Long-term outcomes of primary cystocele repair by transvaginal mesh surgery versus laparoscopic mesh sacropexy: extended follow up of the PROSPERE multicentre randomised trial.

OBJECTIVE: To compare the effectiveness and safety of laparoscopic sacropexy (LS) and transvaginal mesh (TVM) at 4 years. DESIGN: Extended follow up of a randomised trial. SETTING: Eleven centres. POPULATION: Women with cystocele stage ≥2 (pelvic organ prolapse quantification [POP-Q], aged 45-75 years without previous prolapse surgery. METHODS: Synthetic non-absorbable mesh placed in the vesicovaginal space and sutured to the promontory (LS) or maintained by arms through pelvic ligaments and/or muscles (TVM). MAIN OUTCOME MEASURES: Functional outcomes (pelvic floor distress inventory [PFDI-20] as primary outcome); anatomical assessment (POP-Q), composite outcome of success; re-interventions for complications. RESULTS: A total of 220 out of 262 randomised patients have been followed at 4 years. PFDI-20 significantly improved in both groups and was better (but below the minimal clinically important difference) after LS (mean difference -7.2 points; 95% CI -14.0 to -0.05; P = 0.029). The improvement in quality of life and the success rate (LS 70%, 61-81% versus TVM 71%, 62-81%; hazard ratio 0.92, 95% CI 0.55-1.54; P = 0.75) were similar. POP-Q measurements did not differ, except for point C (LS -57 mm versus TVM -48 mm, P = 0.0093). The grade III or higher complication rate was lower after LS (2%, 0-4.7%) than after TVM (8.7%, 3.4-13.7%; hazard ratio 4.6, 95% CI 1.007-21.0, P = 0.049)). CONCLUSIONS: Both techniques provided improvement and similar success rates. LS had a better benefit-harm balance with fewer re-interventions due to complications. TVM remains an option when LS is not feasible. TWEETABLE ABSTRACT: At 4 years, Laparoscopic Sacropexy (LS) had a better benefit-harm balance with fewer re-interventions due to complications than Trans-Vaginal Mesh (TVM).

Serious complications and recurrences after pelvic organ prolapse surgery for 2309 women in the VIGI-MESH registry.

OBJECTIVE: To assess the incidence of serious complications and reoperations for recurrence after surgery for pelvic organ prolapse (POP) and compare the three most common types of repair. DESIGN: Prospective cohort study using a registry. SETTING: Nineteen French surgical centres. POPULATION: A total of 2309 women participated between 2017 and 2019. METHODS: A multivariate analysis including an inverse probability of treatment weighting approach was used to obtain three comparable groups. MAIN OUTCOME MEASURES: Serious complications and subsequent reoperations for POP recurrence. RESULTS: The median follow-up time was 17.6 months. Surgeries were native tissue vaginal repairs (n = 504), transvaginal mesh placements (n = 692) and laparoscopic sacropexies with mesh (n = 1113). Serious complications occurred among 52 women (2.3%), and reoperation for POP recurrence was required for 32 women (1.4%). At 1 year the cumulative weighted incidence of serious complications was 1.8% for native tissue vaginal repair, 3.9% for transvaginal mesh and 2.2% for sacropexy, and the rates for reoperation for recurrence of POP were 1.5, 0.7 and 1.1%, respectively. Compared with native tissue vaginal repair, the risk of serious complications was higher in the transvaginal mesh group (weighted hazard ratio, wHR 3.84, 95% CI 2.43-6.08) and the sacropexy group (wHR 2.48, 95% CI 1.45-4.23), whereas the risk of reoperation for prolapse recurrence was lower in both the transvaginal mesh (wHR 0.22, 95% CI 0.13-0.39) and sacropexy (wHR 0.29, 95% CI 0.18-0.47) groups. CONCLUSIONS: Our results suggest that native tissue vaginal repairs have the lowest risk of serious complications but the highest risk of reoperation for recurrence. These results are useful for informing women and for shared decision making. TWEETABLE ABSTRACT: Laparoscopic sacropexy had fewer serious complications than transvaginal mesh and fewer reoperations for recurrence than vaginal repair.

[Trends in the use of midurethral slings after the new legislation: A nationwide survey]. / Évolution des pratiques après l'arrêté encadrant les bandelettes sous-urétrales : résultats d'une enquête nationale.

