The role of probiotics in women's health: An update narrative review.

Probiotics, live microorganisms that confer health benefits to the host when administered in adequate amounts, have gained considerable attention for their potential role in maintaining women's health. This overview summarizes key clinical findings on the beneficial effects of probiotics in various aspects of women's health. Probiotics, particularly Lactobacillus species, contribute to vaginal health by promoting a balanced vaginal microbiome to prevent infections and maintain an acidic environment. In gynecologic conditions, probiotics show potential in preventing and managing bacterial vaginosis, vulvovaginal candidiasis, and sexually transmitted infections. Probiotic supplementation has also been associated with improvements in metabolic parameters and menstrual irregularities in polycystic ovary syndrome patients. During pregnancy, probiotics may be helpful in reducing the risk of gestational diabetes, maternal group B streptococcal colonization, obstetric anemia, and postpartum mastitis. In recent years, the potential role of probiotics in the prevention and management of gynecologic cancer has gained attention. Further research is needed to better understand the specific mechanisms and determine the optimal Lactobacillus strains and dosages regimens for gynecologic cancer prevention and therapy. In conclusion, probiotics offer a non-invasive and cost-effective approach to support women's health and prevent obstetric and gynecologic complications.

Unscarred uterine rupture with catastrophic hemorrhage immediately after vaginal delivery: diagnosis and management of six consecutive cases.

BACKGROUND: To describe and explore the risk factors, clinical presentations, timely diagnostic approaches, and management in patients experiencing unscarred uterine rupture with catastrophic hemorrhage. METHODS: We retrospectively analyzed clinical and imaging data from women who encountered postpartum hemorrhage (PPH) and were diagnosed with unscarred uterine rupture within a three-year timeframe (2018-2020). The data were extracted from medical records obtained from a multi-hospital 24-hour emergency PPH transfer system. RESULTS: Six patients were identified as having unscarred uterine rupture after vaginal delivery. All six women were para 2, with four of them undergoing vacuum-assisted delivery. One patient experienced out-of-hospital cardiac arrest (OHCA), while five patients presented with hypovolemic shock. Abdominopelvic ultrasound revealed a boggy lower uterine segment. Initially, five patients underwent transarterial embolization (TAE) of the internal iliac arteries in an attempt to achieve hemostasis, but this approach proved unsuccessful. Abdominopelvic computed tomography (CT) confirmed the diagnosis of ruptured uterus by demonstrating disrupted myometrium and hemoperitoneum. Immediate exploratory laparotomy followed by life-saving hysterectomy was performed in all cases. The median estimated total blood loss was 2725 mL ± 900 mL (ranging from 1600 mL to 7100 mL). Lower segment lacerations were observed in all patients, with more extensive uterine damage noted in those who underwent vacuum extraction. The length of hospital stay varied between 9 and 38 days. CONCLUSION: Instrument-assisted obstetric delivery is a possible contributing factor to unscarred uterine rupture in our study. In specific cases, the use of abdominopelvic CT prior to initiating transarterial embolization (TAE) offers valuable information to complement ultrasound findings. This comprehensive approach helps in accurately identifying the underlying cause of intractable postpartum hemorrhage (PPH). Immediate conversion to laparotomy is essential to explore the intra-abdominal factors causing PPH that cannot be controlled by TAE. The rational etiologies of uterine rupture must be clarified while generating practical guideline in the future.

Comparison of Prolift, Perigee-Apogee, Prosima, and Elevate transvaginal mesh systems in pelvic organ prolapse surgery: Clinical outcomes of a long-term observational study.

