Modified autologous fascial sling technique ('sling on a string') for stress incontinence.

INTRODUCTION AND HYPOTHESIS: Describe the modified autologous fascial sling procedure that has been employed in the largest randomized controlled trial comparing autologous slings, mesh slings and xenografts. METHODS: The video aims to demonstrate the modified Aldridge technique. The surgical procedure is demonstrated. A 6-cm suprapubic incision is made to harvest the rectus sheath fascia. Loop-0-PDS sutures are attached on either end of the sling. A marking suture is placed in the middle of the graft to facilitate tension-free adjustment. A vaginal incision is made at the mid-urethra. Paraurethral dissection is performed to create a tunnel for the fascial graft to be passed through (in the same manner as with transvaginal mesh slings). The ends of the graft PDS sutures are passed through the paraurethral tunnel. One hand is placed abdominally below the rectus muscles to palpate the pelvic floor from above. The graft sutures are passed through the pelvic floor with control on either side. A cystoscopy is performed to check the bladder integrity. The graft placement is adjusted to be tenson-free. The incisions are closed. The short- and long-term outcomes of this technique have been investigated and published. RESULTS: The cure rates and complication rates were no different in the mesh and autologous slings. The xenograft had inferior outcomes. CONCLUSION: Autologous fascial slings can be used in the surgical management of urodynamic stress incontinence. The technique demonstrated in this video is the technique employed in the largest randomized controlled trial investigating the efficacy of autologous fascial slings to xenografts and tapes.

Cervical glandular neoplasia referrals and the diagnosis of adenocarcinoma in situ: Correlating cytology, colposcopy findings, and clinical outcomes.

OBJECTIVES: To determine the clinical outcomes of women with possible glandular neoplasia of endocervical type on cervical cytology, and review all diagnoses of cervical adenocarcinoma in situ (AIS) over a 5 year period at our institution. STUDY DESIGN: A retrospective case-note review was conducted of all women referred to colposcopy with possible glandular neoplasia of endocervical type on cervical cytology or diagnosed with cervical AIS after biopsy or excision, from January 2014 until December 2018 in a London district hospital. RESULTS: Of 55 women referred with possible glandular neoplasia of endocervical type, 47 (85.4%) had a significant pathology on histopathological analysis: AIS (n = 22); invasive cancer (n = 7); high-grade cervical intraepithelial neoplasia (n = 18). Women with a history of borderline abnormality on cervical cytology within the last 5 years were significantly more likely to be diagnosed with AIS or invasive cancer (P < .05). For the same period 49 women had histologically proven AIS. Among these 22 (44.8%) were referred as possible cervical glandular intraepithelial neoplasia. Other reasons for referral were the following indications: borderline dyskaryosis (n = 13); high-grade dyskaryosis (n = 8); low-grade dyskaryosis (n = 4); postcoital bleeding (n = 2). CONCLUSION: Due to the raised risk of significant gynaecological pathology in women with possible glandular neoplasia of endocervical type on cervical cytology, excisional biopsy is essential. Colposcopic impression varies significantly and complete excision of the abnormal lesions should be achieved. AIS is a histological diagnosis and should always be considered during colposcopical and cytopathological assessment.

The use of 3D ultrasound in comparing surgical techniques for posterior wall prolapse repair: a pilot randomised controlled trial.

The most appropriate method for repairing posterior vaginal wall prolapse is still debatable. Women with symptomatic prolapse scheduled to undergo surgical repair in the posterior compartment were randomised to standard posterior colporrhaphy (SPC) or fascial and vaginal epithelial plication (FEP). Participants were assessed with the Prolapse Quality of Life (P-QOL) questionnaire, pelvic organ prolapse quantification (POP-Q) examination and three-dimensional ultrasound (3D US) prior to surgery and 6 months postoperatively. The research hypothesis is that 3D US of the pelvic floor is a reliable tool in comparing the anatomical outcomes of the two different surgical techniques. Differences in anatomical outcomes, assessed clinically and by ultrasonographic evaluation, were compared between the two groups using the Independent Mann-Whitney U-test and the Wilcoxon signed-rank sum test. Twenty-two women were included in the analysis. Six months postoperatively, women in the FEP arm had better anatomical outcomes compared to those who had undergone SPC (p = .02). Repeatability of the ultrasound technique was confirmed, showing moderate to very good agreement in all parameters and the 3D US evaluation was corroborated with the clinical examination, showing a greater reduction in the urogenital size in the FEP group.Impact statementWhat is already known on this subject? The low cost and universal availability of the ultrasound (US) makes it the most commonly used diagnostic modality. The ability to see beyond surface anatomy is important and useful in the assessment of the posterior vaginal wall prolapse and the obstructed defaecation, where this method may replace the defaecation proctography (Dietz 2019). Recent advances in pelvic floor ultrasonography (3D US) have achieved repeatability in the measurement of the levator hiatal (LH) dimensions, introducing a valid and readily available tool for researchers and clinicians (Dietz et al. 2005). Ultrasound may distinguish a true rectocele due to the weakening of the rectovaginal fascia from an enterocele, a rectal intussusception, or just a deficient perineum (Guzman Rojas et al. 2016).What do the results of this study add? Our study demonstrates that 3D translabial pelvic floor ultrasound is a useful and reliable tool in assessing the anatomical outcome of prolapse surgery.What are the implications of these findings for clinical practice and/or further research? Our study demonstrates that 3D translabial ultrasound of the pelvic floor is a useful and reproducible method in evaluating the anatomical outcomes of surgical repair for posterior wall prolapse. Genital hiatus (GH) and levator hiatus (LH) dimensions measured by ultrasound can be used as surrogate anatomical markers in comparing the efficacy of different surgical techniques.

