Novel technique of laparoscopic mid-urethral autologous rectus fascial sling for stress urinary incontinence.

Serious concerns have been raised over the safety of vaginal mesh tapes for stress urinary incontinence (SUI). Autologous rectus fascial sling and the more recent 'sling on a string' through a laparotomy are gaining popularity as native tissue options for SUI. We describe a novel technique of laparoscopic mid-urethral autologous rectus fascial sling for SUI. Ten patients underwent this new technique safely. At 12 months, all patients reported cure of SUI with normal voiding. The advantages of this technique include the minimal access approach, introduction of the sutures under laparoscopic guidance, and avoidance of over-tightening of the sling.

Total laparoscopic hysterectomy and bilateral salpingo-oophrectomy for stage 1 endometrial carcinoma under regional anaesthesia.

Total Laparoscopic hysterectomy is most commonly performed under general anesthesia. In elderly patients with severe medical co-morbidities and endometrial malignancy, laparoscopic surgery under general anesthesia can be hazardous. In such patients, regional anesthesia is safe, and can be the only option. We present a case of 75-year old women with severe lung fibrosis, chronic obstructive airway disease and heart failure who presented with severe post-menopausal bleeding and was diagnosed with endometrial carcinoma. She was considered unfit for general anesthesia. After multidisciplinary team meeting, the patient underwent total laparoscopic hysterectomy, bilateral salpingo-oophrectomy and peritoneal washings under regional anaesthesia. The procedure was successful and the patient was discharged 24 h later. In this case report, we demonstrate the anesthetic and surgical techniques for total laparoscopic hysterectomy under regional anesthesia. In the presence of dedicated multidisciplinary team, laparoscopic hysterectomy for endometrial carcinoma under regional anesthesia is safe and feasible.

Two-year anatomical and functional outcomes of laparoscopic sacrocolpopexy using light-weight Y shaped mesh for post hysterectomy vaginal prolapse.

OBJECTIVE: The aim of this study is to evaluate the efficacy, safety, anatomical and functional outcomes of patients undergoing laparoscopic sacrocolpopexy (LSC) using light-weight Y mesh for post hysterectomy vaginal prolapse. STUDY DESIGN: A retrospective observational study of women who underwent LSC for post hysterectomy vaginal vault prolapse between January 2010 and January 2019. Y shaped mesh was used for the LSC after dissection of the rectum and the bladder. Pre-operative evaluation included symptoms' assessment using the Prolpase Quality of Life Questionnaire (P-QOL) and objective assessment using the POP-Q scores. Post operatively, patient symptoms, anatomical outcomes, mesh complications and patient global impression of improvement scores were evaluated. Patients were followed up at 12 months and yearly thereafter. RESULTS: 247 consecutive patients were included in this study. Patients' age ranged from 35 to 86 years old with an average BMI of 28.8. The most common presenting symptoms were vaginal bulge (95%), vaginal heaviness (73%) and urinary urgency (46%). The time interval between hysterectomy and LSC was 10.5 years (5 months - 42 years). Complications reported were bladder injury (1.6%), small bowel injury (0.8%), major haemorrhage (0.4%), vaginal mesh extrusion (1.2 %). 85.8% of women reported cure of prolapse symptoms. 14.2% of patients developed further/unresolved prolapse symptoms and 6.5% went on to have further surgery for prolapse. 10% of women developed new onset dyspareunia. Anatomically, postoperative point C (apex) was at -7.6 cm (range -9 - +3 cm) CONCLUSION: LSC using Y mesh for post hysterectomy vaginal prolapse is safe. LSC is effective in 85% of women who develop vaginal prolapse post hysterectomy. Further surgery for bothersome prolapse symptoms were needed in 6.5% with a 1.2% mesh extrusion rate and 10% new onset dyspareunia. This will help in counselling women undergoing this surgery.

Efficacy and pregnancy outcomes of laparoscopic single sheet mesh sacrohysteropexy.

