International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction.

INTRODUCTION AND HYPOTHESIS: This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction. METHODS: An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed. RESULTS: The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP. CONCLUSIONS: The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.

The effect of day 5 blastocyst assessment timing on live birth prediction and development of a prediction algorithm.

RESEARCH QUESTION: Does variation in day 5 assessment timing confound live birth prediction using snapshot blastocyst morphology and is it possible to develop a numerical prediction algorithm? DESIGN: Retrospective multicentre cohort study including 4851 autologous oocyte single day 5 fresh embryo transfers performed at 11 Monash IVF clinics between 2016 and 2020. Repeat cycles of the same patients were excluded to avoid clustering effects in regression analysis. RESULTS: Hours post insemination (HPI) at day 5 assessment (115.9 ± 2.6 h) significantly correlated with blastocyst developmental stage (r = 0.118, P < 0.001). Independent association (expressed as adjusted odds ratio [aOR] and 95% confidence interval [CI]) was identified between live birth and HPI (aOR 0.950, 95% CI 0.925-0.976, P < 0.001) after accounting for blastocyst morphology and a range of patient/cycle characteristics. Algorithms were constructed using four significant live birth predictors: HPI at day 5 assessment, blastocyst developmental stage (aOR 1.347, 95% CI 1.217-1.491, P < 0.001), morphological grade (aOR 1.314, 95% 1.197-1.443, P < 0.001) and maternal age (aOR 0.922, 95% CI 0.907-0.936, P < 0.001). Receiver operating characteristic (ROC) analysis showed consistent predicting performance of algorithms via five-fold cross-validation, with similar area under the ROC curve (AUC 0.718, 0.715, 0.720, 0.712, 0.726, P < 0.001, respectively, in development subsets; and AUC 0.718, 0.731, 0.709, 0.741, 0.684, P < 0.001, respectively, in validation subsets). A score (ranging from 0.1 to 4.7) calculator based on the final algorithm was subsequently created. CONCLUSIONS: Day 5 assessment timing is a confounding factor for live birth prediction using snapshot blastocyst morphology. A numerical algorithm incorporating day 5 assessment HPI, blastocyst morphology and maternal age can be developed for live birth prediction.

Morphometric and morphokinetic differences in the sperm- and oocyte-originated pronuclei of male and female human zygotes: a time-lapse study.

PURPOSE: To study the morphometric and morphokinetic profiles of pronuclei (PN) between male and female human zygotes. METHOD(S): This retrospective cohort study included 94 consecutive autologous single day 5 transfer cycles leading to a singleton live birth. All oocytes were placed in the EmbryoScope + incubator post-sperm injection with all annotations performed retrospectively by one embryologist (L-SO). Timing parameters included 2nd polar body extrusion (tPB2), sperm-originated PN (tSPNa) or oocyte-originated PN (tOPNa) appearance, and PN fading (tPNF). Morphometrics were evaluated at 8 (stage 1), 4 (stage 2), and 0 h before PNF (stage 3), measuring PN area (um2), PN juxtaposition, and nucleolar precursor bodies (NPB) arrangement. RESULTS: Male zygotes had longer time intervals of tPB2_tSPNa than female zygotes (4.8 ± 0.2 vs 4.2 ± 0.1 h, OR = 1.442, 95% CI 1.009-2.061, p = 0.044). SPN increased in size from stage 1 through 2 to 3 (435.3 ± 7.2, 506.7 ± 8.0, and 556.3 ± 8.9 um2, p = 0.000) and OPN did similarly (399.0 ± 6.1, 464.3 ± 6.7, and 513.8 ± 6.5 um2, p = 0.000), with SPN being significantly larger than OPN at each stage (p < 0.05 respectively). More male than female zygotes reached central PN juxtaposition at stage 1 (76.7% vs 51.0%, p = 0.010), stage 2 (97.7% vs 86.3%, p = 0.048), and stage 3 (97.7% vs 86.3%, p = 0.048). More OPN showed aligned NPBs than in SPN at stage 1 only (44.7% vs 28.7%, p = 0.023). CONCLUSION(S): Embryos with different sexes display different morphokinetic and morphometric features at the zygotic stage. Embryo selection using such parameters may lead to unbalanced sex ratio in resulting offspring.

Use of observed ureteric catheter movement to facilitate laparoscopic identification and dissection of the ureter in complex gynaecological procedures.

INTRODUCTION AND HYPOTHESIS: Ureteric injury is a serious complication in gynaecological surgery. Identification and dissection of the ureter is important to minimise the risk of injury. However, some pelvic pathologies and previous pelvic surgery can render laparoscopic identification and dissection of the ureter difficult and risky. This video demonstrates the use of observing ureteric catheter movement to facilitate identification and dissection of the ureter in complicated laparoscopic gynaecological procedures. MATERIALS: A 42-year-old woman with previous history of total abdominal hysterectomy underwent laparoscopic removal of her right ovary, which was plastered over the course of the ureter. A 5-F ureteric catheter was inserted, and observing its movement facilitated identification and dissection of the ureter from the ovary. RESULTS: The procedure was completed safely, and the patient was discharged the same day. CONCLUSIONS: This video demonstrates that moving the ureteric catheter laparoscopically to facilitate identification and dissection of the ureter in complex gynaecological procedures may be useful for urogynecologists when assisting ureteric dissection in complex cases.

The Impact of Complications on Patients' Assessment of the Outcome of Tension-Free Vaginal Tape Procedure.

INTRODUCTION: Our study aimed to assess the impact of managed complications of tension-free vaginal tape (TVT) on the patients' assessment of the results as measured by Patient Global Impression of Improvement (PGI-I). MATERIALS AND METHODS: This was a retrospective study, supplemented with a telephone interview, comparing patients who had complications of TVT procedures with those where no complications recorded. The primary outcome was the PGI-I score in the 2 groups. RESULTS: A total of 118 invitations were sent. In all, 60 patients returned the signed consent and completed the telephone interview with one of the authors (response rate = 50.8%). Complications were recorded in 21 patients (group 1) and no complications in 39 patients (group 2). There was no statistically significant difference between PGI-I in both groups. CONCLUSIONS: Managed complications of TVT do not seem to affect patients' assessment of outcome as measured by PGI-I score.

Impact of morbid obesity on the mode of delivery and obstetric outcome in nulliparous singleton pregnancy and the implications for rural maternity services.

Obesity represents a rapidly emerging epidemic amongst pregnant women. Our study looks at the impact of morbid obesity on pregnant singleton nulliparous women in comparison with normal body mass index women. We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour. We also found no significant difference in length of hospital stay, postnatal complications and neonatal morbidity.

Surgical management of vaginal mesh erosion: an alternative to excision.

UNLABELLED: HYPOTHESIS AND INTRODUCTION: Management of vaginal mesh erosion can be conservative, but in a large proportion of patients, excision/trimming of the mesh is needed. This paper describes a technique using an intervening vulval pad of fat graft between the vaginal epithelium and the mesh as an alternative to excision. MATERIALS AND METHODS: Three cases are presented where vaginal mesh erosion was treated using an intervening vulval pad of fat as a graft to cover polypropylene mesh erosion, and the technique is described. RESULTS: There were no intraoperative complications. All patients reported no further symptoms at follow-up, and examination revealed no further mesh erosions. CONCLUSION: The use of intervening graft of vulval fat can be an alternative to excision in the management of patients with vaginal mesh erosion.