The Manchester procedure: anatomical, subjective and sexual outcomes.

INTRODUCTION AND HYPOTHESIS: Classical native-tissue techniques for pelvic organ prolapse (POP) repairs, such as the Manchester procedure (MP), have been revitalized because of vaginal mesh complications. However, there are conflicting opinions regarding sufficient apical (mid-compartment) support by the MP and concerns about the risk of dyspareunia. The aims of this study were therefore to investigate anatomical and patient-reported outcomes 1 year after MP. METHODS: Prospective cohort study of 153 females undergoing an MP for anterior compartment POP between October 2014 and June 2016. Pre- and 1-year postoperative evaluations included POP-Q measurements and the questionnaires Pelvic Floor Distress Inventory Short Form 20 (PFDI-20) and POP/Urinary Incontinence Sexual Questionnaire (PISQ-12). RESULTS: At 1 year, 97% (148/153) attended the follow-up. Significant anatomical improvements (p < 0.01) were obtained in all compartments. Mean Ba was -1.1 (± 1.4), mean C -5.9 (± 1.7) and mean D -7.0 (± 1.2) at follow-up. Point C ≤ -5 was present in 81.1%. POP-Q stage 0-1 was obtained in 99.3% in the mid-compartment (C < -1), but only in 48.6% in the anterior compartment (Ba < -1). A significant reduction in symptom scores was obtained for PFDI-20 (p < 0.01) and PISQ-12 (p = 0.01). No significant changes were seen in dyspareunia rates (q.5, PISQ-12), but 5.6% reported de novo dyspareunia. Concerning POP symptoms, 96.0% reported being cured or significantly improved. CONCLUSIONS: The Manchester procedure provides adequate apical support, albeit inferior anatomical anterior compartment results, and 96.0% reported being subjectively cured or substantially better at 1-year follow-up, with no significant change in dyspareunia.

Long-term follow-up after native tissue repair for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: There are large variations in reported frequency of recurrence and subsequent treatment after pelvic organ prolapse (POP) surgery. We hypothesized that native tissue repair entails high subjective satisfaction and good objective results, with low POP reoperation rates and few complications. METHODS: The 1-year results of 699 women having had native tissue repair for POP at our urogynecological unit from 2002 to 2005 were evaluated using an internal quality control database. A short-form physician check list for patient subjective and objective outcomes has been routinely used for 1-year controls since 2002, and results are registered longitudinally in the database. Patients' medical records up to 2012 were reviewed for information on recurrent POP symptoms. A telephone interview was performed to assess POP recurrences potentially treated elsewhere. The cumulative incidence for reoperation was calculated comparing partial with complete (surgical treatment of all three compartments) native tissue repairs. RESULTS: Subjective satisfaction was stated by 94 % of patients at the 1-year control, and 84 % had stage 0-I in any compartment using the POP Quantification (POP-Q) system. The 5-year reoperation rate was significantly lower in the complete vs. the partial (2.6 % vs. 8.9 %) repair group. Cumulative incidence of reoperation showed a slight but constant increase over the years. CONCLUSIONS: POP surgery using native tissue repair entails low reoperation rates with excellent subjective and objective results and should be the first choice in treating primary POP, providing use of adequate surgical technique.

Occult incontinence as predictor for postoperative stress urinary incontinence following pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Recommending prophylactic anti-incontinence procedures to continent women undergoing surgery for pelvic organ prolapse (POP) is controversial. We hypothesized that testing for occult incontinence before surgery using four different tests and three defined test combinations would identify individual women at risk for postoperative stress urinary incontinence (POSUI). The diagnostic accuracy of these tests and test combinations were evaluated. METHODS: We tested 137 women before and after surgery. Fisher's exact test was used when evaluating associations between test results and outcomes. The validity of each test and test combinations was calculated. RESULTS: We found a statistically significant association between occult incontinence and POSUI in two tests and all test combinations. However, all tests and test combinations displayed poor performance when predicting at individual levels. CONCLUSIONS: This study confirms a positive association between occult incontinence and POSUI. Occult incontinence does not, however, adequately identify individual women in need of prophylactic anti-incontinence surgery when undergoing POP repair.

Surgical strategies for women with pelvic organ prolapse and urinary stress incontinence.

INTRODUCTION AND HYPOTHESIS: This study aims to compare the result of an incontinence procedure performed at the time of prolapse repair or 3 months later in women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI). METHODS: In a multicenter prospective randomized trial, women with POP and SUI were randomized to have a tension-free vaginal tape (TVT) at the time of prolapse repair (n = 87; group I) or 3 months later (n = 94; group II). Women in group II were evaluated for SUI 3 months after the prolapse repair. Those with confirmed SUI had a TVT performed (n = 53). The main evaluation of all women was 1 year after the last surgery. RESULTS: On-treatment analysis resulted in 95% cure of SUI in group I and 89% in group II (p = 0.12). Twenty-seven percent were cured after prolapse surgery alone. CONCLUSIONS: No differences were found between the two treatment strategies, but almost one third of women were cured of SUI by prolapse surgery alone.

The development of a questionnaire to measure the severity of symptoms and the quality of life before and after surgery for stress incontinence.

OBJECTIVES: To develop and validate a short questionnaire recording the severity of symptoms and the quality of life, pre- and post-operatively, in women undergoing surgery for stress incontinence. DESIGN: The questionnaire was designed from previously designed questionnaires and pilot studies. In this study, it was tested for validity and reliability using standard psychometric techniques. Data from the questionnaire are reported to a national database, which generates reports for comparison of surgical procedures, departments and surgeons. SETTING: Tertiary referral urogynaecology units at Baerum and Aker Hospitals, Norway, and 22 Norwegian departments of gynaecology. POPULATION: Fifty and 65 women with stress incontinence from Baerum and Aker hospitals, respectively, and 628 women with stress incontinence from 22 Norwegian departments of gynaecology. METHODS: Stress Incontinence, Urge Incontinence and Quality of Life Indices were constructed. Internal consistency of the indices was measured by Cronbach's alpha and test-retest reliability by Bland-Altman plots. Stress Incontinence Index was tested against stress test and Urge Incontinence Index and Stress Incontinence Index were tested against the 24-hour pad test. Quality of Life Index was tested against a part of the King's College Hospital Quality of Life Questionnaire. MAIN OUTCOME MEASURES: Face and content validity. Missing values of the questionnaire. Reliability and internal consistency. Criterion validity. RESULTS: The 628 women completed a mean of 98.2% of all the questions. The content validity was good. The reliability was good in terms of test-retest reliability and internal consistency. The criterion validity of stress and urge incontinence was tested against the stress and 24 hour pad tests. The correlation between the indices and the objective tests was moderate. The correlation between the Quality of Life Index and the physical and social part of the previously validated King's College Hospital questionnaire was good. CONCLUSIONS: The questionnaire is easy to understand and complete and is a valid and reliable instrument for assessment of the symptoms of incontinence and the quality of life. Pre- and post-operative evaluation of women with stress incontinence was performed in a standardised setting in 22 of the 37 Norwegian departments and the reporting to a national database was successful. Comparison of surgical procedures, departments and surgeons is possible.