Impact of Body Mass Index on Postoperative Urinary Symptoms after Miduretheral Sling Surgery in Female Patients

Objectives@#This study aims to examine the clinical outcomes of women who underwent a midurethral sling surgery for stress urinary incontinence and compare postoperative urinary symptoms among different body mass index (BMI) groups. @*Methods@#A retrospective cohort study on results after midurethral sling surgery according to BMI was conducted at the institution of the current study from January 2010 to December 2019. The study population was classified into three groups according to patients’ BMI (in kg/m2 ) during surgery: normal weight (BMI < 23.0 kg/m2 ), overweight (BMI, 23.0–24.9 kg/m2 ), and obese (BMI ≥ 25.0 kg/m2 ). The primary outcome was the recurrence of urinary symptoms after surgery. The secondary outcomes were operation time, estimated blood loss, length of hospital stay, and postoperative complications. @*Results@#This study included 376 patients (normal weight, 148; overweight, 74; and obese women, 154) who underwent midurethral sling surgery. No significant difference was noted in urinary symptom recurrence after midurethral sling surgery. Of the patients, 6.8% (n = 10), 9.5% (n = 7), and 7.8% (n = 12) were normal weight, overweight, and obese women, respectively (P = 0.775). Moreover, operation time (P = 0.589), blood loss (P = 0.138), and complication rate (P = 0.865) showed no significant difference. @*Conclusions@#Midurethral sling surgery is effective regardless of BMI. Even when midurethral sling surgery was performed as a concomitant surgery, no significant difference in urinary symptom recurrence, operation time, intraoperative blood loss, and complication rate was noted among different BMI groups.

Manchester Operation: An Effective Treatment for Uterine Prolapse Caused by True Cervical Elongation

PURPOSE: Descent of the uterus is a major etiology of uterine prolapse. However, true cervical elongation can cause uterine prolapse without uterine descent. The aim of study was to investigate the clinical outcomes of Manchester operation in patients with uterine prolapse caused by “true cervical elongation,” compared with vaginal hysterectomy (VH). MATERIALS AND METHODS: Medical records of patients who underwent Manchester operation or VH from 2006 to 2015 were reviewed. True cervical elongation was defined on the basis of C point of the Pelvic Organ Prolapse Quantification (POP-Q) system ≥0 and D point ≤−4, as well as estimated cervical length of ≥5 cm. The primary outcome was recurrence of pelvic organ prolapse (POP) evaluated by POP-Q system. The outcomes of two groups were compared after propensity score matching, for age, parity, and preoperative POP-Q stage. RESULTS: During the study period, 23 patients underwent Manchester operation and 374 patients underwent VH. The recurrence rate of POP (p=0.317) and complication rate were not statistically significant different between the two study groups. Manchester operation exhibited shorter operation time than VH (p=0.033). In subgroup analysis (POP-Q stage III), body mass index [odds ratio (OR)=1.74; 95% confidence interval (CI), 1.08–2.81] and not having concurrent anterior colporrhaphy (OR for concurrent anterior colporrhaphy, 0.06; 95% CI, 0.01–0.75) were identified as significant risk factors for recurrence of POP. CONCLUSION: The Manchester operation technique seems to be an effective and safe alternative procedure for the treatment of uterine prolapse caused by true cervical elongation, compared with VH.

In Bae Yoon, an Inventor and Pioneer in Laparoscopic Surgery

No abstract available.

Postoperative urinary symptoms after transobturator tape in normal-weight compared with overweight and obese woman

