Further developments of pubourethral ligament surgery for stress urinary incontinence.

Midurethral slings (MUS) have revolutionized the treatment of stress urinary incontinence (SUI). MUS operations work by creating a collagenous pubourethral ligament (PUL). Since 1996, more than 10 million operations have been performed worldwide. Early complications with the MUS included bowel perforations, massive retropubic hemorrhages, nerve injuries, even death. Though the invention of the transobturator tape (TOT) operation, and later, minislings, has eliminated many such complications, the most frequent complication, post-operative urinary retention, remains. MUS operations are unavailable in many countries because of expense. Low-cost surgical options discussed include the tension-free artisan minisling which uses a 10 cm × 1 cm tape inserted as a "U" below the urethra; 91% cure was achieved at 5.7 years in a study of 90 women, though it was accompanied by a 4.2% erosion rate. The more recent urethral ligament plication (ULP) is based on transperineal ultrasound studies which showed that the main cause of the SUI was elongation of weak PULs. This allowed the posterior pelvic muscles to open out the posterior urethral wall to cause SUI. Basic science collagen studies indicated that suturing PULs with No. 2 wide-bore polyester sutures would provide sufficient collagen to repair weakened PULs. Cure of SUI, when it occurred, was immediate. Reference to the original experimental animal studies indicated that collagen 1, the key structural support of PUL, had formed by 3 months. This is an optimistic sign for longer term cure, substantiated by very little deterioration after 3 months over a 12-month period in the first surgical trial (unpublished data). In conclusion, the ULP operation can be performed under local anesthesia/sedation. If it fulfils its promise for longer-term cure, SUI cure will be available for hundreds of millions of women in underdeveloped countries for a few dollars per case.

Wide-bore polyester sutures may create sufficient collagen for cure of prolapse/incontinence: a work in progress.

The main thrust of the Integral Theory Paradigm (ITP) is that inadequate ligament collagen causes pelvic organ prolapses (POP) and pelvic symptoms, a concept validated by multiple publications which cured POP and bladder/bowel/pain dysfunctions by collagen-creating slings. Sling surgery for surgical cure of these conditions was eliminated in the United States, Europe and other regulatory jurisdictions by banning all mesh products (including tapes) in about 2017. The aim of this work was to inform of the progress of a highly promising alternative method for collage creation for ligament repair: wide-bore polyester sutures accurately applied to weak ligaments. The scientific rationale for the wide-bore polyester plication method was a revisit and analysis of prior Instron testing data from a rejected polyester aortic graft from a doctoral thesis. The analysis indicated that the collagen produced by No. 2 polyester sutures would be sufficient to repair weakened pelvic ligaments. The surgical methodology consisted of application of wide-bore No. 2 or No. 3 polyester sutures to existing vaginal surgical techniques such as cardinal/uterosacral ligament (CL/USL) repair in the Fothergill operation, deep transversus perinei (DTP) ligamentous supports of the perineal body (PB) and uniquely, pubourethral ligament (PUL) repair for stress urinary incontinence (SUI). No vaginal tissue was excised. These operations are now being performed in several centres around the world. Because of this, the results detailed below are indicative only, and necessarily incomplete, as they are only from these units. Twelve month data (n=35) for SUI cure (83%) following PUL repair by the urethral ligament plication (ULP) operation has been submitted for publication; POP quantification (POPQ) points Ba, C, Bp, D were significantly improved at 6 weeks postoperative review following repair of CLs (cystocele) and USLs (uterine/apical prolapse) (n=56): deep transverse perinei ligament repair (descending perineal syndrome "DPS") (n=4) were cured at 6-12 months review. Though numbers are few, in the context of DPS being considered incurable, these numbers are significant. Except for the ULP operation, the techniques for cystocele, uterine prolapse, perineocele were essentially evolved versions of the Fothergill and standard PB repairs without any vaginal or ligament excisions. Though promising, more extensive and longer-term results are clearly required before this wide-bore polyester ligament repair method can become mainstream.

Tension-free artisan tape: a low-cost option for cure of pelvic organ prolapse and stress incontinence.