OBJECTIVES: To evaluate and compare the long-term clinical outcomes of four different transvaginal mesh systems. METHODS: This retrospective study included 695 patients classified into four groups (Prolift, n = 132; Perigee-Apogee, n = 186; Prosima, n = 60; Elevate; n = 317), with a median follow-up time of 5.8 years (range 0.5-12.2 years). The outcomes were objective anatomic success (Pelvic Organ Prolapse [POP] Quantification system stage ≤1), mesh exposure, and urologic functional assessments. RESULTS: For anatomic outcomes, we stepwise analyzed the short-term (within 3 years) and long-term (after 3 years) results. Prolift had the highest long-term success rate (9 years: 82.1%, P = .007). Elevate had a comparable short-term success rate (3 years: 87.5%), but its long-term success rate significantly decreased over time (5 years: 78.6%, 9 years: 66.8%, P = .007). Prosima had the lowest short-term success rate (P = .027). For the long-term mesh exposure rate (9-year cumulative), Elevate had the lowest with 11.1%; next were Perigee-Apogee (18.8%) and Prolift (24.6%); and Prosima had the highest with 39.4%, with a significant difference. In terms of urinary functional results, we observed no significant differences in voiding dysfunction, de novo stress urinary incontinence, or de novo overactive bladder symptoms among the four mesh groups, whether combined with midurethral sling surgery or not. CONCLUSION: Different vaginal mesh designs have various advantages and features. Prolift provided the best long-term anatomic success but had a high mesh exposure rate. Elevate gave comparable short-term success but had a decreased long-term success rate. However, Elevate is superior with the lowest long-term mesh exposure rate. Prosima had the worst anatomic correction and highest mesh exposure rates. This study provides a comprehensive long-term comparative result for POP patients and surgeons.

Laparoscopic pectopexy: the learning curve and comparison with laparoscopic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: In addition to laparoscopic sacrocolpopexy (LS), laparoscopic pectopexy (LP) is a novel surgical method for correcting apical prolapse. The descended cervix or vaginal vault is suspended with a synthetic mesh by fixing the bilateral mesh ends to the pectineal ligaments. This study was aimed at developing a learning curve for LP and to compare it with results with LS. METHODS: We started laparoscopic/robotic pectopexy in our department in August 2019. This retrospective study included the initial 18 consecutive women with apical prolapse receiving LP and another group undergoing LS (21 cases) performed by the same surgeon. The medical and video records were reviewed. RESULTS: The age was older in the LP group than in the LS group (65.2 vs 53.1 years). The operation time of LP group was significantly shorter than that of the LS group (182.9 ± 27.2 vs 256.2 ± 45.5 min, p < 0.001). The turning point of the LP learning curve was observed at the 12th case. No major complications such as bladder, ureteral, bowel injury or uncontrolled bleeding occurred in either group. Postoperative low back pain and defecation symptoms occurred exclusively in the LS group. During the follow-up period (mean 7.2 months in LP, 16.2 months in LS), none of the cases had recurrent apical prolapse. CONCLUSIONS: Laparoscopic pectopexy is a feasible surgical method for apical prolapse, with a shorter operation time and less postoperative discomfort than LS. LP may overcome the steep learning curve of LS because the surgical field of LP is limited to the anterior pelvis and avoids encountering the critical organs.

The surgical effect on overactive bladder symptoms in women with pelvic organ prolapse.

This study aimed to explore the effect of pelvic reconstruction surgery on the relation of pelvic organ prolapse (POP) and overactive bladder (OAB) and the impact of preoperative vaginal oestrogen supplement on vaginal tissue. A total of 100 postmenopausal women with symptomatic POP who underwent pelvic reconstruction surgery (laparoscopic sacrocolpopexy or transvaginal mesh) were enrolled in this study. Preoperative vaginal oestrogen was prescribed in 28 cases. The evaluation tools consisted of POP-Q, urodynamic study, Overactive Bladder Symptom Score (OABSS), and urinary NGF. Vaginal maturation index and vaginal specimens for hormone receptors study were investigated during operation to evaluate the effect of topical oestrogen. Follow-up assessments were performed at 1, 3, and 6 months after surgery. Preoperatively, 58 (58%) were POP with OAB. After reconstruction surgery, the OABSS decreased significantly (6.87 ± 0.85 vs 3.77 ± 0.61, p < 0.001) at postoperative 6 months in the group. Remarkable increasing trends of urinary NGF levels are noted till 3 months postoperatively, then decreasing to the baseline level at 6 months postoperative follow-up. Remarkable decrease of mRNA of the androgen receptor and significant higher expression of progesterone receptor (PR) were noted after use of the vaginal oestrogen cream. The severity of OAB in the POP women shows moderate degree according to OABSS. Pelvic reconstruction surgery can significantly improve the OAB symptoms. The surgery induced inflammation effect lasts for about 6 months. Short-term preoperative supplement of topical oestrogen brings alterations of the vaginal epithelium.

