Cystocele and functional anatomy of the pelvic floor: review and update of the various theories.

INTRODUCTION AND HYPOTHESIS: We updated anatomic theories of pelvic organ support to determine pathophysiology in various forms of cystocele. METHODS: PubMed/MEDLINE, ScienceDirect, Cochrane Library, and Web of Science databases were searched using the terms pelvic floor, cystocele, anatomy, connective tissue, endopelvic fascia, and pelvic mobility. We retrieved 612 articles, of which 61 matched our topic and thus were selected. Anatomic structures of bladder support and their roles in cystocele onset were determined on the international anatomic classification; the various anatomic theories of pelvic organ support were reviewed and a synthesis was made of theories of cystocele pathophysiology. RESULTS: Anterior vaginal support structures comprise pubocervical fascia, tendinous arcs, endopelvic fascia, and levator ani muscle. DeLancey's theory was based on anatomic models and, later, magnetic resonance imaging (MRI), establishing a three-level anatomopathologic definition of prolapse. Petros's integral theory demonstrated interdependence between pelvic organ support systems, linking ligament-fascia lesions, and clinical expression. Apical cystocele is induced by failure of the pubocervical fascia and insertion of its cervical ring; lower cystocele is induced by pubocervical fascia (medial cystocele) or endopelvic fascia failure at its arcus tendineus fasciae pelvis attachment (lateral cystocele). CONCLUSIONS: Improved anatomic knowledge of vaginal wall support mechanisms will improve understanding of cystocele pathophysiology, diagnosis of the various types, and surgical techniques. The two most relevant theories, DeLancey's and Petros's, are complementary, enriching knowledge of pelvic functional anatomy, but differ in mechanism. Three-dimensional digital models could integrate and assess the mechanical properties of each anatomic structure.

Artificial urinary sphincter (AMS 800) implantation for women with intrinsic sphincter deficiency: a technique for insiders?

Artificial urinary sphincter (AUS) implantation is one of several surgical options for the treatment of female stress urinary incontinence. It is indicated for women with both clinically and urodynamically defined intrinsic sphincter deficiency that significantly affects quality of life. The erosion/revision risk increases after several previous surgical interventions. Therefore, women believed to be candidates for AUS implantation should be rapidly (after the failure of a maximum of two previous surgical procedures) referred to specialized centres, where the knowledge and experience concerning the diagnosis, surgery and management of female stress urinary incontinence is concentrated. To refer correctly, non-academic urologists/gynaecologists should also be well informed about AUS implantation. Only in this way can the patient weigh the high long-term success rate and high quality of life improvement of AUS implantation against the greater complication/revision risk and take a well-considered decision.

Anterior and middle pelvic organ prolapse repair using a six tension-free strap low weight transvaginal mesh: long-term retrospective monocentric study of 311 patients.

INTRODUCTION: Treatment of pelvic organ prolapse is an important public health issue due to the ageing population. The Food and Drug Administration, in 2011, issued a warning on complications after transvaginal insertion of high weight mesh. We evaluated a 6 tension-free straps, light prosthesis made from polypropylene monofilaments. MATERIALS AND METHODS: This monocentric, retrospective study included patients undergoing anterior or apical prolapse repair surgery by placement of a six tension-free strap low weight vaginal mesh between 2008 and 2017. The surgical history, concomitant surgery, clinical examination results, pre and postoperative results of the Urinary Symptom Profile questionnaire, and intraoperative and postoperative complications were collected from patients' medical records. RESULTS: 311 patients were included (median follow-up: 33 months). The majority (93%) had stage ≥ III cystocele and 26% had stage ≥ III hysterocele. Postoperatively, there were nine cases (2.9%) of asymptomatic cystocele recurrence and 11 (3.5%) cases of hysterocele recurrence, among them six underwent reoperation. Vaginal comfort was significantly improved in 92% vs. 17% before surgery (p < 0,0001); two (1,76%) patients had de novo dyspareunia. Preoperatively, 104 patients had stress urinary incontinence (SUI), 45,2% of them were cured postoperatively. There were 62 (30%) cases of de novo SUI. A significant improvement of dysuria (p < 0,0001) and overactive bladder (OAB) was found for all severity stages (p < 0,0001). Severe complications included haematoma (7,4%), mesh exposure (1.3%), retraction (0.6%), bladder injury (0.6%) and chronic pain (0.6%). CONCLUSION: Treatment of anterior and/or mid-segment prolapse by transvaginal insertion of a six-strap low-weight mesh is long-term effective, with acceptable morbidity.

Retrospective study on the management and follow-up of 18 patients with a mid-urethral sling penetrating the urethra or bladder.