INTRODUCTION: The French Department of Health published on October 23, 2020 a decree governing acts associated with mid-urethral sling (MUS) operations. The aim of this study was to evaluate the changes in practice following this new legislation. METHODS: A cross-sectional study was carried out among French urologists and gynecologists using an online survey to collect changes in practices since the publication of the decree. RESULTS: From January to February 2021, 436 surgeons participated in the survey. Among these surgeons, 87% were aware of the new legislation and 56% of them considered the decree as useless. The order resulted in an increase in working time in 81% of cases. Among these surgeons, 66% of the surgeons worked in tertiary referral centers for the management of incontinence, of which 55% had a multidisciplinary meeting in urogynecology. Among the surgeons, 31% considered this meeting to be useful but 80% considered that it did not lead to any change in surgical indications, even though 33% of complications of BSU were discussed there. In conclusion, 61% of surgeons felt more reluctant to schedule a BSU placement with this new legislation. CONCLUSION: The majority of questioned surgeons considered the decree as useless. It generated few changes in practices which already respected the law on information, consultation, consent, experience and training. Most urologists and gynecologists are more reluctant to offer MUS after this new legislation. LEVEL OF EVIDENCE: 4.

Complications after pelvic floor repair surgery (with and without mesh): short-term incidence after 1873 inclusions in the French VIGI-MESH registry.

OBJECTIVE: To assess the short-term incidence of serious complications of surgery for urinary incontinence or pelvic organ prolapse. DESIGN: Prospective longitudinal cohort study using a surgical registry. SETTING: Thirteen public hospitals in France. POPULATION: A cohort of 1873 women undergoing surgery between February 2017 and August 2018. METHODS: Preliminary analysis of serious complications after a mean follow-up of 7 months (0-18 months), according to type of surgery. Surgeons reported procedures and complications, which were verified by the hospitals' information systems. MAIN OUTCOME MEASURES: Serious complication requiring discontinuation of the procedure or subsequent surgical intervention, life-threatening complication requiring resuscitation, or death. RESULTS: Fifty-two women (2.8%, 95% CI 2.1-3.6%) experienced a serious complication either during surgery, requiring the discontinuation of the procedure, or during the first months of follow-up, necessitating a subsequent reoperation. One woman also required resuscitation; no women died. Of 811 midurethral slings (MUSs), 11 were removed in part or totally (1.4%, 0.7-2.3%), as were two of 391 transvaginal meshes (0.5%, 0.1-1.6%), and four of 611 laparoscopically placed mesh implants (0.7%, 0.2-1.5%). The incidence of serious complications 6 months after the surgical procedure was estimated to be around 3.5% (2.0-5.0%) after MUS alone, 7.0% (2.8-11.3%) after MUS with prolapse surgery, 1.7% (0.0-3.8%) after vaginal native tissue repair, 2.8% (0.9-4.6%) after transvaginal mesh, and 1.0% (0.1-1.9%) after laparoscopy with mesh. CONCLUSIONS: Early serious complications are relatively rare. Monitoring must be continued and expanded to assess the long-term risk associated with mesh use and to identify its risk factors. TWEETABLE ABSTRACT: Short-term serious complications are rare after surgery for urinary incontinence or pelvic organ prolapse, even with mesh.

[Antibiotic prophylaxis in urodynamics: Clinical practice guidelines using a formal consensus method]. / Antibioprophylaxie et bilan urodynamique : recommandations de bonne pratique par consensus formalisé.

