Unilateral levator avulsion increases the risk of de novo stress urinary incontinence after cystocele repair.

INTRODUCTION: Patients without concurrent baseline stress urinary incontinence (SUI) can develop de novo SUI after transvaginal mesh surgery (TVM) for cystocele repair. Surgeons should be aware of de novo SUI risk factors after TVM. METHODS: A total of 1124 women who were underwent TVM surgeries were recruited and assessed for eligibility from January 1, 2012 to April 30, 2021. All data related to patients and surgeries was collected, which included general conditions, clinical examination, surgery records, and follow-up results. Patients were divided into three groups according to follow-up results and data were compared with each group. The relative risk (RR) of de novo SUI with levator avulsion was also calculated. RESULTS: Three hundred thirty-six patients were included in this study. They were divided into no complication group (n = 249), de novo SUI group (n = 68), and other complications group (n = 19). It seemed elder or obese women had a higher risk of de novo SUI after TVM (p < 0.05). In de novo SUI group, incidence of levator avulsion before surgery were higher than the other two groups (p = 0.001). TVM can significantly change a prolapse to point Aa and Ba on POP-Q quantification system (p < 0.05). RR ratios of de novo SUI with unilateral avulsion group is 2.60 (95% confidence interval [CI] 1.39-4.87), and 2.58 (95%CI 0.82-8.15) for bilateral group. CONCLUSION: Unilateral levator avulsion, instead of bilateral levator avulsion, is a risk factor of de novo SUI after cystocele repair surgery.

Maternal and neonatal consequences of cystocele and rectocele in the delivery process.

The study aimed to investigate the effects of cystocele and rectocele on the stages of vaginal birth and maternal and newborn outcomes. A total of 672 multiparous pregnant women between the ages of 18 to 40 who underwent normal vaginal delivery in our tertiary center between November 2022 and February 2023, were included in this prospective study. Among the participants, 348 (51.8%) had no abnormalities, 78 (11.6%) had rectocele only, 112 (16.7%) had cystocele only, and 134 (19.9) had both cystocele and rectocele. Patients with the coexistence of cystocele and rectocele experienced a notably extended duration for both the first stage and second stage of labor, although the extension in the second stage was not statistically significant. Among the maternal complications, the development of maternal laceration and chorioamnionitis was significantly more common in the patient group with cystocele and rectocele compared to the other groups. When the groups were assessed for postpartum bleeding, while the bleeding risk increased from the normal group to the rectocele + cystocele group, this increase was not statistically significant. There was no difference between the groups in terms of neonatal outcomes. The delivery time of pregnant women with cystocele and rectocele, in the absence of additional risk factors, was determined to be significantly longer than that of the control group. We think that these patients should receive more vigilant monitoring, and this criterion should be kept in mind when assessing the indication for a cesarean section.

Analysis of the anatomical and biomechanical characteristics of the pelvic floor in cystocele.

INTRODUCTION: Stress urinary incontinence (SUI) occurs due to disruption of the pelvic floor anatomy; however, the complexity of the pelvic floor support structures and individual patient differences make it difficult to identify the weak points in the pelvic floor support that cause SUI to occur, develop, and recur. This study aimed to analyze the pelvic floor anatomy, structural features, and biomechanics of cystoceles to develop more effective treatment plans with individualized and precise healthcare. MATERIAL AND METHODS: In this observational case-controlled study (clinical trial identifier BOJI201855L), 102 women with normal pelvic floor function and 273 patients diagnosed with cystocele degrees I-III were identified at Shanghai General Hospital from October 2016 to December 2019. We combined ultrasound and vaginal tactile imaging (VTI) to assess the anatomy and biomechanical functions of the anterior and posterior vaginal walls. Both examinations included relaxation and muscle tension tests. RESULTS: Of the 42 VTI parameters, 13 were associated with the degree of cystocele, six with an increase in the urethral rotation angle (pointing to the mobility of the urethra), and six with a decrease in the retrovesical angle (pointing to hypsokinesis and decrease in bladder position). According to these data, the strength of tissues, especially the muscles in both the anterior and posterior compartments, contributes to the stability of the pelvic floor structure. The strength of the levator ani muscle (LAM) is important for the degree of cystocele, mobility of the urethra, hypsokinesis, and decrease in bladder position. CONCLUSIONS: In general, the biomechanical status of the pelvic floor in patients with cystocele is complex and involves various muscles, ligaments, tendons, and fascia. Of these, repair and exercise of the LAM have not received much attention in the treatment of patients with cystoceles, which may be an important risk factor for the high recurrence rate.

Total uterine prolapse: a rare cause of chronic obstructive uropathy associated with renal dysfunction (a case report).