OBJECTIVES: To examine the clinical outcome of obesity in women who underwent the transobturator tape procedure for stress urinary incontinence and to compare postoperative urinary symptoms after transobturator tape surgery between normal-weight women and overweight and obese women. METHODS: We performed a retrospective cohort study of the risk of postoperative urinary symptoms, including recurrence after transobturator tape surgery, in normal-weight women compared with overweight and obese women at our institution from January 2009 through October 2011. We compared the body mass index (BMI) among the four groups. The primary outcome was the occurrence of postoperative urinary symptoms. RESULTS: Three hundred ten patients who underwent transobturator tape surgery were reviewed. At the 1-year follow-up, 281 women were analyzed: 89 (34%) normal-weight women, 78 (25%) overweight women, 101 (37%) obese 1 women, and 13 (3%) obese 2 women. There was a significant difference in the occurrence of postoperative urinary symptoms. They occurred in 3.4% (n=3) of normal-weight women, 5.1% (n=4) of overweight women, and 12.9% (n=13) of obese 1 women (P=0.038). The most common postoperative urinary symptom was frequent urination (n=14). There was a significant difference in leakage; it occurred in 1.1% (n=1) of normal-weight women, 3.9% (n=3) of overweight women, and 7.9% (n=8) of obese 1 women (P=0.139). Postoperative urinary symptoms were almost four times more likely to occur in obese 1 women than in normal-weight women. CONCLUSION: Transobturator tape surgery seems effective regardless of BMI, but obese women had a higher occurrence of postoperative urinary symptoms than did normal-weight women.

Jessie W. Hirst, a Professor Who Challenged Prejudice towards Western Medicine

No abstract available.

Surgical treatments for vaginal apical prolapse

Pelvic organ prolapse is a common condition, occurring in up to 11% of women in the United States. Often, pelvic organ prolapse recurs after surgery; when it recurs after hysterectomy, it frequently presents as vaginal apical prolapse. There are many different surgical treatments for vaginal apical prolapse; among them, abdominal sacral colpopexy is considered the gold standard. However, recent data reveal that other surgical procedures also result in good outcome. This review discusses the various surgical treatments for vaginal apical prolapse including their risks and benefits.

NGF and HB-EGF: Potential Biomarkers that Reflect the Effects of Fesoterodine in Patients with Overactive Bladder Syndrome

PURPOSE: To determine whether levels of nerve growth factor (NGF) and heparin-binding epidermal growth factor-like growth factor (HB-EGF) can be used to objectively assess overactive bladder syndrome (OAB) treatment outcome and to evaluate the effects of fixed-dose fesoterodine on OAB symptoms. MATERIALS AND METHODS: This study included 124 participants (62 patients with OAB and 62 controls) in Severance Hospital between 2010 and 2012. In patients with OAB, 4 mg fesoterodine was administered once daily. Repeated evaluations of putative biomarker levels, urine creatinine (Cr) levels, and questionnaire responses, including the Overactive Bladder Symptom Score (OABSS) and the Overactive Bladder Questionnaire (OAB q), were performed from baseline to 16 weeks. RESULTS: Urinary levels of NGF/Cr (OAB: 1.13+/-0.9 pg/mg; control: 0.5+/-0.29 pg/mg) and HB-EGF/Cr (OAB: 8.73+/-6.55 pg/mg; control: 4.45+/-2.93 pg/mg) were significantly higher in subjects with OAB than in controls (p<0.001). After 16 weeks of fixed-dose fesoterodine treatment, urinary NGF/Cr levels (baseline: 1.13+/-0.08 pg/mg; 16 weeks: 0.60+/-0.4 pg/mg; p=0.02) and HB-EGF/Cr levels significantly decreased (baseline: 8.73+/-6.55 pg/mg; 16 weeks: 4.72+/-2.69 pg/mg; p=0.03, respectively). Both the OABSS and OAB q scores improved (p<0.001). However, there were no a statistically significant correlations between these urinary markers and symptomatic scores. CONCLUSION: Urinary levels of NGF and HB-EGF may be potential biomarkers for evaluating outcome of OAB treatment. Fixed-dose fesoterodine improved OAB symptoms. Future studies are needed to further examine the significance of urinary NGF and HB-EGF levels as therapeutic markers for OAB.

