Trocar-guided trans-vaginal mesh surgery for pelvic organ prolapse: effects on urinary continence and anatomical and functional outcomes. A prospective observational study.

OBJECTIVE: Primary objective of this study was to assess the effects of trocar-guided transvaginal mesh surgery (TVM) on cure and prevention rates for incontinence, without concomitant surgery for Stress Urinary Incontinence (SUI). Our secondary objectives were anatomical outcomes, relief of symptoms and effect on quality of life (QoL). STUDY DESIGN: This prospective observational study evaluated women who underwent TVM for symptomatic stage >2 Pelvic Organ Prolapse (POP). SUI was evaluated objectively using the cough stress test with prolapse reduced. SUI and urge urinary incontinence (UUI) were subjectively evaluated using ICIQ-SF. Anatomical cure was defined as stage <2 at POP-Q. STATISTICAL ANALYSIS: McNemar chi-square test; paired t-test; Mann-Whitney test. RESULTS: Seventy-two patients reached final evaluation (mean follow-up 72 months). In the 40 pre-op continent patients, 34 (85%) remained continent postoperatively and 6 (15%) showed de novo SUI. Only 1 patient chose to undergo subsequent TVT. The number needed to treat was 6 to prevent 1 women developing de novo objective SUI and 39 to prevent 1 woman having to undergo SUI surgery. In the 32 pre-op incontinent patients, 18 (56.3%) became continent postoperatively. Only 1 patient chose to undergo subsequent TVT. UUI was present in 44 patients pre-operatively and 15 (20.8%) post-operatively (1 de novo). Forty-four patients (61.1%) were continent post-operatively for SUI and UUI. We observed a significant improvement in storage, voiding, post-micturition and prolapse-related symptoms. The anatomical cure rate was 87.5% for the anterior compartment and 90.3%.for the apical segment. The apical recurrence was 8.3% in the patients previously hysterectomised, 18.8% in the patients with uterus preservation and 0% in the patients with concomitant hysterectomy. QoL scores improved in all domains except sleep and personal relationships. We observed mesh exposure in 10 patients (13.9%), in 5 of whom it was associated with a concomitant hysterectomy CONCLUSIONS: TVM showed excellent results in terms of continence and can be performed without contemporary anti-incontinence surgery, for both continent and incontinent women. Patients should have pre-operative counselling before POP surgery. For severe uterine prolapse the Perigee™ System should be employed with concomitant hysterectomy because uterus preservation is associated with significantly higher apical recurrence rates.

[Oral health and pregnancy: promotion of oral health during the pre-natal training in the Latina province]. / Salute orale e gravidanza: promozione sanitaria nei consultori di Latina e provincia.

The aim of this study, conducted in the Province of Latina, was to verify knowledge, attitudes, and lifestyles in relation to oral health in a sample of pregnant women, assessing their subjective perception of oral health, and highlight prenatal dental prevention need specialist in the area and provide adequate information on the importance of good oral hygiene in order to achieve a better health level both of the mother and the child. The study was conducted on a sample of pregnant women between the 26th and 39th gestational week, in the period from June to October 2009, during the childbirth training courses in the Province of Latina. Each patient was administered a questionnaire for the assessment of oral habits during pregnancy and for the definition of specific knowledge on and perception of themselves and their own oral condition. The survey shows that more than one third of the sample reported visiting a dentist only in case of pain, over half (56.9%) did not undergo any dental visit during the gestational period, only 24 subjects (33.3%) having applied to a dental hygienist for professional oral hygiene and that only 7 out of 72 women had been prescribed a dental checkup by a gynecologist. The study showed that knowledge about dental problems that may arise during pregnancy is insufficient to guarantee a good threshold to oral health care for the mother hence the need to promote information programs, oral health and pregnancy prevention and training in the territory mainly directed to health-care specialists (gynecologists and obstetricians) and to pregnant women.

Voiding dysfunction after anti-incontinence surgery.

Voiding dysfunction after incontinence surgery is a potential complication of all stress incontinence procedures. The term voiding dysfunction indicates from obstructive voiding symptoms up to complete urinary retention, requiring intermittent catheterization, and also includes irritative storage symptoms such as de novo urgency and detrusor overactivity. Of particular importance is the temporal relationship between symptoms and the previous surgical procedure, and although many different operations can result in voiding dysfunction, the most common cause remains attributable to hypersuspension of the urethra. The diagnosis of postoperative voiding dysfunction can be challenging. First of all surgeons must ask for an accurate history, in order to assess symptomatology and to carry out a physical examination. Further diagnosis could be done through urodynamics, but this is somewhat controversial: despite various proposed cut-off values, there are no absolute urodynamic criteria to define obstruction in women. Fortunately, most voiding dysfunction is transient and resolves spontaneously in a few days to weeks. Persistent voiding dysfunction (longer than 4 weeks) occurs in 5-20% after the Marshall-Marchetti-Krantz procedure, 4-22% after the Burch colposuspension, 5-7% after needle suspension, 4-10% after the pubovaginal sling procedure, and 2-4% after the trans-vaginal tape procedure. However, if symptoms persist, surgery is indicated. Several surgical approaches are described, including sling incision, sling lysis and formal urethrolysis, comprising vaginal and retropubic approach with or without graft interposition. In this article the procedures are described and the results of each type of urethrolysis are reported.

A prospective, randomized, controlled study comparing Gynemesh, a synthetic mesh, and Pelvicol, a biologic graft, in the surgical treatment of recurrent cystocele.

We compared safety and efficacy of Gynemesh PS and Pelvicol for recurrent cystocele repair. One hundred ninety patients were randomly divided into Gynemesh PS and Pelvicol groups and underwent tension-free cystocele repair. The Chi-square test was used to compare categorical variables, the paired t test for continuous parametric variables, and the Mann-Whitney test for continuous nonparametric variables. Ninety-six Gynemesh PS patients and 94 Pelvicol patients were studied. Mesh erosions occurred in 6.3% of Gynemesh PS patients. No erosions were observed in Pelvicol patients (p = 0.02). Objective cure was 71.9% for Gynemesh PS and 56.4% for Pelvicol (p = 0.06). Subjective cure was the same in both groups except for better sexuality in the Pelvicol group. At 24 months follow-up, only Gynemesh PS patients had mesh erosions. Anatomical outcome was similar in the two groups. Pelvicol gave a better impact on voiding and sexuality.

Transvaginal cystocele repair with polypropylene mesh using a tension-free technique.

This study describes an original surgical technique for the correction of medium/high-degree cystocele using a tension-free way to apply a polypropylene mesh: the "tension-free cystocele repair" (TCR). About 218 patients were available with a mean follow-up of 38 months. This technique showed an elevated rate of anatomic correction (75.7%), a statistically significant correction of storage symptoms (48.6 vs 32.5%, p < 0.05), voiding symptoms (40.3 vs 8.3%, p < 0.05), and symptoms associated with pelvic organ prolapse (POP; 55.9 vs 11.4%, p < 0.0001), with no negative impact on ano-rectal function and, in particular, on constipation. The percentage of erosions was 12.3%, but in the group where hysterectomy was not performed, we had erosions in only 2.5%. With the exception of the Personal Relationship domain, all of the categories examined by the Prolapse Quality of Life Questionnaire showed a statistically significant improvement, which confirms the positive impact of this surgery as perceived by patients.