Pelvic organ prolapse is rarely associated with severe bilateral ureteral hydronephrosis and renal dysfunction. The etiopathogenetic mechanism has not been fully elucidated. Contemporary imaging methods of the urinary tract play a decisive role in assessing the morphological function of the kidneys. In cases of moderate and severe pelvic organ prolapse, surgery appears to be the main choice of treatment. Our case concerns a post-menopausal patient with three vaginal deliveries in her obstetric history and with a history of bilateral hydronephrosis and impaired renal function who was referred to the outpatient clinic for a gynecological examination due to complete uterine prolapse. Bilateral hydroureteronephrosis due to prolapse was assessed as the main cause of renal dysfunction. A surgical intervention was decided to the pelvic floor and a vaginal hysterectomy was performed with simultaneous correction of the cystocele and rectocele. The postoperative course was uneventful. Three months later, re-examination of the urinary tract showed complete remediation of kidney morphology and function. The present case report emphasizes the significant degree of bilateral hydroureteronephrosis and deterioration of renal function rarely seen in patients with complete uterine prolapse. At the same time, it is pointed out that the exclusion of renal dysfunction related to complete uterine prolapse should be the main concern of the modern gynecologist even for complex cases with coexisting etiological factors for renal disease, in order to avoid permanent renal parenchymal damage and ensure the best health and quality of life of these patients.

A serious consequence of pelvic organ prolapse: Hydroureteronephrosis.

INTRODUCTION AND HYPOTHESIS: We aimed to determine the association between pelvic organ prolapse (POP) and hydroureteronephrosis (HUN), risk factors for developing HUN and resolution of HUN after surgery. METHODS: A retrospective study was conducted on 528 patients diagnosed with uterine prolapse. RESULTS: All patients with or without HUN were compared in terms of risk factors. The 528 patients were divided into five groups according to the POP-Q classification. A significant relationship was found between POP stage and HUN. The other risk factors for developing HUN were age, rural life, parity, vaginal delivery, smoking, body mass index and increased comorbidity. The prevalence of POP was 12.2% and the prevalence of HUN was 65.3%. All patients with HUN underwent surgery. After surgery, HUN resolved in 292 (84.6%) patients. CONCLUSION: POP is a multifactorial herniation of pelvic organs out of the urogenital hiatus due to pelvic floor dysfunction. The main etiological factors in POP are older age, grand multiparity, vaginal delivery and obesity. The most important problem in patients with severe POP is HUN due to urethral kinking or urethral obstruction, which is a result of the cystocele squeezing the urethra under the pubic bone. In low-income countries, the main aim is to prevent the development of POP, which is the most common cause of HUN. It is important to increase the level of knowledge about contraception methods and to increase screening and training to reduce other risk factors. Women should be made aware of the importance of gynecological examination in the menopausal period.

Investigation of predictive factors for the presence of voiding dysfunction after transvaginal mesh surgery-Can the flow curve shape on uroflowmetry be a predictor?

PURPOSE: This study established the prognostic significance of the uroflowmetry flow curve shape in the presence of voiding dysfunction following transvaginal mesh surgery. METHODS: This is a retrospective study of 439 symptomatic cystocele patients who underwent anterior wall repair with transvaginal mesh surgery. Uroflowmetry and postvoid residual were used to evaluate voiding function both preoperatively and 12 months postoperatively. The patients were divided into two groups: those with and without postoperative voiding dysfunction, and the predictors of postoperative voiding dysfunction were analyzed. The shape of the urine flow curve was analyzed for its influence on the presence of postoperative voiding dysfunction. RESULTS: Thirty-five participants were in the voiding dysfunction group, while 404 were in the nonvoiding dysfunction group. Multivariate analysis was conducted by adding an interrupted-shaped curve to age, Qmax, and postvoid residual, which showed significant differences in univariate analysis, found that age 68 years or older (odds ratio [OR]: 7.68, 95%CI 1.02-58, p = 0.048), postvoid residual ≥110 mL (OR: 2.8, 95%CI 1.25-6.29, p = 0.013) and interrupted-shaped curve (OR: 2.47, 95%CI 1.07-5.69, p = 0.034) were discovered to be independent risk factors for the presence of voiding dysfunction after transvaginal mesh surgery. CONCLUSIONS: Following transvaginal mesh surgery for cystocele, three variables were found to be predictive of voiding dysfunction: the old age, excessive postvoid residual, and an interrupted-shaped flow curve. The uroflowmetry flow curve shape has the potential to be a new predictor of postoperative voiding dysfunction.

Prolapso uretral: diagnóstico solo por la exploración / Urethral prolapse: Diagnosis by examination only

No disponible

Novel insight into the correlation between hernia orifice of cystocele and lower urinary tract function: a pilot study.

BACKGROUND: It has been hypothesized that women with significant pelvic organ prolapse (POP), particularly of the anterior vaginal wall, may have voiding dysfunction (VD). Although the VD mechanism due to cystocele is not fully understood, different vaginal compartments have rarely been closely examined. This study attempted to further elucidate the correlation between POP and VD through a new subgroup classification using cystoscopy. METHODS: This study reviewed clinical records of 49 women who underwent cystocele repair. All patients were scheduled for laparoscopic sacrocolpopexy, preoperatively underwent uroflowmetry and postvoid residual urine volume (PVR) measurement, and completed pelvic floor function questionnaires. Bladder examination by cystoscopy was additionally performed using the lithotomy position with the Valsalva maneuver. RESULTS: Subjects were divided into four groups according to hernia orifice presence determined by cystoscopy, which included the trigone type, posterior wall type, trigone and urethra type, and trigone and posterior wall type. The posterior wall type had statistically higher PVR values versus the trigone and posterior wall type (P = 0.013). The posterior wall type had statistically lower values for average urine flow rate versus the urethra and trigone type (P = 0.020). There were no significant differences noted in the pelvic floor function questionnaires among the four groups. CONCLUSIONS: A new bladder defect classification based upon hernia orifice location was associated with lower urinary tract function. Posterior wall hernia presence caused significant voiding function deterioration. This new subgroup classification, which can more clearly identify and indicate bladder function, is also comparable among patients.