The Lancet PROSPECT Trial has shown that vaginal repair has dismal cure rates of some 20% at 12 months. Meanwhile 10-year data from collagen creating ligament repair methods (implanted mini-sling tapes), with no vaginal excision, report very high, long-term cure rates. The reason for conserving the vagina, is that the vagina's main function is to transmit the muscle forces for external urethral closure or opening. Ligaments provide the main structural support for the organs, much like a suspension bridge. Collagen is the key structural component of the ligaments which structurally support the organs. However, collagen breaks down after the menopause and is excreted as hydroxyproline. If sufficient collagen breaks down, the ligaments weaken, and this explains the 80% failure rates for native ligament in the Lancet PROSPECT Trial. Whereas satisfactory results for pelvic organ prolapse (POP) and symptoms have been obtained with native ligament repair in premenopausal women, it has been shown that collagen-creating ligament repair method, for example, precisely inserted tapes, is required in older women. Tension-free" artisan tapes work in the same way as commercial tape kits which have been used to cure stress urinary incontinence (SUI) and POP. The "tension-free" artisan tape results for POP at three years were encouraging, but were applied only in a small number of cases. Very recently, long-term (5.7 years) tension-free artisan tape data has become available from artisan SUI surgery. Results from 93 women using an artisan transobturator tape (TOT) achieved a cure rate of 91.3% at a mean of 5.7 years postoperatively. The only significant complication was a 4.3% erosion rate. The implications are that tension-free artisan tape for POP is also likely to be long-lasting. Another implication is the cost, which, for each tape, is a few Euros. The low cost allows the artisan method to be applied even in the poorest nations.

A Randomised Trial on the Effects of the Addition of Uterosacral Ligament Plication to Pectopexy Operation on Anatomical Restoration and Female Sexual Functions.

INTRODUCTION AND HYPOTHESIS: The objective was to determine whether the addition of uterosacral ligament plication to pectopexy for pelvic organ prolapse increases anatomical improvement and female sexual functioning. METHODS: This is a prospective randomised study. Forty patients who underwent laparoscopic pectopexy (LP) and laparoscopic pectopexy with uterosacral ligament plication (LPUSL) were included in the study. A total of 38 patients were evaluated in the study. Patients were assessed by the Pelvic Organ Prolapse Quantification (POP-Q) system and the patients who had symptomatic apical prolapse POP-Q ≥ II were included in the study. Patients were evaluated preoperatively and postoperatively at the 3rd, 6th and 12th month, with respect to anatomical changes as well as sexual function. RESULTS: A statistically significant difference was found when the preoperative C points was compared with the C points postoperatively, at 3rd, 6th and 12th months in both the LP and LPUSL groups (p < 0.001). Additionally, there were statistically significant difference between the LP and LPUSL groups in terms of C and Aa points at the 6th and 12th postoperative months in favour of the LPUSL group (p = 0.007, p = 0.005 respectively). There was also a statistically significant difference when Ba points were compared between the two groups at the 12th postoperative month, in favour of the LPUSL group (p = 0.002). There were no statistically significant differences between the groups with respect to the variables of the Female Sexual Function Index. Additionally, all parameters were significantly better in both groups at the 3rd and 12th months than the preoperative values in post hoc analysis; only desire also had a significant improvement between the 3rd and 12th months in the LPUSL group in post hoc analysis. CONCLUSION: Pectopexy operation seems to be a successful surgical approach as an alternative to sacrocolpopexy. The addition of uterosacral ligament plication to pectopexy operation improves the anatomical restoration more drastically than with LP on its own. Moreover, either LP or LPUSL has improved the majority of sexual function indices.

Anatomical and symptomatic mid-term outcomes of patients with isolated anterior compartment defect repair or stress urinary incontinence : Anatomical and symptomatic outcomes of anterior compartment repair or SUI.