OBJECTIVE: The aim of this work was to issue clinical practice guidelines on antibiotic prophylaxis in urodynamics (urodynamic studies, UDS). MATERIALS AND METHODS: Clinical practice guidelines were provided using a formal consensus method. Guidelines proposals were drew up by a multidisciplinary experts group (pilot group = steering group), then rated by a panel of 12 experts (rating group) using a formal consensus method, and then peer reviewed by a reviewing/reading group of experts (different from the rating group). RESULTS: Urine (bacterial) culture with antimicrobial susceptibility testing is recommended for all patients before UDS (strong agreement). In patients with no neurologic disease, the risk factors for tract urinary infection (UTI) after UDS are age > 70 years, recurrent UTI, and post-void residual volume > 100ml. In patients with neurologic disease, the risk factors for UTI after UDS are recurrent UTI, vesicoureteral reflux, and intermicturition pressure > 40cmH2O. If the urine culture is negative before UDS and there is no risk factor for UTI, antibiotic prophylaxis is not recommended (Strong agreement). If the urine culture is negative before UDS, but there are one or more risk factors for UTI, antibiotic prophylaxis is optional. If antibiotic prophylaxis is initiated, a single oral dose (3g) of fosfomycin-tromethamine two hours before UDS is recommended (Strong agreement). If there is bacterial colonization on UCB before UDS, antibiotic therapy is optional (Undecided). If prescribed, it should be adapted to the antimicrobial susceptibility of the identified bacterium or bacteria, started the day before and stopped after UDS (except for fosfomycin-tromethamine: a single dose the day before UDS is necessary and sufficient) (Strong agreement). In the event of UTI before UDS, the UTI should be treated and UDS postponed (Strong agreement). The proposed recommendations should not be changed for patients with a hip or knee replacement (Strong agreement). No antibiotic prophylaxis of bacterial endocarditis is necessary, including in high-risk patients with valvular heart disease (Strong agreement). CONCLUSION: These new guidelines should help to harmonize clinical practice and limit exposure to antibiotics. LEVEL OF EVIDENCE: 4.

[Quality of life and symptoms before and after surgical treatment of rectovaginal fistula]. / Évaluation de la qualité de vie et des symptômes avant et après prise en charge chirurgicale des fistules rectovaginales.

INTRODUCTION: Rectovaginal fistula requires a complex management because it has an important psychological impact associated with impaired quality of life of patients. Thus, the aim of our study was to evaluate the improvement of the quality of life of patients after surgical management. METHODS: This is a retrospective study. We included patients operated between 2009 and 2014 for the treatment of a rectovaginal fistula, whose data were available and who agreed to answer a questionnaire. We evaluated the satisfaction of short-term and long-term patients on the answer to the basic PFDI-20 and PFIQ-7 questionnaires. We then evaluated whether there was an improvement in symptoms and quality of life after surgery. RESULTS: Nine patients were included but only 4 patients completed the PFDI-20 and PFIQ-7 questionnaires. Fistula was secondary to either surgical intervention (44%, n=4) or complicated perineal tear (44%, n=4) or unknown cause (11%, n=1). After surgery, we found the short term a significant decrease in stool incontinence, as there was no stool incontinence (0/5) in the postoperative period, while preoperatively 55% (5/9) (P=0.03). Postoperatively, 33% (3/9) of the patients had genital discomfort and 44% (4/9) had gas incontinence compared to 0% preoperatively (P=0.2 and P=0.6). There appears to be an improvement in pelvic static disorders after surgical management. However, we found a slight improvement in nauseous leucorrhoea in the immediate postoperative period, as the prevalence decreased from 33% (3/9) preoperatively to 22% (2/9) postoperatively (P>0.9). In the long term, we observed an improvement in the sensation of perineal heaviness and gas incontinence because only 25% (1/4) of the 75% (3/4) preoperative patients still showed slight discomfort (P=0.5). The quality of life and the emotional state of the patients were no altered postoperatively. Indeed, preoperatively, 50% (2/4) of the patients reported anxiety compared to 0% (0/4) postoperatively (P=0.4). Similarly, 75% (3/4) complained of a decrease in their quality of life (social, sports, etc.) preoperatively compared with 0% (0/4) postoperatively (P>0.9). CONCLUSION: A simple surgical management of rectovaginal fistulas would allow a significant decrease in stool incontinence and improved quality of life and their emotional state, which confirms the beneficial effect of this therapeutic strategy. LEVEL OF EVIDENCE: 4.

[Clinical practice guidelines: Summary of recommendations for first surgical treatment of female pelvic organ prolapse by 5 French academic societies: AFU, CNGOF, SIFUD-PP, SNFCP, and SCGP]. / Recommandations pour la pratique clinique : Synthèse des recommandations pour le traitement chirurgical du prolapsus génital non récidivé de la femme par l´AFU, le CNGOF, la SIFUD-PP, la SNFCP et la SCGP.