AIMS: To evaluate outcomes following laparoscopic single sheet mesh sacrohysteropexy for the management of uterine prolapse. METHODS: One hundred and fifty-nine women underwent the procedure between August 2010 and August 2014. One hundred and forty-four patients completed the follow up assessment. At each visit, the prolapse symptoms were assessed using the prolapse quality-of-life (P-QOL) questionnaire and objectively with the use of the Pelvic Organ Prolapse Quantification (POPQ) score. The subjective outcomes were also evaluated with the use of the Patient Global Impression of Improvement (PGII) questionnaires. Perioperative complications and further surgery for prolapse were evaluated. Women who conceived following the procedure were evaluated for pregnancy outcomes and prolapse recurrence. RESULTS: Pre-operatively, 85% (135/159) had uterine prolapse ≥ stage 2. Postoperatively, 95.1% (137/144) of women had anatomical success rate defined as stage 0 uterine descent. Eighty-two percent (118/144) of women reported cure of prolapse symptoms and feeling "much better" or "very much better" on postoperative PGII assessment. Eight women (5%) became pregnant following the laparoscopic sacrohysteropexy- seven had full term pregnancies and one had a miscarriage. Six out of the seven (86%) had stage 0 apical prolapse and PGII of "much better" at 6 months postpartum. One patient had symptomatic prolapse recurrence and underwent perineorrhaphy at 3 years. CONCLUSION: Laparoscopic single sheet mesh sacrohysteropexy is associated with subjective and objective improvement in prolapse symptoms and QoL that is maintained up to 48 months. Laparoscopic sacrohysteropexy can be offered to women desiring future fertility; however, further research is needed to advise on best surgical approach in women of childbearing age. Neurourol. Urodynam. 36:787-793, 2017. © 2016 The Authors. Neurourology and Urodynamics Published by Wiley Periodicals, Inc.

New onset stress urinary incontinence following laparoscopic sacrocolpopexy and its relation to anatomical outcomes.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the incidence of stress urinary incontinence (SUI) following laparoscopic sacrocolpopexy in continent women and its relation to postoperative prolapse stage. METHODS: A total of 220 continent women with symptomatic apical prolapse who underwent laparoscopic sacrocolpopexy were prospectively evaluated; 100 women had previous hysterectomy. Patients were followed up at 3 and 12 months after surgery. All subjects completed the King's Health Questionnaire (KHQ) and Prolapse Quality of Life Questionnaire (P-QOL) and were examined using the Pelvic Organ Prolapse Quantification (POP-Q) system. The primary outcome measure was the number of women who developed new onset moderate/severe SUI at 3 and 12 months postoperatively and its relation to postoperative prolapse stage. RESULTS: At 3 months, 52 women (23.6 %) developed moderate/severe SUI; 27 (12.2 %) had severe SUI. Eleven women (5.0 %) underwent surgery for SUI within 6 months of sacrocolpopexy. All surgery for SUI was in women who had post-hysterectomy sacrocolpopexy. Postoperatively, the vaginal apex (point C) was at stage 0/I in 195 cases (88.6 %). There were no differences in postoperative POP-Q stage of the anterior and apical vaginal walls between continent women and those with SUI (p = 0.45). The posterior vaginal wall was higher in women who developed de novo SUI (p = 0.03). CONCLUSIONS: The incidence of SUI following apical prolapse repair is 23.6 %. Subsequent continence procedures were performed in 5.0 % of patients. All were in women who had previous hysterectomy making the risk in this group 11 %. Higher POP-Q stage of the posterior vaginal wall was associated with SUI.

Safety and one year outcomes following vaginally assisted laparoscopic uterine sacropexy (VALUES) for advanced uterine prolapse.

AIMS: To assess the safety and outcomes of vaginally assisted laparoscopic uterine sacropexy (VALUES) as a surgical treatment for stage 3 and 4 uterine prolapse. METHODS: Seventy consecutive women with stage 3 and 4 uterine prolapse who underwent VALUES over 2-year period were prospectively evaluated. Women filled the Prolapse Quality of Life Questionnaire (P-QOL), and underwent examination using pelvic organ prolapse quantification system (POP-Q) pre- and post-operatively. In addition, patients filled the patient global impression of improvement questionnaire post-operatively. Mesh related complications were evaluated post-operatively. Patients were followed up at 3 and 12 months following surgery. This study reports the 12 months outcomes. RESULTS: Sixty-four women (91.4%) reported cure of their prolapse symptoms. On examination, 67 women (95.7%) had POP-Q stage 0 or 1 uterine support at 12 months. Six women needed further surgical intervention for prolapse (8.5%); three women developed recurrent uterine prolapse and three other women developed symptomatic recurrent anterior vaginal wall prolapse. The total vaginal length was not different between the pre- and post-operative periods. Two patients developed mesh related complications. Significant improvement was noted in prolapse symptoms and quality of life. CONCLUSIONS: VALUES is a safe and effective treatment for women with stage 3 and 4 uterine prolapse up to 12 months without the risk of vaginal shortening. Long-term results are needed to fully establish the value of this technique.