BACKGROUND: An evaluation of preoperative and postoperative 12th month Pelvic Organ Prolapse Quantification (POP-Q) and Lower Urinary Tract Symptoms (LUTS) changes in patients operated for the diagnosis of isolated anterior compartment defect (ACD) or Stress Urinary Incontinence (SUI). METHOD: Patients who were diagnosed with isolated ACD or SUI were retrospectively analyzed at urogynecology unit of our tertiary referral center. All pelvic examinations were performed by the same experienced urogynecologist. Pre-operative and post-operative 12th month POP-Q scores and the responses to a detailed LUTS questionnaire in the unit were assessed. RESULTS: Of the 90 patients with isolated ACD or SUI, midurethral sling with mini-sling and retropubic transobturator tape methods was applied in 24, iliococcygeal fixation in 28, trapezoid repair in 9 patients, anterior bridge operation in 14, and plication of pubocervicovaginal fascia to the cervical ring in 15. We compared the POP-Q score and pre and post-operative 12th month LUTS. Between pre and post-operative 12th month, there was a statistically significant difference at Aa and Ba points (p < 0.00, 0.001). Comparative LUTS questionnaire showed statistically significant differences in stress urinary incontinence, frequency, urgency, abnormal emptying, nocturia, pelvic pain (p: <0.001, p < 0.001, p: <0.001, p:0.001, p:<0.001, p:0.003, respectively). CONCLUSION: Anatomical and symptomatic recovery is achieved with appropriate surgical intervention in women with isolated ACD or SUI. When LUTS were evaluated in terms of symptomatic recovery, they were found to be related not only to symptoms involving the anterior compartment, but also to symptoms involving other compartments.

Long-term efficacy of the single-incision mini-sling procedure using surgeon-tailored mesh.

OBJECTIVES: To evaluate the long-term efficacy of a surgeon-tailored single-incision mini-sling procedure (SIMS) for the surgical treatment of stress urinary incontinence (SUI) in terms of objective cure rates, quality of life, and cost-effectiveness. STUDY DESIGN: This retrospective study included 93 women with pure SUI who underwent surgeon-tailored SIMS. All patients were evaluated with a stress cough test and quality of life questionnaire (Incontinence Impact Questionnaire [IIQ-7]) at 1 month, 6 months, 1 year, and last follow-up visit (4-7 years). Early and late (after 1 month) complication rates and the reoperation rate were also evaluated. RESULTS: Mean operative time and follow-up duration were 12 ± 2.5 min and 5.7 years (4-7 years), respectively. Objective cure rates determined by the stress cough test were 83.8%, 94.6%, 93.5%, and 91.3% at 1 month, 6 months, 1 year, and last follow-up, respectively. IIQ-7 scores improved at every visit compared to the preoperative value. There were no cases of hematuria, bladder perforation, or major bleeding requires a blood transfusion. CONCLUSION: Our results suggest that the surgeon-tailored SIMS procedure has high efficacy and low complication rates and offers a practical and inexpensive alternative to commercial high-cost SIMS systems.

Anatomical and symptomatic outcomes in patients with Le Fort colpocleisis with or without hysterectomy.

BACKGROUND: We aimed to evaluate the short-term anatomical and clinical outcomes of elderly patients who underwent the Le Fort colpocleisis operation due to pelvic organ prolapse (POP) in our clinic. METHODS: The medical records of fifty-nine sexually inactive females, with stage 2 or higher vaginal or uterine prolapse who underwent Le Fort colpocleisis operations were prospectively analysed. Preoperative and 12th month postoperative data were recorded. Lower urinary tract symptoms (LUTS) was also evaluated preoperatively and 12 months postoperatively in all patients. Anatomical success was determined as no prolapse of any POP-Q point at or below 1 cm above vaginal introitus. RESULTS: A total of 59 patients were included in this study. The average age of the patients was 71.67 ± 7.01 (years). The mean BMI was 27.1 ± 9.52 kg/m2. POP-Q point, C (6.70 ± 2.44 vs. - 2.66 ± 1.21) measurements were significantly deeper, as well as Gh (4.83 ± 0.94 vs. 4.26 ± 0.94) and TVL (3.51 ± 1.24 vs. 8.93 ± 1.73) measurements were significantly higher after surgery than during the preoperative period (p < 0.01, p < 0.01, p < 0.01, respectively). There were no cases of recurrence. The evaluation of LUTS at the 12-months postoperative follow-up revealed significant differences for SUI, urinary frequency, nocturia, and pelvic pain symptoms (p = 0.007, p < 0.001, p = 0.01, p < 0.001, respectively). CONCLUSIONS: Le Fort colpocleisis is a simple and effective procedure that provides successful anatomical and clinical outcomes in sexually inactive and elderly women with POP. However, the long-term results of this procedure need further investigation.