Short-term results of stress urinary incontinence in women undergoing laparoscopic sacrocolpopexy with and without midurethral sling.

OBJECTIVES: This study aimed to assess the short-term results of stress urinary incontinence (SUI) in women undergoing laparoscopic sacrocolpopexy (LSC) with and without midurethral sling (MUS). METHODS: This retrospective study was conducted from July 2012 to December 2017. Women with stage 3 or 4 in the Pelvic Organ Prolapse Quantification (POP-Q) who underwent LSC were recruited. Multichannel urodynamic studies were performed in all women. Assessment included pre- and postoperative POP-Q stages, urodynamic parameters, peri- and postoperative complications, and symptoms. RESULTS: One hundred and eighteen patients met the inclusion criteria in total. A total of 19.5% (23/118) of them had concomitant MUS. The mean follow-up duration was 16.9 ±  16.0 (range 3-69) months. Meanwhile, 33.9% (40/118) of the patients were diagnosed with overt SUI, and 50% (20/40) underwent MUS. In the concomitant MUS group, the rate of having postoperative SUI was only 5% (1/20). Patients diagnosed with SUI and without concomitant MUS had a 45% rate (9/20), and 25% of them (5/20) received MUS later. Preoperatively, 16.1% (19/118) of the patients were diagnosed with occult SUI. Among the patients without anti-incontinence sling during prolapse surgery, 25% (4/16) of them complained about having SUI during the follow-up. However, none of the women required subsequent anti-incontinence surgery. Postoperative de novo SUI occurred to 13.6% (16/118) of them. None of the patients received further operation. Based on the preoperative and postoperative urodynamic studies in the combination surgery group, a significant improvement was observed in the pad test. CONCLUSIONS: The combination of LSC with MUS procedure is likely to be beneficial in selected patients.

Botulinum toxin A injection in the treatment of chronic pelvic pain with hypertonic pelvic floor in women: Treatment techniques and results.

Chronic pelvic pain (CPP) is an extremely bothersome condition which leads to major effects in women's everyday life. In addition to visceral sources of pain, pelvic floor dysfunction including myofascial pain and spasm on the pelvic floor muscles causing hypertonicity are causes often overlooked. Injecting botulinum toxin type A (BoNT-A) into hypertonic pelvic floor muscles may aid the relaxation of pelvic floor musculature. The muscles that are injected in CPP treatment include the obturator internus, levator ani (pubococcygeus, iliococcygeus, and puborectalis), and coccygeus. Generally, injections can be performed tolerably with safety under conscious sedation combined with local anesthesia. Most practitioners perform BoNT-A injection of pelvic floor muscles using anatomical landmarks identified by manual palpation only. For the precise location of injection sites, some needle guidance techniques were proposed, including electromyography, electrical stimulation, ultrasound, fluoroscopy, and/or computed tomography. Side effects of BoNT-A injection in CPP are rare and self-limiting. Because of the reversible nature of BoNT-A, reinjection appears to be necessary. Increasing proof points out that BoNT-A is a promising treatment option for CPP in women. We conducted a review of published literature in Pubmed, using chronic pelvic pain in women, hypertonic pelvic floor, and botulinum toxin as the keywords. This article aims to summarize the treatment techniques and results of BoNT-A injection for hypertonic pelvic floor in women with chronic pelvic pain.

Sacrospinous ligament fixation with uterine preservation reduces the risk of anatomical recurrence in pelvic organ prolapse.