INTRODUCTION: The mid-urethral sling (MUS) procedure is the gold-standard for the surgical treatment of stress urinary incontinence (SUI). Urethro-vesical sling exposure is one of the most serious complications of this procedure. We describe the treatment and follow-up of 18 patients with bladder or urethral sling exposure. PATIENTS AND METHODS: This single-center, retrospective study assessed the diagnosis and management of MUS penetrating the lower urinary tract in 18 women. The lesions included were classed as 4B, T3-4, S3 according to the international classification of complications related to the insertion of prostheses. Diagnosis was confirmed by flexible urethro-cystoscopy. The patients were treated surgically. In all cases, the aim was to remove all synthetic materials eroding the bladder or urethra. The patients were reassessed 6 weeks after the procedure, and functional urologic sequelae were treated. Urologic symptoms were evaluated using the USP questionnaire and urologic comfort was assessed using the Contilife questionnaire. RESULTS: Seven MUSs were retro-pubic and 11 were trans-obturators. The material was 11 polypropylene macroporous monofilament, four polypropylene silicone coated and three non-available. There were six cases of urethral sling exposure, nine cases of bladder sling exposure, and three cases of urethral and bladder sling exposure, including five complicated cases of lithiasis and one urethra-vaginal fistula. Thirteen patients underwent one surgical procedure, four underwent two, and one underwent five procedures. Seven patients received a Martius flap. Three surgical approaches were necessary: (i) vaginal approach; (ii) urologic (urethral and suprapubic) cystoscopy approach; and (iii) laparoscopy approach. Median follow-up time was 34.5 months. At the end of follow-up, 17/18 patients had no sling exposure from the MUS, and 12/13 patients were considered comfortable from a functional urologic viewpoint. CONCLUSION: Our study showed that surgery could treat urethro-vesical sling exposure. Three surgical approaches may be necessary. Controlled cystoscopy is vital to confirm healing due to the recurrences of sling exposure in our study.

Selective arterial embolization of symptomatic and asymptomatic renal angiomyolipomas: a retrospective study of safety, outcomes and tumor size reduction.

BACKGROUND: Angiomyolipoma (AML) is the most common renal benign tumor. Treatment should be considered for symptomatic patients or for those at risk for complications, especially retroperitoneal bleeding which is correlated to tumor size, grade of the angiogenic component and to the presence of tuberous sclerosis complex (TSC). This study reports our single-center experience with the use of selective arterial embolization (SAE) in the management of symptomatic and asymptomatic renal AMLs. METHODS: In this retrospective mono-centric study, all demographic and imaging data, medical records, angiographic features, outpatient charts and follow-up visits of patients who underwent prophylactic or emergency SAE for AMLs between January 2005 and July 2016 were reviewed. Tumor size and treatment outcomes were assessed at baseline and after the procedure during follow-up. Computed tomography (CT), magnetic resonance imaging (MRI) or ultrasonography was used to evaluate AML shrinkage. Renal function was measured pre- and post-procedure. RESULTS: Twenty-three patients (18 females, 5 males; median age, 45 years; range, 19-85 years) who underwent SAE either to treat bleeding AML (n=6) or as a prophylactic treatment (n=17) were included. Overall, 34 AMLs were embolized. TSC status was confirmed for 6 patients. Immediate technical success rate was 96% and 4 patients benefitted from an additional procedure. Major complications occurred in 3 patients and minor post-embolization syndrome (PES) in 14 patients. The mean AML size reduction rate was 26.2% after a mean follow-up was 20.5 months (range, 0.5-56 months), and only non-TSC status was significantly associated with better shrinkage of tumor (P=0.022). Intralesional aneurysms were significantly more frequent in patients with hemorrhagic presentation (P=0.008). There was no change in mean creatinine level after SAE. CONCLUSIONS: SAE is a safe and effective technique to manage renal AMLs as a preventive treatment as well as in emergency setting, with significant reduction in tumor size during follow-up. A multidisciplinary approach remains fundamental, especially for TSC patients. In addition to size, the presence of intralesional aneurysms should be considered in any prophylactic treatment decision.

Transvaginal treatment of anterior or central urogenital prolapse using six tension-free straps and light mesh.

OBJECTIVE: To evaluate the feasibility, efficacy, complications, and outcomes of treatment of anterior or central compartment urogenital prolapse by placement of an anteroposterior 22-g/m(2) mesh with six straps through one anterior vaginal incision. METHODS: In a prospective study, patients treated for urogenital prolapse at a center in France between February 2008 and June 2011 were enrolled. Previous treatments, related interventions, intraoperative and postoperative complications, and anatomic outcomes were recorded during 3years of follow-up. Failure was defined as recurrence of prolapse of stage II or higher according to the Pelvic Organ Prolapse Quantification system. RESULTS: Overall, 74 patients were included. Preoperatively, 55 (74%) patients had stage III cystocele, 13 (18%) had stage IV cystocele, and 44 (59%) had associated uterine prolapse of at least stage II. Postoperative hematoma occurred in three patients and vaginal exposure in two patients. There were no cases of visceral injury. Vaginal comfort improved postoperatively: 68 (92%) patients were satisfied with the outcome and there were no cases of de novo dyspareunia. Seventeen (23%) patients subsequently had stress urinary incontinence that was treated by placement of suburethral tape. The anatomic outcomes were satisfactory for 72 (97%) women, including sexually active patients. CONCLUSION: Transvaginal prolapse repair by placement of an anteroposterior six-strap 22-g/m(2) mesh was feasible and effective with satisfactory 3-year outcomes.