Changes in Sexual Function and Comparison of Questionnaires Following Surgery for Pelvic Organ Prolapse

PURPOSE: The aim of this study was to evaluate the effect of surgical repair of pelvic organ prolapse on female sexual function and to assess correlations between the two using two current standardized questionnaires. MATERIALS AND METHODS: From October 2009 to September 2010, 143 patients with posterior compartment or combined vaginal prolapse were included. We assessed surgical outcomes according to anatomical change in the vagina and results of the Female Sexual Function Index (FSFI) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function questionnaire (PISQ-12) both pre- and postoperatively. RESULTS: Among the 143 preoperative patients, 99 and 84 patients responded to the PISQ-12 and FSFI, respectively. The mean PISQ-12 score increased after surgery (p<0.001). Specifically, postoperative scores for questions 8 and 12 were higher than their respective preoperative scores (p<0.001). Postoperatively, mean FSFI score changed only slightly (p=0.76), and only the score for the satisfaction domain was improved (p=0.023). In regards to vaginal anatomy, vaginal length was significantly greater postoperatively (6.99+/-0.18 vs. 7.56+/-1.08, p<0.001), and postoperative vaginal caliber was narrowed to a two-finger width. CONCLUSION: In this study, surgery for pelvic organ prolapse was shown to affect female sexual function. Moreover, menopause was associated with a change in postoperative sexual function.

Comparison of midurethral sling outcomes with and without concomitant prolapse repair

OBJECTIVE: We compared the outcomes of the midurethral sling (MUS) with and without concomitant prolapse repair. METHODS: We retrospectively reviewed the outcomes of 203 women who underwent MUS at Severance Hospital from January 2009 to April 2012 with and without concomitant prolapse repair. Patients completed the urogenital distress inventory questionnaire preoperatively and postoperatively. The outcomes were assessed by using validated questionnaires and reviewing medical records. McNemar's test, t-test, and multiple logistic regression were used for analysis. RESULTS: We noted that women who underwent MUS alone were more likely to experience urinary frequency (12% vs. 25%, P = 0.045), urgency (6% vs. 24%, P < 0.001), and bladder emptying difficulty (2% vs. 10%, P = 0.029) compared to those who underwent concomitant repair. Women who only MUS were more likely to experience discomfort in the lower abdominal or genital region compared to those who than those who underwent concomitant repair; however, the difference was not significant (5% vs. 11%, P = 0.181). In the MUS only group, maximal cystometric capacity (MCC) was a significant parameter of preoperative and postoperative urinary frequency (P = 0.042; odds ratio, 0.994; P = 0.020; odds ratio, 0.993), whereas the Valsalva leak point pressure (VLPP) was a significant factor of postoperative bladder emptying difficulty (P = 0.047; odds ratio, 0.970). CONCLUSION: The outcomes did not differ between patients who underwent MUS alone and those with concomitant repair. In the MUS only group, MCC and VLPP were significant urodynamics study parameters related to urinary outcome.

The significance and factors related to bladder outlet obstruction in pelvic floor dysfunction in preoperative urodynamic studies: A retrospective cohort study

OBJECTIVE: To demonstrate the significance of bladder outlet obstruction (BOO) in preoperative urodynamic studies (UDS) in women who have been diagnosed with pelvic floor dysfunction including pelvic organ prolapsed (POP) and stress urinary incontinence (SUI). METHODS: The medical records of 150 patients with pelvic floor dysfunction who underwent preoperative UDS at Yonsei University Health System from 2006 to 2012 were reviewed. Under the criteria of BOO, as a maximal flow rate in free-flow study (Qmax) less than 12 mL/sec and a detrusor pressure at Qmax in pressure-flow study (PdetQmax) higher than 20 cmH2O in UDS, they were divided into two groups: a group of 50 patients with BOO and a group of 100 patients without BOO. Comparisons were made between the patients with and without BOO in preoperative UDS. RESULTS: In the POP-with-SUI group, 25 patients with BOO had lower mean Qmax (10.0 vs. 25.4 mL/sec, P < 0.001), higher PdetQmax (49.6 vs. 21.5 cmH2O, P < 0.001), lower maximum cystometric capacity (422.7 vs. 454.0 mL, P = 0.007), and higher postvoidal residual volume (44.3 vs. 21.1 mL, P = 0.021) than the patients without BOO. In the SUI-only group, the mean Qmax was significantly lower in the 25 patients with BOO (9.4 vs. 25.4 mL/sec, P < 0.001). The mean PdetQmax was significantly higher with BOO (39.6 vs. 25.4 cmH2O, P = 0.004). In the univariate analyses, menopause, maximum cystometric capacity, and cystoscopic bladder trabeculation were associated with BOO. CONCLUSION: In the univariate analysis, menopause, MCC and cystoscopic bladder trabeculation were associated with BOO. In the multivariate model, however, no significant association with BOO was found.