OBJECTIVES: This study investigated the effectiveness of sacrospinous ligament fixation (SSLF) and whether uterine preservation reduces the anatomical recurrence rate. METHODS: The medical records of 82 patients who received SSLF in a single medical center were reviewed retrospectively. Anatomical recurrence was defined as Pelvic Organ Prolapse-Quantification stage 2 or higher in any compartment. The primary outcome was intergroup analysis for uterine preservation and concomitant hysterectomy patients. The secondary outcomes were anatomical recurrence risk factors and the incidence of adverse events. Propensity score matching (PSM) was used to adjust for demographic differences between groups. RESULTS: The anatomical recurrence rate was 19.5%, and the retreatment rate was 11.0% (mean follow-up duration: 22.9 months). Cystocele was the most common recurrent compartment (17.1%). The uterine preservation group (n = 66) was younger, had lower parity, and had fewer stage 3 to 4 cystoceles and uterine prolapses than the concomitant hysterectomy group (n = 16). Shorter operation times (99.4 minutes vs 153.7 minutes, P = .002) and lower anatomical recurrence rates (11.5% vs 45.5%, P = .039) were found in the uterine preservation group before and after PSM. Previous pelvic organ prolapse surgery (hazard ratio 3.14) and concomitant hysterectomy (hazard ratio 4.08) were identified as risk factors for anatomical recurrence. The most common adverse event was buttock pain (14.6%), which resolved spontaneously within 4 weeks. CONCLUSIONS: SSLF is an effective surgical method using native tissue for pelvic reconstruction. Compared with concomitant hysterectomy, SSLF with uterine preservation reduces the anatomical recurrence rate.

Serum ß-human chorionic gonadotropin profile and its correlations with ultrasound parameters in low-lying-implantation ectopic pregnancy in the first trimester.

AIM: Cervical pregnancy (CP) and cesarean scar pregnancy (CSP), defined as low-lying-implantation ectopic pregnancy (LLIEP), are rare conditions of aberrant implantation around the lowest portion of the uterus. This study aimed to illustrate the serum ß-human chorionic gonadotropin (ß-hCG) profile of LLIEP and to explore its implications with the clinical characteristics. METHODS: Women with LLIEP during the first trimester were retrospectively evaluated at a tertiary referral center from August 1999 to July 2016. Demographic and clinical data were recorded, including maternal age, gestational age (GA), serum ß-hCG level, maximal diameter of the gestational mass/sac (MDM/MDS) by ultrasonography and CSP implantation types. The serum ß-hCG level was measured on the day of ultrasound imaging. The significance of pretreatment the serum ß-hCG level and its correlations with the clinical characteristics were analyzed. RESULTS: A total of 88 LLIEP with 64 CSP and 24 CP was included. The mean GA at the time of diagnosis was 7 weeks (range, 5-12 weeks). The ß-hCG concentrations rapidly increased from GA 5 to 9 weeks and fluctuated thereafter. The ß-hCG levels correlated positively with GA and ultrasound MDM/MDS. In the CSP group, there was no difference in the ß-hCG level between superficial and deep implantation types. ß-hCG levels demonstrated no significant differences among simple and complicated LLIEP. CONCLUSION: This study established the serum ß-hCG profile in LLIEP in the first trimester. The exponential increase of ß-hCG levels was similar to that of normal intrauterine pregnancies. The ß-hCG levels were not associated with placentation complexity of CSP. Higher ß-hCG levels did not implicate less success in conservative surgical management.

Mesh-related complications in single-incision transvaginal mesh (TVM) and laparoscopic abdominal sacrocolpopexy (LASC).

OBJECTIVE: Few studies have investigated the long-term impact of synthetic mesh reconstructive surgery for pelvic organ prolapse (POP) on patient outcomes. This study aimed to examine the incidence and risk factors of mesh exposure and the subsequent requirement for surgical interventions due to mesh-related complications. MATERIALS AND METHODS: This retrospective study was conducted from November 2010 to April 2018. We recruited women with Pelvic Organ Prolapse Quantification (POP-Q) stage 3 or 4 who underwent mesh reconstructive surgery for POP, and enrolled 487 women who received transvaginal mesh (TVM) and 110 women who received laparoscopic abdominal sacrocolpopexy (LASC). Assessments included mesh exposure rate and mesh-related complications requiring surgical interventions in both groups. RESULTS: In the LASC group, the overall mesh-related complication rate was 8.18% over a mean follow-up period of 18 months. Concomitant laparoscopic-assisted vaginal hysterectomy was associated with mesh exposure (OR = 9.240; 95% CI = 1.752-48.728). No patients in the concurrent supracervical hysterectomy group were exposed to mesh. In the single-incision TVM group, the overall rate of mesh-related complications was 3.29% over a mean follow-up period of 19 months. Concomitant total vaginal hysterectomy was also a risk factor for mesh exposure (OR = 4.799; 95% CI = 1.313-17.359). CONCLUSION: Preserving the cervix or uterus decreased the rate of mesh exposure in those undergoing TVM and LASC surgery. The overall rate of mesh-related complications was low after up to 8 years of follow-up.

