESIS: Postpartum urinary retention (PUR) is a well-known condition after childbirth. Often clinicians assume that this condition is transient, either through belief or by not being aware that its occurrence as measurement of post-void residual volume (PVRV) is often not routine. However, long lasting urinary retention is a serious condition that needs management in order to prevent urogenital tract morbidity. By performing a systematic review of the adverse effects of PUR and management of this condition, we aimed to identify the necessity of diagnosing this condition in the puerperium and to evaluate whether treatment is required. METHODS: We searched for all studies on PUR in OVID MEDLINE, OVID EMBASE, and ongoing Trial registers. Two reviewers independently screened and extracted the data. RESULTS: Twenty-four papers were included in this review. Limited data on adverse effects demonstrate potential morbidities, like micturition symptoms and sporadically spontaneous bladder ruptures, related to PUR. CONCLUSIONS: Based on current literature, evidence stating that PUR is harmless is lacking. Future research should focus on management strategies for overt PUR and the long-term consequences of covert PUR. Until these results are available, clinicians should be aware of the potential consequences and therefore keep trying to identify patients at risk of PUR and patients with the actual condition.

Prediction of successful revision surgery for mesh-related complaints after inguinal hernia and pelvic organ prolapse repair.

PURPOSE: With this retrospective case series, we aim to identify predictors for reduction of pain after mesh revision surgery in patients operated for inguinal hernia or pelvic organ prolapse with a polypropylene implant. Identifying these predictors may aid surgeons to counsel patients and select appropriate candidates for mesh revision surgery. METHODS: Clinical records before and after mesh revision surgery from 221 patients with chronic postoperative inguinal pain (CPIP) and 59 patients with pain after pelvic organ prolapse (POP) surgery were collected at two experienced tertiary referral centers. Primary outcome was patient reported improvement of pain after revision surgery. A multivariable logistic regression model was used to specify predictors for pain reduction. RESULTS: The multivariable logistic regression was performed for each patient group separately. Patients with CPIP had higher chances of improvement of pain when time between mesh placement and mesh revision surgery was longer, with an OR of 1.19 per year. A turning point in chances of risks and benefits was demonstrated at 70 months, with improved outcomes for patients with revision surgery ≥ 70 months (OR 2.86). For POP patients, no statistically significant predictors for reduction of pain after (partial) removal surgery could be identified. CONCLUSION: A longer duration of at least 70 months between implantation of inguinal mesh and revision surgery seems to give a higher chance on improvement of pain. Caregivers should not avoid surgery based on a longer duration of symptoms when an association between symptoms and the location of the mesh is found.

Risk indicators for obstetrical anal sphincter injury in vaginal birth after caesarean section compared to first vaginal delivery.

OBJECTIVES: Comparison of the rate of obstetric anal sphincter injury (OASI) between women having their first vaginal birth after caesarean section (CS) and true nulliparous women with a vaginal delivery. Assessment of risk indicators for OASI in women with vaginal birth after one CS (VBAC). STUDY DESIGN: 28 535 women with their first VBAC and a cohort of 275 439 nulliparous women with a vaginal delivery of a liveborn infant in a cephalic position from the Dutch perinatal registry were analyzed. We compared the OASI rate with univariate and multivariate analysis. In women with VBAC possible risk indicators for OASI were assessed using univariate and multivariate logistic regression analysis. RESULTS: The rate of OASI was 5.2% in women with vaginal birth after CS and 4.0% in women with a first vaginal delivery. The adjusted OR (aOR) for vaginal birth after an elective CS was higher (aOR 1.34, 95% CI 1.23-1.47) compared to vaginal birth after an emergency CS (aOR 1.16, 95% CI 1.08-1.25). In women with vaginal birth after emergency CS, the aOR for the indication non-progressive labor was 1.18 (95% CI 1.08-1.29), whereas CS for suspected fetal distress was not significantly associated with obstetric anal sphincter injury in VBAC. In the 28 535 women with a VBAC, mediolateral episiotomy (MLE), birth weight < 3000 g and maternal age < 25 years were associated with a significantly lower rate of OASI. A gestational age of 42 weeks, birth weight ≥ 3500 g, operative vaginal delivery and duration of the 2nd stage of labour of ≥ 60 min were associated with a significantly higher rate of OASI. CONCLUSIONS: Women with a VBAC have a higher rate of OASI in comparison with women with a first vaginal delivery, with the exception of women with a vaginal birth after an emergency CS for suspected fetal distress. Factors associated with a significantly lower rate for OASI were MLE, maternal age < 25 and birth weight < 3000 g. A gestational age of 42 weeks, birth weight between 3500 and 4000 g and ≥ 4000 g, operative vaginal delivery and duration of the 2nd stage of delivery longer dan 60 min were associated with a significantly higher rate of OASI.

Complications of Synthetic Midurethral Slings: Is There a Relevant Discrepancy Between Observational Data and Clinical Trials?