Translation and linguistic validation of Korean version of short form of pelvic floor distress inventory-20, pelvic floor impact questionnaire-7

The short forms of pelvic floor distress inventory (PFDI) and pelvic floor impact questionnaire (PFIQ) are useful disease specific questionnaires evaluating symptoms, quality of life for pelvic floor disorders. The purpose is to develop linguistic validation of the PFDI-20 and PFIQ-7 questionnaires. Three types of Korean version of questionnaires have been used in four locations of University Hospitals in Korea. Each version of questionnaires was developed by forward translation and back-translation by bilingual translators and was verified by the patients with pelvic floor disorder and healthy persons. For harmonization of 3 types of questionnaires, four authors reviewed, discussed all discrepancies, incorporated and produced a new version. The multi-step processes of translation and linguistic validation of the Korean version of PFDI-20 and PFIQ-7 questionnaire were completed. Further process of validation of Korean version of these questionnaires is required.

Outcome of mid urethral sling procedures according to age / 대한산부인과학회지

OBJECTIVE: To compare the morbidity and treatment outcomes of mid urethral sling procedures for older women and younger women, and to evaluate whether mid urethral sling procedures can be effectively used in older women. METHODS: This retrospective study included 381 patients who underwent mid urethral sling procedures, tension free vaginal tape (TVT) or transobturator tape (TOT) for urodynamic stress urinary incontinence from March 2000 to June 2006. The patients were divided into two age groups: younger women (30~69 years old) and older women (70~90 years old). Patients were followed up with clinic visits at 1, 3, 6, 12 months, and every year thereafter. RESULTS: 341 (89.7%) were in younger women, 40 (10.5%) in older women. The rates of intra and perioperative complications including hemoglobin difference, urinary retention, UTI, mesh erosion, wound infection were no significant differences between the groups. De novo urgency was more common in older women than younger women (15.9% vs. 30.0%: P0.05) showed no significant differences. CONCLUSION: Our data showed subjective cure rates without any significant increase in intraoperative complications in older women. Postoperative complications of de novo urgency were more common in the older women. Hospital stay and recovery period were short, making TVT and TOT a suitable procedure for all ages.

Polymorphism of a COLIA1 Gene Sp1 Binding Site in Korean Women with Pelvic Organ Prolapse

PURPOSE: To evaluate the possible influence of G-->T substitution at the Sp1-binding site of the COLIA1 gene on the risk of pelvic organ prolapse (POP). MATERIALS AND METHODS: The study group consisted of 15 women with advanced stage POP. Fifteen control subjects with uterine myomas among the postmenopausal women were matched for age and parity. DNA was obtained from peripheral blood leukocytes. The fragments of the first intron of the COLIA1 gene were amplified by real time polymerase chain reaction. The polymorphism was identified using LightCycler Technology with hybridization probes. Sequencing reactions were performed on each template using commercial primer. RESULTS: Two groups had no significant difference in medical history, surgical, and smoking history. The homozygous peaks in two groups were noted at 57degrees C on melting curve analysis. Sequencing reactions confirmed the G/G alleles in the 30 specimens tested. We could not find any polymorphism at the Sp1-binding site in COLIA1 gene with advanced stage POP. Statistical significance was considered to be p < .05. CONCLUSION: The polymorphism of the Sp1-binding site in the COLIA1 gene did not contribute to the development of POP in Korea.

