Enhanced recovery after surgery (ERAS) in prolapse repair: A prospective study on pre-emptive uterosacral/cervical block.

OBJECTIVE: Enhanced recovery after surgery (ERAS) protocols have been introduced in gynecology. Postoperative pain management after vaginal procedures remains a relevant issue. In the present study we aimed to evaluate the effectiveness of pre-emptive uterosacral/cervical block (PUCB) for postoperative pain control in patients with uterovaginal prolapse undergoing vaginal hysterectomy and pelvic floor repair. We also evaluated the impact on the length of recovery. METHODS: This was a pilot study analyzing 40 women who underwent pelvic organ prolapse repair through uterosacral ligament suspension. Patients who chose to undergo PUCB were considered as cases, otherwise as controls. After general or spinal anesthesia induction, the treatment group received the PUCB with ropivacaine plus clonidine injections at 2, 4, 8, and 10 o'clock of the cervix. The control group did not receive additional treatment. Pain intensity was measured at rest and after forceful cough at 1, 4, 8, 12, 24, and 48 h postoperatively. RESULTS: We found a significant reduction in pain values at 1 h (rest and forceful cough) and 24 h (forceful cough) in the PUCB group. The incidence of moderate/severe pain was inferior in the PUCB group at 1 h (rest) and 24 h (rest and forceful cough). There were no differences in terms of the use of rescue opioids (0% vs. 5%; P = 0.311) and length of hospital stay (2.5 ± 0.6 vs. 2.3 ± 0.6; P = 0.180). CONCLUSIONS: For the first time, we demonstrated the impact of pre-emptive uterosacral/cervical block on pain control up to 24 h after surgery. Clonidine as a sensory blockade extender appears promising in enhancing the efficacy of local anesthetics.

High Uterosacral Ligaments Suspension for Post-Hysterectomy Vaginal Vault Prolapse Repair.

Background and Objectives: Uterosacral ligaments (USLs) suspension is a well-studied, safe, and long-lasting technique for central compartment correction. Preliminary clinical experiences showed encouraging data for this technique, also for post-hysterectomy vaginal vault prolapse surgical treatment. However, up-to-date evidence for post-hysterectomy vaginal vault prolapse repair through high uterosacral ligaments suspension is limited. Consequently, with this study, we aimed to assess the efficiency, complications frequency, and functional results of native-tissue repair through USLs in vaginal vault prolapse. Materials and Methods: This was a retrospective study. Women with symptomatic vaginal vault prolapse (≥stage 2) who underwent surgery with transvaginal native-tissue repair by high uterosacral ligaments were included. Patient characteristics, preoperative assessment, operative data, postoperative follow-up visits, and re-interventions were collected from the hospital's record files. High uterosacral ligament suspension was performed according to the technique previously described by Shull. A transverse apical colpotomy at the level of the post-hysterectomy scar was performed in order to enter the peritoneal cavity. USLs were identified and transfixed from ventral to dorsal with three absorbable sutures. Sutures were then passed through the vaginal apex and tightened to close the transverse colpotomy and suspend the vaginal cuff. At the end of the surgical time, a diagnostic cystoscopy was performed in order to evaluate ureteral bilateral patency. Using the POP-Q classification system, we considered an objective recurrence as the descensus of at least one compartment ≥ II stage, or the need for a subsequent surgery for POP. The complaint of bulging symptoms was considered the item to define a subjective recurrence. We employed PGI-I scores to assess patients' satisfaction. Results: Forty-seven consecutive patients corresponding to the given period were analyzed. No intraoperative complications were observed. We observed one postoperative hematoma that required surgical evacuation. Thirty-three patients completed a minimum of one-year follow-up (mean follow-up 21.7 ± 14.6 months). Objective cure rate was observed in 25 patients (75.8%). No patients required reintervention. The most frequent site of recurrence was the anterior compartment (21.2%), while apical compartment prolapse relapsed only in 6% of patients. An improvement in all POP-Q parameters was recorded except TVL which resulted in a mean 0.5 cm shorter. Subjective recurrence was referred by 4 (12.1%) patients. The mean satisfaction assessed by PGI-I score was 1.6 ± 0.8. Conclusion: This analysis demonstrated that native-tissue repair through high USL suspension is an effective and safe procedure for the treatment of post-hysterectomy vaginal vault prolapse. Objective, subjective, functional, and quality of life outcomes were satisfactory, with minimal complications.

Flat Magnetic Stimulation for Stress Urinary Incontinence: A 3-Month Follow-Up Study.