Knowledge, Fear, and Anxiety Levels Among Pregnant Women During the COVID-19 Pandemic: A Cross-Sectional Study.

This study aimed to evaluate pregnant women's knowledge, fear, and anxiety levels during the coronavirus outbreak. This cross-sectional study was conducted on 170 pregnant women between May 20 and July 10, 2020. Data collection form for demographics and obstetric details, questionnaire on knowledge, attitudes, and practice toward COVID-19, and State-Trait Anxiety Inventory-I were used. The vast majority of pregnant women were afraid of being infected with the COVID-19 and causing mother-to-baby transmission. A positive correlation was found between fear of coronavirus transmission and the level of anxiety (p < .05). Risk perceptions regarding COVID-19 have affected the anxiety and knowledge levels of pregnant women. Based on the findings, knowledge levels, concerns, and fears about the risk of COVID-19 exposure have implications on the anxiety levels of pregnant women. Pregnant women experienced high stress and anxiety levels due to increased risk of COVID-19 transmission during face-to-face antenatal visits.

Can the application of a temporary uterine tourniquet during an abdominal myomectomy reduce bleeding?

Objective: Uterine fibroids are common, benign uterine tumours. The three most common surgical treatment approaches for uterine fibroids are laparoscopic, robotic and abdominal myomectomies. Bleeding is a risk with all three approaches. The present study compared post-operative and pregnancy outcomes in patients with bilateral uterine artery occlusion who underwent an abdominal myomectomy, with or without a temporary uterine tourniquet. Material and Methods: This retrospective study included patients with intra-mural fibroids (≥5 cm) who underwent an abdominal myomectomy. The patients were divided into two groups according to the use or non-use of a temporary uterine tourniquet. Post-operative and pregnancy outcomes in the tourniquet use and non-use groups were compared. The association of the number of uterine fibroids removed (≤3 vs >3) with laboratory parameters was also evaluated. Results: A total of 84 patients were included, divided into use (n=36) and non-use (n=48) of the temporary tourniquet. There was a statistically significant difference between the groups with >3 myomas removed and with a uterine tourniquet applied and not applied in terms of reduction in hemoglobin and hematocrit, transfusion amounts, operation times and lengths of hospitalization in favour of the uterine tourniquet use group (p=0.019, p=0.023, p=0.012, p=0.044 and p=0.036, respectively). Bilateral uterine arterial occlusion using a temporary uterine tourniquet had no negative effects on pregnancy outcomes. Conclusion: A temporary uterine tourniquet may be an effective method for reducing the amount of perioperative bleeding in patients with multiple, large-sized myomas located close to vascular structures.

Searching for radiologic and histologic evidence on live vaginal tissue: Does the G-spot exist?

OBJECTIVE: There is a growing debate on the existence of the G-spot. G-spot amplification by various surgical interventions has become mainstream for esthetic vaginal surgery despite a lack of conclusive proof of the G-spot. The aim of this study was to search for histologic evidence in regions of so-called hyperintense focus (HF) (considered as the G-spot) using magnetic resonance imaging (MRI) mapping and biopsied tissues. MATERIALS AND METHODS: Fifteen patients who had grade 2 or higher anterior compartment defects were enrolled in the study. All patients were subjected to MRI. When a HF was seen, its localization, dimensions, and distances to adjacent structures were measured in images. Dissections in the anterior vaginal wall were performed in accordance with the measurements derived from MRI and tissue measuring 0.5x0.5 cm was biopsied from the determined HF. RESULTS: An HF was determined in MRI of three (20%) patients. However, no significant neurovascular tissue density was observed histologically in any of the biopsy specimens obtained from the surgical dissections under the guidance of MRI mapping. CONCLUSION: Our findings denote that there is no G-spot in the anterior vaginal wall.

SMAD2, SMAD3 and TGF-ß GENE expressions in women suffering from urge urinary incontinence and pelvic organ prolapse.