A Long-Term Treatment Outcome of Abdominal Sacrocolpopexy

PURPOSE: The aim of this study was to evaluate the long-term treatment outcome and major complication rates of abdominal sacrocolpopexy (ASC). MATERIALS AND METHODS: This retrospective study included 57 Korean women who underwent ASC with mesh for symptomatic uterine or vault prolapse and attended follow-up visits for at least 5 years. Forty-seven women with urodynamic stress incontinence concomitantly received a modified Burch colposuspension. The long-term anatomical and functional outcomes and complication rates were assessed. RESULTS: The median follow-up was 66 months (range 60-108). Overall anatomical success rates (no recurrence of any prolapse > or = stage II according to the pelvic organ prolapse-quantification system) were 86.0%. Urinary urgency and voiding dysfunction were significantly improved after surgery, however, recurrent stress urinary incontinence developed in 44.7% (21/47) of cases and half of them developed within 1-3 months post-op. Bowel function (constipation and fecal incontinence) and sexual function (sexual activity and dyspareunia) did not significantly change after surgery. Major complication requiring reoperation or intensive care developed in 12 (21.0%) cases. CONCLUSIONS: ASC provides durable pelvic support, however, it may be ineffective for alleviating pelvic floor dysfunction except for urinary urgency and voiding dysfunction, and it contains major complication risk that cannot be overlooked.

Comparison between tension-free vaginal tape (TVT) and transobturator tape (TOT) with concomitant surgery for pelvic organ prolapse / 대한산부인과학회지

OBJECTIVE: To compare tension-free vaginal tape (TVT) and transobturator tape (TOT) for surgical treatment of stress urinary incontinence (SUI) associated with pelvic organ prolapse (POP). METHODS: Two hundred seventy eight consecutive patients affected by SUI associated with POP more than stage II were included in this retrospective study. Cure rate and postoperative complications such as hemoglobin difference between preoperative and postoperative period, vaginal hematoma, bladder and bowel injury, vaginal mesh erosion, urinary retention, de novo urgency, urinary tract infection were compared. Student's t-test and chi square test were used for statistical analysis. A P-value below 0.05 was considered statistically significant. RESULTS: The number of patients underwent TVT was 145 and TOT was 133. All patients were followed up for more than 12 months. The general characteristics of patients showed no significant difference between the two groups. There was no difference between two groups in cure rate. However, hemoglobin difference (TVT, 2.91+/-0.93 g/dL; TOT, 1.53+/-0.77 g/dL; P=0.04) was higher in TVT group than TOT group and urinary retention within 1 month (TVT, 35.17%; TOT, 21.05; P=0.02), and urinary tract infection (TVT, 11.72%; TOT, 3.75%; P=0.02) more frequently appeared in TVT group than TOT group. Other postoperative complications such as vaginal hematoma (TVT, 6.89%; TOT, 6.76%; P=0.86), bowel injury (TVT, 0%; TOT, 1.5%; P=0.64), vaginal mesh erosion (TVT, 7.58%; TOT, 4.51%; P=0.47), urinary retention after 1 month (TVT, 2.76%; TOT, 3.00%; P=0.35), de novo urgency (TVT 7.58%, TOT: 6.01%, P=0.48) were not different between two groups. CONCLUSION: Both procedures appear to be equally effective in the surgical treatment of SUI associated with POP. However, TOT seems to be a more safe procedure in postoperative complications.

The comparison of treatment outcome of Transobturator tape and Tension-free vaginal tape obturator as the treatment of stress urinary incontinence / 대한산부인과학회지

OBJECTIVE: The aim of this study was to compare the treatment outcome of Transobturator tape (TOT) and Tension-free vaginal tape obturator (TVT-O) as the treatment of stress urinary incontinence (SUI). METHODS: This prospective study included 332 women who were urodynamically diagnosed as stress urinary incontinence from April 2005 to January 2007. Patients showing pelvic organ prolapse higher than stage II by the Pelvic Organ Prolapse Quantification system or patients with detrusor overactivity were excluded from this study. The patients were alternatively selected to undergo TOT (n=192) or TVT-O (n=140) procedure and followed up at 1, 3, 6, 12 months postoperatively to compare the treatment outcome. Three hundred and six of them were available at 1 year follow up, 185 had the TOT operation, 121 the TVT-O procedure. The student t-test, chi square test were used for statistical analysis. RESULTS: There were no statistically significant differences in general characteristics between two groups. No differences were found between 2 groups in the cure rates, postoperative complication such as voiding difficulty, De novo urgency, urinary tract infection, vaginal mesh erosion except groin pain. The groin pain rate of two groups showed significant difference. (TOT; 3.78% vs TVT-O; 9.92%, P=0.030). CONCLUSIONS: This study indicates that the TOT and TVT-O procedures are safe and effective treatments for female stress urinary incontinence. However, TVT-O shows high incidence of groin pain rate and it may be related to nerve irritation by inflammation of surrounding tissue around the pudendal and obturator nerve, according to anatomical differences of the tape position in two procedures.