BACKGROUND: flat magnetic stimulation is based on a stimulation produced by electromagnetic fields with a homogenous profile. Patients with stress urinary incontinence (SUI) can take advantage of this treatment. We aimed to evaluate medium-term subjective, objective, and quality-of-life outcomes in patients with stress urinary incontinence to evaluate possible maintenance schedules. METHODS: a prospective evaluation through the administration of the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), the Incontinence Impact Questionnaire (IIQ7), and the Female Sexual Function Index (FSFI) was performed at three different time points: at the baseline (T0), at the end of treatment (T1), and at 3-month follow-up (T2). The stress test and the Patient Global Impression of Improvement questionnaire (PGI-I) defined objective and subjective outcomes, respectively. RESULTS: 25 consecutive patients were enrolled. A statistically significant reduction in the IIQ7 and ICIQ-SF scores was noticed at T1 returned to levels comparable to the baseline at T2. However, objective improvement remained significant even at a 3-month follow-up. Moreover, the PGI-I scores at T1 and T2 were comparable, demonstrating stable subjective satisfaction. CONCLUSION: despite a certain persistence of the objective and subjective continence improvement, the urinary-related quality of life decreases and returns to baseline values three months after the end of flat magnetic stimulation. These findings indicate that a further cycle of treatment is probably indicated after 3 months since benefits are only partially maintained after this timespan.

Superinfection of Rectovaginal Endometriosis: Case Report and Review of the Literature.

BACKGROUND: A peculiar complication of endometriosis is a superinfection. However, the superinfection of extra-ovarian endometriosis is anecdotal, and only a few cases have been described. We wanted to present the first cases of the superinfection of rectovaginal endometriosis and to perform a literature review of the superinfection of extra-ovarian endometriosis. METHODS: We present a case of a 24-year-old woman who was referred to our Pelvic Floor Unit for rectal-perineal pain, dyspareunia, and recurrent episodes of dense purulent vaginal discharge for one year, in which the superinfection of rectovaginal endometriosis was diagnosed. Moreover, we performed a systematic search of the literature indexed on PubMed up to 31 January 2023. RESULTS: Laparoscopic drainage was successful in managing this condition. In the literature, clinical presentation and instrumental and microbiological findings are very heterogeneous. However, the gold standard of management is represented by surgical or percutaneous drainage. CONCLUSIONS: In the case of a pelvic abscess, the superinfection of endometriosis lesions should be suspected, and this can represent the onset symptom of endometriosis. Ultrasonography may show nodular or flat hypoechoic lesions with hyperechoic debris and peripheral positive color/power Doppler intensities. The goal of management is to drain the abscess, either percutaneously or via traditional surgery, followed by proper hormonal therapy to reduce recurrence.

Urethral Injury After Vaginal Birth and Stress Urinary Incontinence: Bulking Agents are Feasible Options.

Introduction and Hypothesis: Lower urinary tract tears after vaginal delivery are a very rare event, estimated to occur in 0.03-0.05% of women and may be associated with severe stress urinary incontinence, due to great reduction of urethral resistance resulting in a significant intrinsic urethral deficit. Urethral bulking agents represent an alternative, minimally invasive anti-incontinence procedure in the management of stress urinary incontinence. Our aim is to present the management of severe stress urinary incontinence in a patient with concomitant urethral tear caused by obstetric trauma using a minimally invasive treatment option. Methods: A 39-year-old woman referred to our Pelvic Floor Unit for severe stress urinary incontinence. Our evaluation demonstrated an undiagnosed urethral tear involving the ventral portion of the middle and distal urethra, for about 50% of urethral length. Urodynamic evaluation confirmed the presence of severe urodynamic stress incontinence. After proper counseling, she was admitted to mini-invasive surgical treatment with urethral bulking agent injection. Results: The procedure was completed in 10 minutes and she was successfully discharged home on the same day, and no complications occurred. The treatment resulted in total relief of urinary symptoms, which persists at 6-month follow-up. Conclusion: Treatment with urethral bulking agent injection represents a feasible mini-invasive option to manage stress urinary incontinence related to urethral tears.

Italian validation of the Pelvic Floor Distress Inventory (PFDI-20) questionnaire.