OBJECTIVE: Providing clinical practice guidelines for first surgical treatment of female pelvic organ prolapse. METHODS: Systematic literature review, level of evidence rating, external proofreading, and grading of recommendations by 5 French academic societies: Association française d'urologie, Collège national des gynécologues et obstétriciens français, Société interdisciplinaire d'urodynamique et de pelvi-périnéologie, Société nationale française de coloproctologie, and Société de chirurgie gynécologique et pelvienne. RESULTS: It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (Grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (Grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (Grade B). A bowel preparation before vaginal (Grade B) or abdominal surgery (Grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (Grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (Grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (Grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (Grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (Grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (Grade C). Clinical practice guidelines. © 2016 Published by Elsevier Masson SAS.

Biomechanical pregnant pelvic system model and numerical simulation of childbirth: impact of delivery on the uterosacral ligaments, preliminary results.

INTRODUCTION AND HYPOTHESIS: We created a pregnant woman pelvic model to perform a simulation of delivery to understand the pathophysiology of urogenital prolapse by studying the constraints on the pelvic components (muscles, ligaments, pelvic organs) during childbirth. These simulations will also provide valuable tools to understand and teach obstetrical mechanics. METHODS: We built a numerical model of the pelvic system from a term pregnant woman, using the finite element method on a mesh built from magnetic resonance images of a nulliparous pregnant woman. Mechanical properties of pelvic tissues already determined by the team were adapted to account for pregnancy. RESULTS: The system allows delivery to be simulated. When a fetal head at the 50th percentile for the term goes through the pelvic system, uterosacral ligaments undergo a deformation of around 30 %. Uterosacral ligaments are the major pelvic sustaining structures, their lesion may be a potential cause of urogenital prolapse. We built a model of childbirth as a function of pregnancy term by varying volumes of fetal head and uterus. The impact on uterosacral ligaments is higher when the fetal head is larger. CONCLUSIONS: Our modelling is rather complete considering that it involves many organs including ligaments. It allows us to analyse the effect of childbirth on uterosacral ligaments and to understand how they impact on pelvic statics. First results are promising, but optimisation and future simulations will be needed. We also plan to simulate various delivery scenarios (cephalic, breech presentation, instrumental extraction), which will be useful to study perineal lesions and also to teach obstetrical mechanics.

[Idiopathic overactive bladder and BOTOX(®): Literature review]. / Hyperactivité vésicale idiopathique et BOTOX(®): revue de la littérature.

AIM: Systematically review literature on the efficacy and tolerability of botulinum toxin A (onabotulinumtoxineA, BOTOX(®), Allergan, CA, USA) in refractory idiopathic overactive bladder (iOAB) METHODS: Pubmed search on the efficacy, toxicity and adverse events of onabotulinumtoxinA in clinical trials only with level 1 and 2 evidence. RESULTS: Eleven controlled randomised trials have been selected, of which 3 phase III trials. The studies published data of 1008 patients with refractory iOAB treated with onabotulinumtoxineA. In the phase II and III trials, doses from 50 U to 300 U have been evaluated; more than half of the patients (n = 676) with 100 U. In the 2 main phase III trials, onabotulinumtoxinA has demonstrated to be more efficient compared to placebo on continence, symptoms and quality of live (QoL). Urodynamic results, reported in the phase II trials, demonstrated higher changes compared to placebo only from dose 100 U on, although not always significant. Adverse events (urinary retention, dysuria, urinary tract infection) were easily treated and did not influence patient's QoL. CONCLUSION: Intradetrusor injections of onabotulinumtoxinA (BOTOX(®)), a minimally-invasive procedure, seem to be efficient and well tolerated in the treatment of refractory iOAB.

Mechanical properties of pelvic soft tissue of young women and impact of aging.

INTRODUCTION AND HYPOTHESIS: The female pelvic floor is a complex network of ligaments and muscles whose mechanical properties have not been completely understood. The goal of this study is to understand the biomechanical properties of the pelvic floor tissues of young women and the impact of aging. METHODS: Biomechanical uniaxial tension tests were performed on pelvic floor tissues (ligaments and organs) of six young female cadavers (average 29 years old). Results have been analyzed in order to define the characteristics of the mechanical properties of young pelvic soft tissues. Results have been compared with those in the literature in order to understand the similarities and discrepancies between young and old patients. RESULTS: Damageable, nonlinear elastic biomechanical behavior is observed. The variation in stiffness among the pelvic floor organs could be shown. Ligaments and the vaginal wall are the most rigid organs, whereas the rectum and bladder tend to be less rigid (approximately two times less rigid for small deformations and three times less rigid for large deformations). This study shows that ligaments and the vaginal wall of young women have similar mechanical behavior while those of older women differ. Furthermore, young women's tissues differ slightly from older women's tissues. CONCLUSIONS: Results show that aging and possibly diverse "trauma" have an impact on modifying the mechanical behavior of pelvic floor tissues. Over time pelvic floor ligaments and vaginal tissues will differentiate and acquire different mechanical behavior, as seen within the literature in older cadavers.