CONTEXT: The complications of synthetic midurethral slings (MUSs) in women with stress urinary incontinence (SUI) have become a globally debated issue. OBJECTIVE: To systematically review the short- and long-term complications of mesh slings reported in observational data compared with clinical trial data, to determine whether the complication rates from clinical trials reflects "real-world" observational data. EVIDENCE ACQUISITION: PubMed and Cochrane Library were searched. Methods as detailed in Preferred Reporting Items for Systematic Reviews and Meta-analyses and Cochrane Handbook for Systematic Reviews of Interventions were followed. EVIDENCE SYNTHESIS: Thirty registries/databases including 709 335 MUS procedures (1-22 yr of follow-up) were identified. MUS procedures were associated with intraoperative bladder perforation in 0.86-3.6%, urethral perforation in 0-0.1%, vascular injury in 0.04-0.1%, voiding lower urinary tract symptoms (LUTS) in 1.47-3.5%, vaginal exposure in 0.2-1.9%, and reoperation in up to 9% of cases. Forty-three randomised clinical trials were identified, including 6284 women who underwent MUS procedures and 2177 women who underwent other interventions (1-10 yr of follow-up). MUS procedures were associated with urinary tract perforation in 2.58%, vaginal injury in 1.43%, de novo voiding LUTS in 4.37%, de novo storage LUTS in 5.41%, mesh extrusion/exposure (vaginal/urinary tract) in 2.54%, dyspareunia in 2.26%, pain (pelvic/suprapubic/perineal) in 2.83%, and reoperation for complications required in 1.82% of cases. Meta-analyses of the randomised controlled trials revealed that retropubic MUSs were associated with more events of urinary tract perforation (risk ratio [RR] 9.81, 95% confidence interval [CI] 5.05-19.04, high certainty of evidence [COE]) and voiding LUTS (RR 1.57, 95% CI 1.19-2.07, high COE) than transobturator MUSs. MUSs were associated with more events of pain than mini-slings (RR 1.72, 95% CI 1.04-2.87, moderate COE). CONCLUSIONS: Short- and long-term data on complications of polypropylene mesh used for female SUI are fairly comparable when using outcome data from well-designed clinical trials or from less structured prospective or retrospective registries. Comparisons have to be made with caution since the two systems of data collection are inherently incomparable. This knowledge should be incorporated in the discussion on how to implement polypropylene mesh for female stress incontinence. PATIENT SUMMARY: In order to know whether mesh tapes used for treating stress incontinence work well and are safe, high-quality information is important. It appears that well-designed clinical studies give similar results to large registration databases. These data should be interpreted with caution in view of the different ways the information was collected. These results will help physicians and patients understand the risks of mesh tapes.

Evaluation of the female pelvic floor in pelvic organ prolapse using 3.0-Tesla diffusion tensor imaging and fibre tractography.

OBJECTIVES: To prospectively explore the clinical application of diffusion tensor imaging (DTI) and fibre tractography in evaluating the pelvic floor. METHODS: Ten patients with pelvic organ prolapse, ten with pelvic floor symptoms and ten asymptomatic women were included. A two-dimensional (2D) spin-echo (SE) echo-planar imaging (EPI) sequence of the pelvic floor was acquired. Offline fibre tractography and morphological analysis of pelvic magnetic resonance imaging (MRI) were performed. Inter-rater agreement for quality assessment of fibre tracking results was evaluated using weighted kappa (κ). From agreed tracking results, eigen values (λ1, λ2, λ3), mean diffusivity (MD) and fractional anisotropy (FA) were calculated. MD and FA values were compared using ANOVA. Inter-rater reliability of DTI parameters was interpreted using the intra-class correlation coefficient (ICC). RESULTS: Substantial inter-rater agreement was found (κ = 0.71 [95% CI 0.63-0.78]). Four anatomical structures were reliably identified. Substantial inter-rater agreement was found for MD and FA (ICC 0.60-0.91). No significant differences between groups were observed for anal sphincter, perineal body and puboperineal muscle. A significant difference in FA was found for internal obturator muscle between the prolapse group and the asymptomatic group (0.27 ± 0.05 vs 0.22 ± 0.03; P = 0.015). CONCLUSION: DTI with fibre tractography permits identification of part of the clinically relevant pelvic structures. Overall, no significant differences in DTI parameters were found between groups. KEY POINTS: Diffusion tensor MRI offers new insights into female pelvic floor problems. DTI allows 3D visualisation and quantification of female pelvic floor anatomy. DTI parameters from pelvic floor structures can be reliably determined. No significant differences in DTI parameters between groups with/without prolapse.

Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for vaginal hysterectomy: a randomised controlled trial.