Prospective study of anterior transobturator mesh kit (Prolift™) for the management of recurrent anterior vaginal wall prolapse.

INTRODUCTION AND HYPOTHESIS: Assessment of the 2-year outcome of anterior Prolift™ for women with recurrent anterior vaginal wall prolapse. This is a prospective study which was conducted in a tertiary unit in the North West of England and comprised 36 consecutive women with recurrent anterior vaginal wall prolapse. METHODS: Women were assessed preoperatively and postoperatively at 6 months and 2 years. Women completed the Prolapse Quality of Life Questionnaire (P-QOL), Prolapse and Incontinence Sexual Function Questionnaire-Short Form (PISQ-12), and postoperatively, the Global Impression of Improvement Questionnaire. Women were examined using the Pelvic Organ Prolapse Quantification System (POP-Q). Anatomical success was defined as stage ≤1 prolapse in the anterior compartment. Main outcome measures Postoperative POP-Q stage, quality of life domains and mesh exposure rate. RESULTS: Preoperatively all but two women had stage 2 or greater anterior vaginal wall prolapse. At a mean follow-up of 24.6 months, 19 women (53%) had stage ≤1 anterior wall prolapse. Fifteen women had stage 2 anterior wall prolapse and two women had stage 3 prolapse. Twenty-nine women felt improvement in their prolapse symptoms. 16 women were sexually active preoperatively, of whom seven reported worsening dyspareunia. There was poor correlation between anatomical and functional outcomes. Seven women had mesh exposure. Five needed revision in theatre. CONCLUSIONS: Anterior Prolift™ for recurrent anterior vaginal wall prolapse has 53% anatomical success rate in the medium term, with mesh exposure rate of 19%. Majority of patients felt overall improvement in their symptoms, but this did not correlate with the anatomical outcome.

Urine production and bladder diary measurements in women with type 2 diabetes mellitus and their relation to lower urinary tract symptoms and voiding dysfunction.

AIMS: To establish bladder diary measurements in women with type 2 diabetes mellitus (DM) and their relation to bothersome LUTS and voiding dysfunction. METHODS: One hundred ten women with type 2 DM were assessed using the King's Health and ICIQ-FLUTS questionnaires. Patients were divided into bothersome and non-bothersome LUTS according to bother scale of the ICIQ-FLUTS. Voiding was assessed with free flow rate and residuals. Three day bladder diary measurements were obtained and 24 hr, daytime and nighttime urine production, daytime frequency, nighttime frequency, maximum bladder capacity, mean voided volume, mean daytime and nighttime voided volumes, and incontinence episodes were recorded. Differences in bladder diary measurements between bothersome and non-bothersome groups and between normal and abnormal voiding groups were established with multivariate analysis. Correlations between urine production and voided volumes and between diary measurements and domains of the ICIQ-FLUTS were established. RESULTS: There were no differences in urine production, between bothersome and non-bothersome LUTS groups. Women with bothersome LUTS had greater nighttime frequency (2.6 vs. 1.4) and number of incontinence episodes (3.3 vs. 0.4). Abnormal voiding group had higher nocturnal urine production (1,007 ml vs. 654 ml). There were significant correlations between nighttime frequency, number of incontinence episodes, and the storage and incontinence domains of the ICIQ-FLUTS. Bladder capacity significantly increased with increased total urine volumes. CONCLUSIONS: Bothersome LUTS in DM is not associated with increased urine production. Bladder capacity increased with total urine volume. Nocturia and incontinence episodes were significantly associated with bothersome LUTS.

Prevalence and risk factors for bothersome lower urinary tract symptoms in women with diabetes mellitus from hospital-based diabetes clinic.