Guidelines for practical usage of botulinum toxin type A (BoNTA) for refractory idiopathic overactive bladder management: Translation of French recommendations.

OBJECTIVE: Provide guidelines for practical usage of botulinum toxin type A (BoNTA) for refractory idiopathic overactive bladder management. PATIENTS AND METHODS: Guidelines using formalized consensus guidelines method. These guidelines have been validated by a group of 13 experts quoting proposals, subsequently reviewed by an independent group of experts. RESULTS: In the case of patients with urinary tract infection, it must be treated and injection postponed. Before proposing an injection, it is recommended to ensure the feasibility and acceptability of self-catheterisation by patient. The injection can be performed after local anesthesia of the bladder and urethra (lidocaine), supplemented where necessary by nitrous oxide inhalation and sometimes under general anesthesia. Injection is performed in the operating room or endoscopy suite. The bladder should not be too filled (increased risk of perforation). Treatment should be applied in 10 to 20 injections of 0.5 to 1 mL homogeneously distributed in the bladder at a distance from the urethral orifices. It is not recommended to leave a urinary catheter in place except in cases of severe hematuria. The patient should be monitored until resumption of micturition. After the first injection, an appointment must be scheduled within 3 months (micturition diary, uroflowmetry, measurement of residual urine and urine culture). Performance of self-catheterisation should be questioned in the case of a symptomatic post-void residual and/or a residue>200 mL. A new injection may be considered when the clinical benefit of the previous injection diminishes (between 6 and 9 months). A period of three months must elapse between each injection. CONCLUSIONS: Implementation of these guidelines may promote best practice usage of BoNTA with optimal risk/benefit ratio.

Renal transplantation in 4 patients with methylmalonic aciduria: a cell therapy for metabolic disease.

INTRODUCTION: Patients with methylmalonic acidemia (MMA) may develop many complications despite medical treatment, in particular, severe central nervous system damage and chronic kidney disease (CKD). A kidney transplant may partially correct the metabolic dysfunctions. Liver, kidney and combined liver-kidney transplantations have been advocated but no guidelines are available to identify the most suitable organ to transplant. PATIENTS AND METHODS: Four patients with MMA (mut° phenotype) received a kidney graft because of repeated metabolic decompensations, with progression to CKD in 3 patients (end-stage kidney disease in two patients and CKD stage III in one patient with an estimated glomerular filtration rate [eGFR] of 40ml/min/1.73m(2)) but normal renal function in one (eGFR of 93ml/min/1.73m(2)) before transplantation. RESULTS: The medium age at transplantation was 7.9y (5-10.2) and the median follow-up was 2.8years (1.8-4.6). Renal transplantation improved the relevant metabolic parameters in 4/4 patients and renal function in the patients with CKD. Plasma and urinary MMA levels immediately decreased and remained normal or subnormal (mean values of plasma MMA before transplantation 1530µmol/L versus 240µmol/L after transplantation, and mean values of urine MMA before transplantation 4700mmol/mol creatinine versus 2300mmol/mol creatinine after transplantation). No further acute metabolic decompensation was observed and protein-intake was increased from 0.60 to 0.83g/Kg/day. One patient transplanted at age 9.7years developed a hepatoblastoma at age 11years with subsequent neurological complications and eventually died. The three other patients are alive. Two of them remained neurologically stable. The 3rd patient who displayed choreoathetosis transiently improved his neurological condition immediately after transplantation and then remained stable. CONCLUSION: Kidney transplantation represents an interesting alternative therapeutic option in methylmalonic aciduria, for renal complications but also as a "cellular therapy" that may significantly reduce metabolic decompensations and hospitalizations. However, further neurological impairment remains possible.