[Transobturator tape (Uratape). A new minimally invasive method in the treatment of urinary incontinence in women]. / La bandelette trans-obturatrice (Uratape). Un nouveau procédé mini-invasif de traitement de l'incontinence urinaire de la femme.

OBJECTIVE: To evaluate the one-year results of transobturator suburethral tape for the treatment of female stress urinary incontinence. MATERIAL AND METHODS: Suburethral tape was implanted via the transobturator technique. UraTape non-woven, non-elastic polypropylene tape with a 15 mm wide central (suburethral) silicone-coated zone was inserted without tension in a horizontal plane underneath the middle of the urethra from one obturator foramen to the other. The lateral ends of the tape were tunnelled percutaneously with a tunnelling device. The retropubic space was preserved and cystoscopy was not required. From May 2000 to February 2002, 32 patients with a mean age of 64 years (range: 50 to 81 years), suffering from stress urinary incontinence without associated prolapse, were operated by the same surgeon (ED). All patients were evaluated before the operation by clinical and urodynamic examination: 5 patients presented sphincter incompetence (maximum closing pressure < 20 cmH2O); five patients presented recurrent urinary incontinence after Burch or TVT; 18 patients presented mixed incontinence and detrusor instability was demonstrated on cystometry in 6 of them. The results were evaluated by two independent doctors (clinical examination, uroflowmetry, cough test). Voiding disorders suggestive of bladder outflow obstruction were defined by the presence of the following two criteria: Qmax < 15 ml/s, residual volume > 20%. RESULTS: The mean follow-up of the study was 17 months (range: 13 to 29 months). The mean operating time was 15 minutes. No intraoperative complication was observed. One patient presented complete postoperative bladder retention that resolved after 4 weeks of self-catheterization. 29/32 patients (90.6%) were cured and 3/32 (9.4%) were improved. No urethral erosions were observed. No residual pain and no functional impairment related to the tape was observed. 5/32 patients presented voiding disorders suggestive of bladder outflow obstruction. Two patients developed de novo urge incontinence. CONCLUSIONS: Transobturator Uratape is a simple and effective procedure with a follow-up of one year for the treatment of female stress urinary incontinence. The transobturator approach avoids the risks of bladder, intestinal and vascular injuries. Evaluation of the results with a longer follow-up is necessary to validate this technique.

Transobturator tape (Uratape): a new minimally-invasive procedure to treat female urinary incontinence.

OBJECTIVE: Assessment of one-year results of a new technique of transobturator suburethral tape in the treatment of female stress urinary incontinence. METHODS: UraTape, a non-woven, non-elastic polypropylene tape with a 15 mm long central (suburethral) silicone-coated section was inserted via the transobturator route. The tape is inserted tension-free in a horizontal plane underneath the middle of the urethra between the two obturator foramens. The ends of the tape are tunnelled percutaneously with a tunneller. As the retropubic space is preserved intact, cystoscopy is not required. From May 2000 to February 2002, 150 patients with stress urinary incontinence without associated prolapse were operated and a minimum of 1 year follow-up was available for 32 patients (mean follow-up 17 months; range 13-29). The mean age was 64 years (range 50-81). All patients were assessed before surgery by clinical and urodynamic examination: 5 patients presented sphincter incompetence (maximum closure pressure <20 cm H(2)O); 5 patients presented with recurrent urinary incontinence after Burch procedure or TVT; 18 patients presented with mixed incontinence, six of them with detrusor instability confirmed by cystometry. The results were evaluated by two independent investigators (clinical examination, uroflowmetry, cough test). Voiding disorders suggesting bladder outflow obstruction were defined as the presence of the following two criteria: Q(max)<15 ml/s, residual urine volume >20%. RESULTS: 29/32 patients (90.6%) were cured and 3/32 (9.4%) were improved. Mean operating time was 15minutes. No intra-operative complications were recorded. One patient had complete postoperative bladder retention which resolved after 4 weeks of self-catheterization. There were no problems with urethral erosion, residual pain or functional impairment related to the tape. 5/32 patients had voiding disorders suggesting bladder outflow obstruction. Two patients developed de novo urge incontinence. CONCLUSION: Uratape transobturator tape is a simple and effective procedure with follow-up of one year for the treatment of female stress urinary incontinence confirmed after 1 year of follow-up. The transobturator approach avoids the risk of bladder, bowel or vascular injuries. Evaluation of the results after a longer follow-up period is needed to validate this technique.