An animal experimental study on pubourethral ligament restoration with platelet rich plasma for the treatment of stress urinary incontinence.

INTRODUCTION: Minimally invasive methods for injured ligament and tendon restoration have been developed and gained popularity in recent years. Injury and relaxation of the pubourethral ligament (PUL) can lead to stress urinary incontinence (SUI). The aim of this study was to investigate the impact of injecting platelet rich plasma (PRP) into the PUL following its surgical transection resulting in SUI, confirmed by leak point pressure (LPP) measurements pre- and post-intervention in an experimental animal model. MATERIAL AND METHODS: Twenty female adult Sprague-Dawley rats were assigned in 2 groups: 1) treatment group with transection of the PUL and application of PRP at the time of transection and at one month follow-up and 2) a control group, with transection of the PUL only. Leak point pressures (LPPs) were measured prior to transection, immediately following the transection and at 1 and 2 months in both groups. RESULTS: The median LPPs for the control group were: LPP - preT: 35.6 (29.8-44.8) cmH2O, LPP - postT: 14.6 (5.8-19.0) cmH2O, LPP - 1 month: 27.3 (19.2-33.8) cmH2O, LPP - 2 months: 29.0 (27.0-34.0) cmH2O, whereas for the PRP group were: LPP-preT: 40.5 (33.2-46.3) cmH2O, LPP - postT: 15.7 (3.0-24.0) cmH2O, LPP - 1month: 31.6 (24.8-37.4) cmH2O, LPP - 2 months: 36.8 (32.5-45.4) cmH2O. PRP injections on transected PULs significantly increased LPPs at one month follow-up [31.6 cmH2O vs. 27.3 cmH2O, p = .043]. This effect was confirmed at two months [36.8 cmH2O vs. 29.0 cmH2O, p <.001]. CONCLUSIONS: Injection of PRP into transected PULs significantly improved LPPs at one and two months' follow-up. However, further experimental and clinical research is needed to evaluate the safety and efficacy of this treatment, in clinical practice.

Restoration of the pubourethral ligament with platelet rich plasma for the treatment of stress urinary incontinence.

Stress urinary incontinence (SUI) is a major health problem, which affects nearly 20% of adult women and has a detrimental impact on their daily activities and quality of life. Several surgical techniques have been proposed for the treatment of SUI including the Burch colposuspension, retropubic mid-urethral slings (TVT), trans-obturator tapes (TOT), trans-obturator tapes inside out (TVT-O), bladder neck injections and the insertion of an artificial urethral sphincter. All of these treatments aim to either restore the urethral support, which is naturally preserved by the pubourethral ligament (PUL) or to increase the urethral resistance at rest. Most surgical techniques are associated with a variety of intraoperative and postoperative complications. Platelet rich plasma (PRP) is extremely rich in growth factors and cytokines, which regulate tissue reconstruction and has been studied extensively among trauma patients and trauma experimental models. To date, however, there is no evidence to support or oppose its use in women who suffer from SUI due to PUL damage. PRP is an easily produced and relatively inexpensive biologic material. It is produced directly from the patient's blood and is, thus, superior to synthetic materials in terms of potential adverse effects such as from foreign body reaction. In the present article we summarize the existing evidence in the field, which supports the conduct of animal experimental and clinical studies to elucidate the potential role of PRP in treating SUI.

The surgical management of recurrent stress urinary incontinence: a systematic review.

BACKGROUND: Despite a wide spectrum of interventions, surgical treatments of recurrent stress urinary incontinence (SUI) are associated with high failure rates. OBJECTIVES: To systematically review current evidence on the effectiveness of surgical interventions for recurrent SUI. DATA SOURCES: An electronic database search was undertaken (1980-2014). Keywords were: "stress urinary incontinence," "failure," "recurrence," "treatment." References of identified studies and abstracts from conferences were considered. STUDY SELECTION: We restricted the search to female patients and currently used surgical procedures, including studies with five or more cases. After the initial yield, studies were selected following title screening, abstract and full text scrutiny. RESULTS: The pooled objective cure rates of colposuspension for recurrent SUI are 76% (95% CI ±5.04), whereas rates for midurethral sling procedures are 68.5% (95% CI ±3.11). Repeat midurethral sling procedures have pooled success rates of 66.2% (95% CI ±4) but those of the transobturator approach appear lower than retropubic procedures. Pubovaginal slings for recurrent SUI have pooled success of 79.3% (95% CI ±6.54). Success rates for adjustable continence therapy and adjustable slings for recurrent SUI are 53.8% (95% CI ±5.28), whereas for midurethral sling fixation procedures the pooled success is 61% (95% CI ±10.56). Urethral bulking injections have success rates of 38% (95% CI ±10.7). Laparoscopic two-team sling procedures, salvage spiral slings, and artificial urinary sphincter have shown promising results, but there are limited data on recurrent cases. CONCLUSION: There is a wide spectrum of surgical interventions reported for secondary or tertiary treatment of SUI. A common characteristic for all recurrent procedures is a lower success rate compared with those reported following primary procedures.