INTRODUCTION AND HYPOTHESIS: The use of validated Quality of Life (QoL) questionnaires is useful in the standardization and interpretation process of pelvic floor patient symptoms, due to their functional nature and high prevalence. The Pelvic Floor Distress Inventory QoL questionnaire (PFDI-20) serves both as a symptom inventory and a measure of the degree of bother and distress caused by pelvic floor symptoms. It includes items related to pelvic organ prolapse and lower gastrointestinal and bladder dysfunction. METHODS: After consensus translation and a comprehension test, the Italian version of the questionnaire was submitted to patients reporting bowel, bladder, or pelvic disorders (cases) and to asymptomatic women (controls). Cases received the questionnaire once again 2 weeks later by email. RESULTS: A total of 254 patients answered the questionnaire. Construct validity was demonstrated by discriminating between cases and controls. Convergent validity was demonstrated for each domain (F < 0.001). In-ernal consistency reliability showed a satisfactory range (0.816-0.860). CONCLUSIONS: The PFDI-20 allows a comprehensive assessment of the effect of pelvic floor disorders on the quality of life of women. Moreover, the PFDI-20 represents a very solid QoL tool, since it has been extensively used in literature, and its use is highly recommended by the International Consultation on Incontinence. The present study demonstrated good features for the Italian version of the PFDI-20 questionnaire.

Flat Magnetic Stimulation for Stress Urinary Incontinence: A Prospective Comparison Study.

BACKGROUND: Flat Magnetic Stimulation (FMS) is characterized by a stimulation generated by electromagnetic fields with a homogenous profile. One possible application is the treatment of stress urinary incontinence (SUI). We aimed to compare the objective, subjective, quality of life, and instrumental outcomes in women with SUI not eligible for surgery undergoing either FMS or pelvic floor muscle training (PFMT). METHODS: This was a prospective interventional study. After proper counseling, patients with isolated SUI were divided according to their treatment of choice into FMS and PFMT groups. At baseline and after treatment, patients completed the International Consultation on Incontinence Questionnaire-Short Form, the Female Sexual Function Index, and the Incontinence Impact Questionnaire, and volumetric measurement of the urethral rhabdosphincter (RS) was performed. The Patient Global Impression of Improvement questionnaire and stress test defined subjective and objective cure rates, respectively. RESULTS: We observed improvements in urinary-related quality of life scores and an increase in RS volume after FMS compared to baseline. All these outcomes were significantly better compared to women who underwent PFMT. CONCLUSION: Our study demonstrated that FMS is a safe and effective conservative option for SUI management in terms of objective and subjective cure rates.

Surgical management of rectovaginal fistula after stapled transanal rectal resection for prolapsed hemorrhoids.

INTRODUCTION AND HYPOTHESIS: Rectovaginal fistula is an epithelium-lined direct communication route between the vagina and the rectum. The gold standard of fistula management is surgical treatment. Rectovaginal fistula after stapled transanal rectal resection (STARR) may be challenging to treat, due to the extensive scarring, the local ischemia, and the risk of rectal stenosis. We aimed to present a case of iatrogenic rectovaginal fistula after STARR that was successfully treated with a transvaginal primary layered repair and bowel diversion. METHODS: A 38-year-old woman was referred to our division for continuous fecal discharge through her vagina that developed a few days after she had a STARR for prolapsed hemorrhoids. Clinical examination revealed a 2.5 cm-wide direct communication between the vagina and rectum. After proper counseling, the patient was admitted to transvaginal layered repair and temporary laparoscopic bowel diversion RESULTS: No surgical complications were observed. The patient was successfully discharged home on postoperative day 3. Bowel diversion was reversed after 2 months. At the current follow-up (6 months), the patient is asymptomatic and without recurrence. CONCLUSIONS: The procedure was successful in obtaining anatomical repair and relieving symptoms. This approach represents a valid procedure for the surgical management of this severe condition.

Total introital obliteration as a consequence of lichen sclerosus: a rare cause of urinary retention.

INTRODUCTION AND HYPOTHESIS: Lichen sclerosus is a chronic inflammatory dermatitis, with a predilection for the anogenital area. In later stages, lichen sclerosus may develop into widespread scarring, and occasionally leading to severe introital stenosis and urinary retention. Our video is aimed at presenting a case of surgical management of lichen sclerosus-related introital stenosis determining urinary retention. METHODS: An 82-year-old woman was evaluated for almost complete urinary retention, with concomitant continuous enuretic urinary leakage all day and night and recurrent urinary tract infection symptoms. The gynecological evaluation demonstrated a complete introital obliteration, without obvious communications for urine passing. After proper informed consent, the patient was admitted for vulvo-perineoplasty. RESULTS: The featured procedure was completed in 25 min and blood loss was negligible. No surgical complications were observed. On postoperative day 1, the patient was successfully discharged home with topical steroid treatment. Histological examination confirmed typical features of lichen sclerosus pathology. At follow-up visits the patient was asymptomatic and examination confirmed persistence of introital patency. CONCLUSIONS: The featured video shows a vulvo-perineoplasty performed in a patient with lichen sclerosus-related complete introital obliteration and urinary retention. The procedure was successful in obtaining anatomical repair and relieving urinary symptoms.