INTRODUCTION AND HYPOTHESIS: There is limited data on prevalence and risk factors for bothersome lower urinary tract symptoms (LUTS) in women with diabetes mellitus (DM). This study assesses prevalence and risk factors for bothersome LUTS and voiding dysfunction in women with DM. METHODS: Two hundred twenty women participated in this study. Participants completed the King's health questionnaire and the international consultation on incontinence-female lower urinary tract symptom questionnaire. Symptoms prevalence and urinary flow rate were assessed. Logistic regression models for risk factors of bothersome LUTS and voiding dysfunction were constructed. RESULTS: One hundred forty-eight women completed the study. Sixty-one women (41%) had bothersome LUTS. Urgency incontinence, urgency, and nocturia were the most bothersome. Fifty-six (38%) had voiding dysfunction. Neuropathy and glycosylated haemoglobin were independent risk factors for voiding dysfunction. Voiding dysfunction did not affect quality of life in women with DM. CONCLUSIONS: Overactive bladder symptoms are the most bothersome in diabetic women. Neuropathy and glycosylated haemoglobin are risk factors for voiding dysfunction.

Diabetes mellitus and female lower urinary tract symptoms: a review.

Diabetes mellitus (DM) has reached epidemic proportions world wide. Many chronic complications of DM, including neuropathy, retinopathy and nephropathy, have been well studied and although urologic complications have been recognized since 1935, little is known about DM as a pathophysiological risk factor for development of lower urinary tract symptoms (LUTS) in women. Diabetic nephropathy, a life-threatening condition, has received considerable attention in the last few years. Diabetic cystopathy, on the other hand, has received far less attention despite having a significant impact on quality of life, and with significant individual health risks. Initial studies suggested that long standing DM causes paralysis of the detrusor muscle leading to voiding difficulties and this has been the received wisdom regarding diabetic cystopathy for many years. In this review, we discuss what is currently known about lower urinary tract function and urinary incontinence in diabetic females, with a critical analysis of the available evidence and suggest areas for future research.

Symptomatic and quality of life outcomes after site-specific fascial reattachment for pelvic organ prolapse repair.

The aim of this study was to assess symptomatic and quality of life outcome scores following site specific fascial reattachment surgery for pelvic organ prolapse using the validated Prolapse Quality of Life (P-QOL) questionnaires. One hundred and ninety two women underwent surgery for pelvic organ prolapse; ninety four underwent anterior repair (thirty four of them had vaginal hysterectomy), and ninety eight had posterior repair. Patients filled P-QOL questionnaires 24 hours prior to surgery and a postal P-QOL questionnaire six months post operatively. Pre and post operative questionnaires were paired. Quality of life and symptoms scores were calculated using Wilcoxon signed rank test. One hundred and one women returned their questionnaires and were suitable to include in the study. Forty nine underwent anterior repair (fifteen had vaginal hysterectomy) and 52 underwent posterior repair. Quality of life scores showed significant improvement in the anterior and posterior repair groups with the exception of general health in the anterior repair group and general health and prolapse impact in the posterior repair group. Anterior repair significantly improved urinary voiding and storage symptoms. Posterior repair group showed significant improvement in defecatory symptoms. Both groups showed improvement in sexual function and general prolapse symptoms. Prolapse repair with site specific fascial reattachment results in significant improvement in quality of life scores six months after surgery. Anterior repair improves urinary voiding and storage symptoms and posterior repair improves defecatory dysfunction and urinary voiding. Sexual function improves following prolapse repair with site specific fascial reattachment.

How accurate is symptomatic and clinical evaluation of prolapse prior to surgical repair?