We evaluated the changes in the levels of TGF-ß and SMAD gene and protein expression in the uterosacral ligament (USL) of patients with concomitant pelvic organ prolapse (POP) and urgency urinary incontinence (UUI) to illuminate the pathophysiology of UUI. The TGF-ß pathway is involved in collagen synthesis and degradation. The Transforming Growth Family-ß (TGF-ß) superfamily has essential intracellular signaling components, such as newly identified SMAD family members. We evaluated the changes in the levels of TGF-ß and SMAD gene and protein expression in the USL of patients with concomitant pelvic organ prolapse (POP) and UUI. This study included 10 patients who had been diagnosed with POP and UUI in the study group and 14 asymptomatic women without complaints of POP and UUI in the control group. Biopsy samples were collected from bilateral USL tissues during vaginal or abdominal hysterectomy. Total RNA was extracted from USL tissue and analyzed by qPCR. The protein expression levels were also analyzed with ELISA. In UUI patients, SMAD3 and TGF-ß1 gene expression levels significantly decreased compared to the control patients (p = 0.008 and p = 0.006, respectively). SMAD2 mRNA levels did not differ between the study and control groups (p = 0.139). No differences was found in the levels of SMAD2, SMAD3, and TGF-ß1 protein expression between the two groups. The reduction in the gene and protein expression levels of SMAD3 and TGF-ß1 in women with UUI and lax uterosacral ligaments may indicate a causal link.Clinical trial registration: NCT04525105.

Reliability and validity of Five Times Sit to Stand Test in pregnancy-related pelvic girdle pain.

BACKGROUND: Pelvic girdle pain (PGP) is a common musculoskeletal disorder during pregnancy, and functional mobility evaluation is very important in reflecting the treatment effects. OBJECTIVES: To investigate reliability and validity of Five Times Sit-to-Stand (5TSS) test in pregnant women with and without PGP. DESIGN: A cross-sectional observational study. METHODS: One hundred sixty-seven women in the second or third trimester of pregnancy participated in two assessments one week apart. The 5TSS and Timed Up & Go (TUG) tests were used to assess functional mobility, in a randomized sequence, by two independent raters. Time to complete the tests were recorded. Perceived pain and difficulty during functional mobility tests were marked on two Visual Analogue Scales. Following tests of functional mobility, seven clinical tests were used to classify the subjects as with or without PGP. RESULTS: The 25% of subjects had PGP. Inter-rater reliability of 5TSS was excellent for subjects with and without PGP (ICC = 0.999, 95% CI = 0.999-1.000; ICC = 0.999, 95% CI = 0.999-0.999, respectively). Test-retest reliability of 5TSS was also very high for subjects with and without PGP (ICC = 0.986, 95% CI = 0.959-0.995; ICC = 0.828, 95% CI = 0.632-0.920, respectively). The 5TSS scores were positively correlated with TUG scores (r = 0.420, p = 0.006 and r = 0.404, p = 0.000, respectively). The subjects reported higher pain (95% CI = 0.322-0.824) and difficulty (95%Cl = 0.500-1.042) during 5TSS than the TUG test. CONCLUSIONS: The 5TSS test is a reliable and valid functional mobility outcome measure in pregnant women with and without PGP. Further psychometric properties of the measure such as responsiveness, should be investigated in the future.

The impact of vaginal cone therapy on stress urinary incontinence compared with transobturator tape.

OBJECTIVE: To emphasize the efficiency of vaginal cone (VC) therapy in stress urinary incontinence (SUI) through a comparison with transobturator tape (TOT). MATERIALS AND METHODS: A prospective randomized controlled study was conducted at the Etlik Zübeyde Hanim Maternity and Women Hospital during a one year study period. Forty women were allocated into two equal groups; those treated with VCs for a 3 month period, and women who underwent TOT procedures. These women were followed up at 6 weeks and 6 months after the treatments. Subjective cure was assessed using Wagner's Quality of Life Questionnaire. Objective cure was evaluated through a cough stress and pad test results. RESULTS: Maternal demographic features were comparable among groups. We observed improvement in pad weight test among groups when compared with the pretreatment state (p=0.015, p=0.005). Although the subjective cure rate was similar in both groups at the 6th week and 6th month follow up (65% vs. 75%; 75% vs. 80%) (p>0.05), the objective cure rate was significantly higher in the TOT group than in the VC group, as expected (10% vs. 80%; 30% vs. 75%) (p<0.05). CONCLUSION: The main treatment of SUI is surgery; however, VC could be offered as an alternative treatment for women who refuse surgery, those at high risk for surgery or it could be used temporarily before surgery.