The effects of "unilateral midurethral sling cut down" in women with voiding dysfunctions after anti-incontinence surgery.

PURPOSES: Midurethral synthetic sling (MUS) placement via either the retropubic or transobturator route is the standard surgical procedure for women with stress urinary incontinence. However, a small portion of patients experienced voiding dysfunction after the surgery, which was debilitating to their quality of life. Our study was aimed at demonstrating the effectiveness of the unilateral sling cut down for post-midurethral sling (MUS) voiding dysfunction and, secondarily, at evaluating the changes in urodynamic parameters. METHODS: We retrospectively reviewed the charts of patients who received unilateral midurethral sling cut down for voiding dysfunction after an MUS procedure. The cut-down procedures were performed at the urethral meatus, in the 9 or 3 o'clock direction. Preoperative and postoperative subjective and objective parameters were compared to evaluate the outcome of the cut-down procedures. RESULTS: We selected 15 patients who underwent unilateral MUS cut down for voiding dysfunction after anti-incontinence procedures with various MUSs. The cut-down procedures were performed at a median interval of 7.1 months after sling insertion. The subjective results of the Patient Global Impression of Improvement (PGI-I) after the cut-down procedure showed an overall satisfaction of 93.33%. After the cut-down procedure, the median flow rate increased from 14.8 to 22 ml/s (P > 0.05), and the post-void residual urine volume decreased from 193.5 to 35.0 ml (P < 0.05). All patients attained continence after the cut-down procedures. CONCLUSIONS: Unilateral MUS cut down is effective in the management of voiding dysfunction after anti-incontinence surgery, with a low risk of recurrence of urinary incontinence.

Evaluating the efficacy of the single-incision uphold system for pelvic organ prolapse repair.

OBJECTIVE: The aim of this study was to assess the efficacy and clinical outcomes of pelvic floor reconstruction with transvaginal mesh of the Uphold™ Vaginal Support System (Boston Scientific Corporation). MATERIALS AND METHODS: This retrospective study reviewed the medical records of patients with pelvic organ prolapse stage 3 or 4 who underwent pelvic reconstructive surgery with transvaginal mesh of the Uphold™ Vaginal Support System from January 2015 to March 2017. Patients who were treated with laparoscopic sacrocolpopexy, transvaginal sacrospinous ligament suspension or other mesh kits were excluded. Assessments included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage, Urogenital Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire-7 (IIQ-7), urodynamic parameters, peri- and postoperative complications and symptoms. RESULTS: Of the 111 enrolled women, the anatomical success rate was 97.3% after a median 18.4 months of follow-up. POP-Q parameters, UDI-6 and IIQ-7 scores, maximum urine flow rate, and post-void residual urine all significantly improved after surgery. Complications included one case (0.9%) of infected hematoma, two cases (1.8%) of mesh exposure, three cases (2.7%) of recurrent prolapse, and 12 cases (10.8%) of transient urine retention. No bladder or bowel injuries occurred during surgery. CONCLUSIONS: Pelvic reconstructive surgery with transvaginal mesh of the Uphold™ System yielded satisfactory anatomical and urinary functional outcomes in a median 18.4 months of follow-up. IRB IDENTIFIER: IRB: 201700645B0.

Urodynamic characteristics of detrusor underactivity in women with voiding dysfunction.