3D simulation of pelvic system numerical simulation for a better understanding of the contribution of the uterine ligaments.

INTRODUCTION AND HYPOTHESIS: Genital prolapse remains a complex pathological condition. Physiopathology remains poorly understood, aetiology is multi-factorial, surgery is not always satisfying, as the rate of relapse cannot be overlooked. More over a good anatomical result will not always guarantee functional satisfaction. The aim of our study is to have a better understanding of the involvement of uterine ligaments in pelvic statics via 3D simulation. METHODS: Simulation of pelvic mobility is performed with a validated numerical model in a normal situation (standing up to lying down) or induced pathological ones where parts of the constitutive elements of the model are virtually "cut" independently. Displacements are then discussed. RESULTS: Numerical results have been compared with dynamic MRI for two volunteers. Dynamic sequences had 90 images, and 180 simulations have been validated. Results are coherent with clinical data and the literature, thus validating our mechanical approach. Uterine ligaments are involved in pelvic statics, but their lesions are not sufficient to generate a genital prolapse. Round ligaments play a part in uterine orientation; the utero-sacral ligaments support the uterus when standing up. CONCLUSIONS: Pelvic normal and pathological mobility study via modelling and 3D simulation is a new strategy in understanding the complex multifactorial physiopathology of genital prolapse. This approach must be validated in a larger series of patients. Nevertheless, pelvic ligaments seem to play an important role in statics, especially, in agreement with a literature survey, utero-sacral ligaments in a standing position.

Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 5-year prospective follow-up study.

INTRODUCTION AND HYPOTHESIS: To evaluate clinical effectiveness and complication rates at 5 years following the total Trans Vaginal Mesh (TVM) technique to treat pelvic organ prolapse. METHODS: Prospective, observational, multi-centre study in patients with prolapse of stage II or higher. RESULTS: Of the 90 women enrolled in the study, 82 (91%) were available for the 5-year follow-up period. At the 5-year endpoint, success, defined as no surgical prolapse reintervention and leading edge <-1 (International Continence Society [ICS] criteria) or above the level of the hymen, was 79% and 87% respectively. A composite criterion of success defined as: leading edge above the hymen (<0) and no bulge symptoms and no reintervention for prolapse was met by 90%, 88% and 84% at the 1-, 3-, and 5-year endpoints respectively. Quality of life improvement was sustained over the 5 years. Over the 5-year follow-up period, a total of only 4 patients (5%) required re-intervention for prolapse, while a total of 14 patients (16%) experienced mesh exposure for which 8 resections needed to be performed. Seven exposures were still ongoing at the 5-year endpoint, all asymptomatic. Only 33 out of 61 (54%) sexually active patients at baseline remained so at 5 years. De novo dyspareunia was reported by 10%, but no new cases at the 5-year endpoint. One patient reported de novo unprovoked mild pelvic pain at 5 years, 5 reported pains during pelvic examination only. CONCLUSIONS: Five-year results indicated that TVM provided a stable anatomical repair. Improvements in QOL and associated improvements in prolapse-specific symptoms were sustained. Minimal new morbidity emerged between the 1- and 5-year follow-up.

[Guidelines for practical usage of botulinum toxin type A (BoNTA) for refractory idiopathic overactive bladder management]. / Recommandations pour l'utilisation de la toxine botulinique de type A (Botox®) dans l'hyperactivité vésicale réfractaire idiopathique.

OBJECTIVES: Provide guidelines for practical usage of botulinum toxin type A (BoNTA) for refractory idiopathic Overactive Bladder management. PATIENTS AND METHODS: Guidelines using formalized consensus guidelines method. These guidelines have been validated by a group of 13 experts quoting proposals, subsequently reviewed by an independent group of experts. RESULTS: In the case of patients with urinary tract infection, it must be treated and injection postponed. Before proposing an injection, it is recommended to ensure the feasibility and acceptability of self-catheterisation by patient. The injection can be performed after local anesthesia of the bladder and urethra (lidocaine), supplemented where necessary by nitrous oxide inhalation and sometimes under general anesthesia. Injection is performed in the operating room or endoscopy suite. The bladder should not be too filled (increased risk of perforation). Treatment should be applied in 10 to 20 injections of 0.5 to 1mL homogeneously distributed in the bladder at a distance from the urethral orifices. It is not recommended to leave a urinary catheter in place except in cases of severe hematuria. The patient should be monitored until resumption of micturition. After the first injection, an appointment must be scheduled within 3 months (micturition diary, uroflowmetry, measurement of residual urine and urine culture). Performance of self-catheterisation should be questioned in the case of a symptomatic post-void residual and/or a residue>200mL. A new injection may be considered when the clinical benefit of the previous injection diminishes (between 6 and 9 months). A period of three months must elapse between each injection. CONCLUSIONS: Implementation of these guidelines may promote best practice usage of BoNTA with optimal risk/benefit ratio.