Is the simple closure technique effective in the treatment of genital fistulas?

Aim. Genitourinary fistulas are bothersome clinical entities not only for the patient but also for the treating surgeon as well. A lot of surgical procedures have been proposed; however, most of the fistulas can be easily treated with plain surgical techniques, such as the simple surgical closure of the fistula tract. Material and Method. The study was carried out in the urogynecology department of Ankara Etlik Zübeyde Hanim Maternity Training and Research Hospital. The study included 12 cases with vesicovaginal fistulas and 15 cases with rectovaginal fistulas. Twenty-six patients underwent simple surgical closure technique. The age, the referral time to the hospital, the longest diameter of the fistula opening, the hospitalization time, the follow-up period and identifiable risk factors of the patients were evaluated. Results. Caeserean section was detected as primary risk factor for vesicovaginal fistulas and prolonged labor was detected as the most important risk factor for rectovaginal fistulas. In our study, we found that the simple closure technique cured 91% of vesicovaginal fistulas and 93% of rectovaginal fistulas. Conclusion. The simple closure technique has very high cure rates for both vesicovaginal and rectovaginal fistulas when the longest diameter of the fistula openings is ≤5 mm.

Role of pelvic floor muscle exercises in the prevention of stress urinary incontinence during pregnancy and the postpartum period.

OBJECTIVE: The aim of this study was to determine the role of pelvic floor muscle exercises (PFME) in the prevention of stress urinary incontinence (SUI) during pregnancy and the postpartum period. METHODS: A total of 102 women was included in the study. Data, collected through forms, included characteristics of the women, follow-up data during the pregnancy and postpartum period and a three-day urinary diary. Both groups were evaluated in terms of SUI at the 14th-20th, 28th and 32nd weeks of gestation and at 12 weeks postpartum. RESULTS: As shown by the pad test, SUI developed in 5.8, 17.3 and 1.9% of the subjects in the intervention group at the 28th and 32nd gestational week and the 12th postpartum week, respectively. The relevant ratios in the control group were 30, 48 and 18%, respectively. A statistically significant difference was found between the intervention and control groups in terms of SUI development at the 28th and 32nd weeks of gestation and the 12th postpartum week (p < 0.05). CONCLUSION: PFME are effective for prevention of SUI development during pregnancy and in the postpartum period. Health care providers are therefore recommended to provide education and counseling to pregnant women about SUI prevention.

A large primary vaginal calculus in a woman with paraplegia.

OBJECTIVE: The study aimed to report a primary vaginal stone, an extremely rare entity, without vesicovaginal fistula in a woman with disability. CASE: We describe the case of a large primary vaginal calculus in a 22-year-old woman with paraplegia, which, surprisingly, was not diagnosed until she was examined under general anesthesia during a preparation for laparoscopy for an adnexal mass. The stone had not been identified by physical examination with the patient in a recumbent position or by transabdominal ultrasonography and pelvic tomography during the preoperative preparation. Vaginoscopy was not performed because the vagina was completely filled with the mass. As a result of its size and hard consistency, a right-sided episiotomy was performed and a 136-g stone was removed using ring forceps. A vesicovaginal fistula was excluded. There was no evidence of a foreign body or other nidus on the cut section of the stone, and it was determined to be composed of 100% struvite (ammonium magnesium phosphate). Culture of urine obtained via catheter showed Escherichia coli. After the surgical removal of the calculus without complications, a program of intermittent catheterization was started. The follow-up period was uneventful, and the patient was symptom free at 6 months after the operation. CONCLUSIONS: We postulate that the calculus formed as a consequence of urinary contamination of the vagina in association with incontinence and prolonged maintenance in a recumbent posture. This report is important because it highlights that, although vaginal stones are very rare, their possibility should be considered in the differential diagnosis of individuals with long-term paraplegia.