The aim of this study is to assess the accuracy of pre-operative evaluation of pelvic organ prolapse. The design is a prospective observational audit set at the gynaecology department, Teaching Hospital, UK. The population is composed of patients undergoing surgery for prolapse. One hundred and four patients admitted for prolapse surgeries were enrolled in the audit. Patients' notes were initially reviewed for adequacy of prolapse assessment in the clinic. Patients were then interviewed by the researchers and assessed using a validated Prolapse Quality of Life (P-QOL) questionnaire. The presence of unrecorded symptoms was noted. Prolapse examination in theatre under anaesthesia was compared to the findings in the clinic and the operation performed compared to the proposed operation. The outcome measures were as follows: (1) number of patients who had accurate prolapse symptom assessment before surgery when comparing clinical records with entries on P-QOL questionnaires; (2) number of patients having symptoms related to their pelvic organ prolapse that were not accurately assessed pre-operatively; and (3) the differences, if any, between pre-operative and intra-operative examination of prolapse. Sixteen patients in our cohort (15%) had adequate assessment of their prolapse pre-operatively. Symptoms that were not adequately assessed in descending order were the impact of prolapse on quality of life (76%), sexual function (75%), bowel function (27%) and lower urinary tract symptoms (12.5%). Thirty one patients (30%) had sexual dysfunction, 24 (23%) had bowel symptoms and 23 patients (22%) had urinary symptoms that were not recorded before surgery. Prolapse physical examination was adequate in 59% of the cases. Examinations in theatre were different from clinic findings in 38 cases (37%); 16 cases (42%) had a greater or lesser degree of prolapse than that described in the notes; and 11 cases (29%) had prolapse in a different compartment in the vagina. A combination of both (i.e. different degree of prolapse and prolapse in a different vaginal compartment) was found in another 11 cases (29%). The operation performed was different from the one proposed in the clinic in 21% of the cases (n=22). Clinical evaluation and examination of patients with vaginal prolapse is often inadequate. Prolapse physical examination in a clinic setting could be different from findings under anaesthesia. This can affect the operation to repair the prolapse. Patients should be counselled about this when listed for surgery.

Prediction and prevention of preeclampsia and IUGR.

Preeclampsia, being one of the leading causes of maternal and perinatal morbidity and mortality, has been the subject of extensive research since its description. Preeclampsia has been called the disease of theories due to the enigma surrounding its exact pathophysiology. Despite the absence of treatment that reverses the disease process once started, screening for preeclampsia and intrauterine growth restriction (IUGR) has been a major clinical and research issue since the disease was first reported. This review evaluates the current evidence for prediction and prevention of preeclampsia and IUGR using clinical tests, maternal serum markers, and uterine artery Doppler screening. In addition, we critically evaluate the evidence regarding the different therapeutic strategies for the prevention of preeclampsia and IUGR and the latest clinical recommendations for their use.

Delayed normalization of uterine artery Doppler waveforms is not a benign phenomenon.

OBJECTIVE: To evaluate the pregnancy outcome in patients with abnormal uterine artery Doppler flow velocity waveforms (FVW's) at 19-21 weeks, which were subsequently normal by 24-26 weeks, and to study the effect of low-dose aspirin on these waveforms. DESIGN: The study group consisted of 49 patients who had abnormal uterine artery flow velocity waveforms (FVW's) at 19-21 weeks. These women were initially commenced on 100 mg slow-release aspirin at 20 weeks, which was discontinued at the follow-up visit, after confirming normal uterine artery Doppler FVW. The control group consisted of 730 patients with normal uterine artery Doppler waveforms at 19-21 weeks. The main outcome measures were: small for gestational age (SGA) <10th centile, pre-eclampsia, placental abruption, and perinatal mortality rate (PMR). RESULTS: When compared with the control group, the study group had an increased risk of placental abruption (2% versus 0.27%, P = 0.05) 95% Confidence Intervals CI = 0.01-0.13), low birth weight (3087 versus 3383 gm, P = 0.0003), SGA <10th centile (32.7% versus 11.9%, P

Prediction of fetal anaemia.

The perinatal outcome of the anaemic fetus has dramatically improved over the last 20 years, as a result of early recognition of the problem and treatment by intrauterine transfusion. Traditionally assessment of the anaemic fetus relied on obstetric history and maternal antibody titre, which proved to be inadequate tests to accurately predict fetal condition. More recently, invasive testing with techniques such as amniocentesis and cordocentesis have allowed a more accurate evaluation of the degree of anaemia, while at the same time enabling transfusion to take place. Such techniques are not without danger, with perinatal loss and fetomaternal haemorrhage being significant risks. The clinical community has therefore sought to find accurate, non-invasive methods for assessing the degree of fetal anaemia, thereby reducing the number of unnecessary invasive procedures, while at the same time providing more precise data on the quantity and timing of the transfusion. Recent publications focusing on the diagnosis and management (including plasmapheresis, immunoglobulins and intrauterine transfusion) of fetal anaemia will be discussed.