Comparison of first versus second line sacrocolpopexies in terms of morbidity and mid-term efficacy.

To compare pelvic organ prolapse (POP) recurrence and morbidity between first and second line sacrocolpopexies. We conducted a retrospective chart review of all laparoscopic or robotic sacrocolpopexies for POP-Q stage ≥ 2, with or without a history of previous prolapse repair, performed with a similar technique between January 2012 and June 2019 in 3 European Gynecologic Surgery Departments. Patients were separated into two groups: first line sacrocolpopexy (FLS) and second line sacrocolpopexy (SLS). Each patient from the SLS group was age-matched with a patient from the FLS group. The primary outcome measure was reoperation procedures for recurrent POP defined as a symptomatic POP-Q stage ≥ 2 POP in at least one vaginal compartment. Secondary outcomes included operative time, intraoperative organ trauma, intraoperative blood loss, postoperative POP recurrence (operated on or not), global reoperation and mesh-related complications. During this period, 332 patients were included. After age-matching, 170 patients were analyzed: 85 patients in the FLS and SLS groups, respectively. After a mean follow-up of 3 years, there was no statistically significant difference between the two groups in terms of recurrent POP (9.4% versus 10.6%, p = 0.7), recurrent POP reoperation (3.5% versus 5.9% p = 0.7), mesh-related reoperation (0% versus 2.4%, p = 0.5), global reoperation (3.5 versus 8.2%, p = 0.3), operative time (198 ± 67 min versus 193 ± 60 min, p = 0.5), intraoperative complications such as organ injury (4.7% versus 7.1%, p = 0.7) and blood loss > 500 mL (2.4% versus 0%, p = 0.5). Patients who underwent a first or a second line sacrocolpopexy seemed to have similar rates of prolapse recurrence and complications.

Evaluating the morbidity and long-term efficacy of laparoscopic sacrocolpopexy with and without robotic assistance for pelvic organ prolapse.

OBJECTIVE: The aim of our study was to compare the morbidity and long-term efficacy after laparoscopic sacrocolpopexy with and without robotic assistance. METHODS: We conducted a retrospective chart review of all laparoscopic or robotic sacrocolpopexies for POP-Q stage 2-4 vaginal prolapse performed between September 2015 and October 2018 in 2 Gynecologic Surgery Departments of France. Patients were separated into two groups: a laparoscopic sacrocolpopexy group (LS) and a robotic-assisted sacrocolpopexy group (RAS). The primary outcome measure was reoperation procedures for recurrent pelvic organ prolapse (POP). RESULTS: Two hundred and fourteen patients were included, 160 patients (75%) in the LS group and 54 patients (25%) in the RAS group. After a mean follow-up of 32.8 months, reoperation rate for recurrent POP and the recurrent POP rate were greater in the RAS group (9.2% versus 1.2%, p = 0.01 and 25.9% versus 7.5%, p = 0.0003, respectively). No significant difference was found in terms of immediate intraoperative (3.1% versus 1.8%, p = 1) and postoperative complications (1.9% versus 1.8%, p = 1). On comparing the 2 groups by bivariate analysis, RAS significantly increased the odds of reoperation for POP recurrence (OR = 7.8 CI 95% [1.5-41.6], p = 0.02) and the odds of global reoperation (OR = 3.8 CI 95% [1.4-10.4], p = 0.0095). Similarly, multivariate logistic analysis showed that RAS increased the risks of global reoperation (OR = 3.8 CI 95% [1.3-10.6], p = 0.01) after controlling high-grade prolapse. CONCLUSION: Robotic sacrocolpopexy does not appear to give long-term clinical benefits. Recurrent POP and reoperation procedures seem to be more frequent in case of robotic-assisted surgery.