Hormone-Dependent Aging Problems in Women

One of the major social issues nowadays is the aging society. Korea is already an aging society, and 63 cities and districts are ultra-aged societies where the rate of people older than 65 yr exceeds 20%. Among them, more than 67% are women. These statistics reveal the importance of healthcare for older women. Disease and disability of older women are very closely related to the loss of female sex hormones after menopause. Major hormone-dependent aging problems in women such as osteoporosis, Alzheimer's disease (AD), urinary incontinence, and coronary atherosclerosis were surveyed in this review, and the key role of hormones in those diseases and hormone replacement therapy (HRT) were summarized. We expect that this review would provide some understanding of factors that must be considered to give optimal care to older women for healthy lives.

Anatomy of female pelvic floor for clinician: Concentrate upon the bladder, urethra and support of pelvis / 대한산부인과학회지

The female pelvic floor is an understudied region of the body in the aspect of physiologic and biomechanical perspective. The anatomic structures in the female that prevent incontinence and pelvic organ prolapse are important field to support sphincteric system and pelvic floor against increased daily abdominal activities. In the urethra, the action of the vesical neck and urethral sphincteric mechanisms maintains urethral closure. A supportive hammock under the urethra and vesical neck provides a firm backstop against which the urethra is compressed during increases in abdominal pressure. This supporting layer consists of the anterior vaginal wall and connective tissue that attaches it to the pelvic bones through the pubovaginal portion of the levator ani muscle, and the uterosacral and cardinal ligaments comprising the tendinous arch of the pelvic fascia. The endopelvic fascia plays an important role in pelvic floor supporting system and three support axes maintain the central portion of pelvic organs. No one structure is solely responsible for the proper functioning of this region.

Current opinion of the treatment of female voiding dysfunction / 대한산부인과학회지

The incidence of female voiding dysfunction is increasing nowadays and is getting more of attention with the aging society. Various treatment methods have been applied to treat stress urinary incontinence, overactive bladder, and voiding difficulty. However, surgery for stress urinary incontinence, medication and bladder training for overactive bladder, and intermittent self-catheterization to treat voiding difficulty remain as the mainstay of management. These standard methods cannot be applied to all patients, and does not always lead to successful outcomes, suggesting that we should acquire the correct knowledge in possible ways to treat these patients. In this review, we will focus on the treatment effects of conservative, medical, and surgical treatment which are currently available, based on the evidence of literatures, and address the promising therapeutic modalities such as new minimally invasive surgical procedures for stress urinary incontinence, botulinum toxin A injection, electrical stimulation (sacral neuromodulation, posterior tibial nerve stimulation), radiofrequency therapy, new pharmacologic agents for overactive bladder and voiding difficulty.

Current opinion of the treatment of female voiding dysfunction / 대한산부인과학회지

The incidence of female voiding dysfunction is increasing nowadays and is getting more of attention with the aging society. Various treatment methods have been applied to treat stress urinary incontinence, overactive bladder, and voiding difficulty. However, surgery for stress urinary incontinence, medication and bladder training for overactive bladder, and intermittent self-catheterization to treat voiding difficulty remain as the mainstay of management. These standard methods cannot be applied to all patients, and does not always lead to successful outcomes, suggesting that we should acquire the correct knowledge in possible ways to treat these patients. In this review, we will focus on the treatment effects of conservative, medical, and surgical treatment which are currently available, based on the evidence of literatures, and address the promising therapeutic modalities such as new minimally invasive surgical procedures for stress urinary incontinence, botulinum toxin A injection, electrical stimulation (sacral neuromodulation, posterior tibial nerve stimulation), radiofrequency therapy, new pharmacologic agents for overactive bladder and voiding difficulty.