OBJECTIVE: To compare the effects of electrical bipolar vessel sealing and conventional suturing on postoperative pain, recovery, costs and micturition symptoms in women undergoing vaginal hysterectomy. DESIGN: Randomised controlled trial. SETTING: Eight teaching hospitals in the Netherlands. POPULATION: One hundred women scheduled to undergo vaginal hysterectomy for benign conditions excluding pelvic organ prolapse. METHODS: Women were randomised to vessel sealing or conventional surgery. The quality of life related to pelvic floor function was assessed using validated questionnaires before surgery and 6 months after surgery. Pain scores and recovery were assessed using a diary, including daily visual analogue scale scores, starting from the day before surgery until 6 weeks after surgery. MAIN OUTCOME MEASURES: Visual analogue scale pain scores, surgery time, blood loss, complications, quality of life related to pelvic floor function and costs. RESULTS: The evening after surgery, women in the vessel-sealing group reported significantly less pain (5.7 versus 4.5 on a scale of 0-10, P = 0.03), but after that pain scores were similar. Operation duration was shorter for vessel sealing (60 versus 71 minutes, P = 0.05). Blood loss and hospital stay did not differ. We observed no major difference in costs between the two interventions (2903 versus 3102 €, P = 0.26). Changes in micturition and defecation symptoms were not affected by the surgical technique used. CONCLUSION: Using vessel sealing during vaginal hysterectomy resulted in less pain on the first postoperative day, shorter operating time, similar morbidity and similar pelvic floor function. No major differences in costs were found between the two interventions.

Risk factors for postpartum urinary retention: a systematic review and meta-analysis.

BACKGROUND: Postpartum urinary retention (PUR) is a common condition with varying prevalence. Measurement of the post-void residual volume (PVRV) is not regularly performed. Various studies have been published on overt (the inability to void after giving birth, requiring catheterisation) and covert (an increased PVRV after spontaneous micturition) PUR. To evaluate which clinical prognostic factors are related to PUR, the identification of independent risk factors for covert and overt PUR is needed. OBJECTIVES: We performed a systematic review and meta-analysis of observational studies reporting on risk factors for PUR. SEARCH STRATEGY: Systematic search of MEDLINE and EMBASE to September 2011. SELECTION CRITERIA: Articles that reported on women diagnosed with PUR or with an abnormal PVRV. DATA COLLECTION AND ANALYSIS: The included articles were selected by two authors. We constructed two-by-two tables for potential risk factors of overt and covert PUR and calculated pooled odds ratios (ORs) with 95% confidence intervals. MAIN RESULTS: Twenty-three observational studies with original data were eligible for data extraction, of which 13 could be used for meta-analysis. Statistically significant risk factors for overt PUR were epidural analgesia (OR 7.7), instrumental delivery (OR 4.5), episiotomy (OR 4.8) and primiparity (OR 2.4). For covert PUR, variety in the definitions used resulted in heterogeneity; no significant prognostic factors were found. CONCLUSIONS: Instrumental delivery, epidural analgesia, episiotomy and nulliparity are statistically significantly associated with a higher incidence of overt PUR. The same factors were identified for covert PUR, but without statistical significance. Uniformity in definitions in future research is essential to create a prognostic model.

Anterior colporrhaphy does not induce bladder outlet obstruction.

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate if anterior colporrhaphy causes incomplete voiding due to bladder outlet obstruction. METHODS: Women scheduled for anterior colporrhaphy were asked to undergo multichannel urodynamic investigation before surgery and the first postoperative day. Bladder outlet obstruction was assessed using the Blaivas­Groutz voiding nomogram. Maximum flow rate, detrusor pressure and residual volume were compared between pre- and postoperative measurements and between women with and without an abnormal post-void residual volume (PVR; volume exceeding 150 ml). RESULTS: Seventeen women participated. One woman who was unobstructed before surgery was obstructed after surgery. Overall, detrusor pressure and maximum flow rate before and after surgery did not differ. After surgery, six women had an abnormal PVR, one was unable to void, four were mildly obstructed and one moderately obstructed. CONCLUSION: Urodynamic investigation the first day after anterior colporrhaphy did not show that anterior colporrhaphy induces bladder outlet obstruction. The explanation for postoperative urinary retention can therefore also lie in nonanatomical causes such as postoperative pain and psychological factors.

Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: reliability of assessment and correlation with clinical findings and pelvic floor symptoms.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the interobserver agreement of magnetic resonance imaging (MRI)-based staging of pelvic organ prolapse (POP) and to quantify associations between MRI-based POP staging, findings at pelvic examination, and pelvic floor symptoms. METHODS: This was a cross-sectional study of ten symptomatic POP patients, ten symptomatic patients without POP, and ten nulliparous asymptomatic women. Three different observers performed MRI-based POP staging using the pubococcygeal line (PCL), midpubic line (MPL), perineal line, and H line as references. RESULTS: The interobserver agreement of MRI-based staging of the anterior and middle compartment was good to excellent. In symptomatic women without prolapse, MRI-based and pelvic-examination-based POP staging were poorly correlated. In none of the women were MRI-based POP Quantification (POP-Q) staging and pelvic floor symptoms strongly associated. CONCLUSION: The interobserver agreement of MRI-based POP staging is excellent, but the added clinical value of such staging is questionable due to poor association with clinical findings and pelvic floor symptoms.