Pelvic pain after laparoscopic lateral suspension for pelvic organ prolapse: an unrecognized problem?

INTRODUCTION AND HYPOTHESIS: The laparoscopic lateral suspension (LLS) represents an alternative mesh procedure to avoid the dissection at the promontory. However, mesh-related complications such as chronic pelvic pain, dyspareunia, and bladder pain are emerging. The present study is aimed to present a video case report and describe a small case series of patients referred to our center for chronic pelvic pain after LLS. METHODS: A surgical video of the management of a 50-year-old woman with chronic abdominal and pelvic pain, dyspareunia, and recurrent urinary tract infection (UTIs) after uterus sparing LLS is provided. Moreover, we performed a retrospective chart review of similar cases in our institution. RESULTS: The featured procedure was completed without complications and was successful in obtaining symptom relief. Between 2018 and 2022 five patients underwent total or subtotal mesh removal for pain-related symptoms after LLS. At the median follow-up of 24 months, all patients were free from pain, but two (40%) required reoperation for prolapse recurrence CONCLUSIONS: Our experience suggests that LLS involves a certain risk of chronic pelvic pain, which may be challenging to manage and require surgical treatment.

Coexistent Detrusor Overactivity-Underactivity in Patients with Pelvic Floor Disorders.

INTRODUCTION AND HYPOTHESIS: Pelvic floor disorders represent a series of conditions that share, in part, the same etiological mechanisms, so they tend to be concomitant. Recently, awareness of a new lower urinary tract clinical syndrome has risen, namely the coexisting overactive-underactive bladder (COUB). The etiopathogenetic process, prevalence, and related instrumental findings of COUB are not well-established. We aimed to evaluate the prevalence, clinical features, and urodynamic findings of patients with COUB in a large cohort of patients with pelvic floor disorders. Methods: A cohort of 2092 women was retrospectively analyzed. A clinical interview, urogenital examination, and urodynamic assessment were performed by a trained urogynecologist. Based on baseline symptoms, patients were divided into COUB and non-COUB groups, and the degree of concordance between COUB and urodynamic findings, and other parameters related to the clinical aspects of these patients were measured and analyzed. Results: 18.8% of patients were classified as COUB. The association between COUB and patients with coexisting detrusor overactivity-underactivity (DOU) was statistically significant and there were substantial similarities in terms of population characteristics, symptoms, and urodynamic findings. Conclusions: Our study showed a high prevalence of COUB, and a link between this clinical syndrome and DOU was demonstrated. They showed substantial similarities in terms of clinical and urodynamics correlates. Based on these findings, we do think that urodynamic tests can be useful to improve knowledge on COUB and may be of help in the management of this condition.

Native Tissue Posterior Compartment Repair for Isolated Posterior Vaginal Prolapse: Anatomical and Functional Outcomes.

Background and Objectives: Posterior compartment prolapse is associated with constipation and obstructed defecation syndrome. However, there is still a lack of consensus on the optimal treatment for this condition. We aim to investigate functional, anatomical, and quality-of-life outcomes of native tissue transvaginal repair of isolated symptomatic rectocele. Materials and Methods: We retrospective analyzed patients who underwent transvaginal native tissue repair for stage ≥ II and symptomatic posterior vaginal wall prolapse between January 2018 and June 2021. Anatomical and functional outcomes were evaluated. Wexner constipation score was used to assess bowel symptoms, while the Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. Results: Twenty-eight patients were included in the analysis. The median age was 64.5 years, and half of them underwent a previous hysterectomy for benign reasons. The median follow-up time was 33.5 months. A significant anatomical improvement in the posterior compartment was noticed compared with preoperative assessment (p < 0.001 for Ap and Bp), with only two (7.1%) anatomical recurrences. Additionally, obstructed defecation symptoms decreased significantly compared to baseline (p < 0.001), as well as vaginal bulging, with no new-onset cases of fecal incontinence or de novo dyspareunia. PGI-I resulted in 89.2% of patients being satisfied (PGI-I ≥ 2), with a median score of 1.5. Conclusions: Transvaginal native tissue repair for isolated posterior prolapse is safe and effective in managing bowel symptoms, with excellent anatomical and functional outcomes and satisfactory improvement in patients' quality of life.