INTRODUCTION AND HYPOTHESIS: Voiding dysfunction has gained interest due to its high prevalence in the elderly. This study characterized bladder dysfunction in women with voiding dysfunction using video urodynamic studies (VUDS) focused on detrusor underactivity (DU). METHODS: We studied 1914 women in which first-line medical treatment failed. Age, comorbidities, and urodynamic parameters were analyzed to determine the association between bladder sensation and contractility. RESULTS: VUDS were normal in 2.9% (n = 56) of patients and showed DU in 23.1% (n = 443), detrusor hyperactivity and impaired contractility (DHIC) in 12.0% (n = 231), hypersensitive bladder in 17.0% (n = 325), detrusor overactivity (DO) in 2.6% (n = 49) and bladder outlet obstruction in 42.3% (n = 810). The mean age of patients in the DU and DHIC groups was significantly older than in women with normal VUDS and those with hypersensitive bladders (p<0.01). Decreased bladder sensation and larger cystometric bladder capacity were noted in the DU group compared to the DHIC, HSB, and DO groups. Bladder sensation was negatively associated with the bladder contractility. Bladder contractility index and voiding efficiency were lower in the DU and DHIC groups compared to the normal group. CONCLUSIONS: The bladder conditions of women with voiding dysfunction included DU, DHIC, HSB and DO. Bladder contractility index and voiding efficiency were significantly lowest in DU and DHIC groups and lower in HSB and DO groups than normal tracing group. Reduced bladder sensation was noted in DU and negatively associated with detrusor contractility.

Comparing the midterm outcome of single incision vaginal mesh and transobturator vaginal mesh in treating severe pelvic organ prolapse.

OBJECTIVE: The aim of this study is to compare perioperative parameters and midterm clinical outcomes using two different mesh kits: transobturator vaginal mesh (TVM) (both Perigee and Apogee), versus single incision vaginal mesh (SIM) (combined Elevate anterior/apical system and Elevate posterior/apical system) in treating severe pelvic organ prolapse (POP). MATERIALS AND METHODS: This is a retrospective cohort study. During 2008 and 2013, those women with severe POP [POP quantification system (POP-Q), Stage III and Stage IV], who received either TVM or SIM operation, were enrolled for cohort comparison. There were 111 patients in the TVM group, and 136 in the SIM group. Those with an incomplete POP-Q record, or who did not complete postoperative urodynamic study were excluded. Perioperative characteristics and outcomes, postoperative urinary symptoms, urodynamic parameters, prolapse recurrence (defined as the leading edge > 0 using the POP-Q system), and mesh extrusion rate were compared. RESULTS: There were no differences in the operation time, blood loss, hospital stay, and the postoperative visual analog scale for pain. Urodynamic studies showed improvement in bladder outlet obstruction in both groups. The postoperative stress urinary incontinence was significantly higher in the SIM group. The recurrence of prolapse was comparable between the two groups at a median follow-up of 2 years. The mesh extrusion rate was significantly lower in the SIM group. CONCLUSION: At an average of 2 years of follow-up, the mesh extrusion rate was lower in the SIM group than in the TVM group, but there was no difference in postoperative visual analog scale for pain. The postoperative stress urinary incontinence was higher in the SIM group.

Comparison of the clinical outcomes of transobturator and single-incision slings for stress urinary incontinence.

The aim of this study was to compare the clinical outcomes of anti-incontinence surgeries employing the transobturator sling and single-incision sling (SIS). Our hypothesis is that the outcome of the SIS is not inferior to the obturator sling. This retrospective study reviewed the medical records of patients who underwent anti-incontinence surgery with the transobturator sling or SIS from July 2005 to November 2014. Patients who underwent concomitant pelvic organ reconstruction with an artificial mesh were excluded. Assessments included preoperative and postoperative urodynamic examinations, perioperative complications, and postoperative urogenital symptoms. A total of 122 women were recruited according to the inclusion and exclusion criteria. Among them, 68 patients underwent transobturator sling procedures while 54 patients underwent SIS procedures. The subjective failure rate of the transobturator sling and SIS were 10.2% and 18.5%, respectively (p = 0.292). The objective failure rate, defined as a pad test showing more than 2 g of urine, was 10.2% for the transobturator sling and 12.9% for the SIS (p = 0.777). SIS resulted in less blood loss, operative time, length of hospital stay, and transient voiding dysfunction after the operation. No major complication occurred after either surgical intervention. In conclusion, SIS and transobturator slings might have similar efficacy, safety, and effects on new-onset urogenital symptoms.