[INVESTIGATION OF SURGICAL CORRECTION OF ANTERIOR APICAL PROLAPSE OF THE PELVIC ORGANS USING A COMBINED TECHNIQUE, MONOLATERAL CYRENE POSTERIOR IN COMBINATION WITH ANTERIOR COLPORRHAPHY].

Objective - to evaluate the results of surgical correction of anterior apical prolapse of the pelvic organs with a combined technique monolateral CYRENE posterior (using monofilament polypropylene tape CYRENE) in combination with anterior colporrhaphy. A prospective cohort study included 240 patients with urogenital prolapse. The subjects were followed up for three months, and the anatomical outcome according to the POP-Q System classification, intra- and postoperative complications, absence or presence of relapse, quality of life and sex life were assessed. A relapse was considered to be grade 3 or more anterior prolapse, grade 2 or more central prolapse. Quality of life and sex life were assessed using the PFDI-20, PFIQ-7 and PSIQ-12 questionnaires. The average age of women was 57.8 years. All 240 patients had grade 3 cystocele, prolapse of the anterior vaginal wall, and prolapse of the uterus. In 23 (9.6%) patients, de novo urinary incontinence developed, 8 patients had stress urinary incontinence before surgery, 6 of them persisted stress urinary incontinence after surgery, 2 of them stress urinary incontinence was arrested without the simultaneous use of a mid-urethral sling. According to questionnaires, the quality of life improved in 225 (96.9%) women according to PFDI-20 and in 210 (90.5%) according to PFIQ-7. There were no changes in the quality of sex life. Anatomically, 235 (96.9%) achieved the desired result (Ba≤ II, C≤ I according to the POPQ System). At the same time, in 36 (15%), 3 months after the operation, cystocele of the 2nd degree was revealed. In all cases, there was minimal blood loss, in 9 cases (3.75%) there was a hematoma of the anterior vaginal wall that did not require additional intervention, at discharge had signs of organization and was completely stopped 6 weeks after surgery; 3 (1.25%) patients had urinary retention after surgery. Dyspareunia was not identified in any patient. The study of the treatment of urogenital prolapse using a combined technique, monolateral CYRENE posterior in combination with anterior colporrhaphy, demonstrates high efficiency and relative safety. The technique showed excellent anatomical results for apical prolapse and good for anterior prolapse. A small number and low significance of postoperative complications were revealed. Longer postoperative follow-up is needed to assess long-term results and long-term prospects in order to form a more complete understanding of this technique.

A modified technique for paravaginal repair of cystocele with paravaginal defect: A retrospective study.

OBJECTIVE: We aimed to determine the efficacy and safety of a modified protocol for paravaginal repair of symptomatic paravaginal defects and cystocele. METHODS: This study was an observational case series of 98 consecutive female patients, referred to our hospital between June 2014 and May 2018, with symptomatic grade II to IV paravaginal defects and cystocele. Our modified technique for paravaginal repair is based on the conventional protocol but incorporates reverse bridge repair and the cross-stitching of bilateral sutures. The curative effect of this new technique was evaluated subjectively and objectively during postoperative follow-up. RESULTS: All operations were successful. Patients were followed up for 12 to 48 months, until June 2019; the mean follow-up period was 32.4 months. Three months after surgery, the rate of success was 100% (98/98 cases); in each case, the top of the vagina lay above the level of the sciatic spine. The rate of success was 94.9% (93/98 cases) at 12 months after surgery, 91.0% (61/71 cases) at 24 months after surgery, and 76.2% (16/21 cases) at 48 months after surgery. Four cases required a second surgery; three of these cases were treated with sacrocolpopexy, and one case was treated with sacrospinous ligament fixation. CONCLUSION: Our modified technique for paravaginal repair was safe and effective for anterior vaginal prolapse and cystocele, as confirmed by the results observed over a mean follow-up period of 32.4 months.

Robot-Assisted Laparoscopic Paravaginal Repair and Sacrocolpopexy in Patients With Pelvic Organ Prolapse.

OBJECTIVE: To evaluate the surgical effects of robotic paravaginal repair and sacrocolpopexy in patients diagnosed with lateral cystocele due to paravaginal defect. PATIENTS AND METHODS: Robotic paravaginal repair and sacrocolpopexy were performed contemporaneously in 43 patients with high-grade pelvic organ prolapse combined with a lateral or mixed cystocele. To objectively evaluate prolapse correction, the Pelvic Organ Prolapse Quantification (POP-Q) test was performed at the 12-month visit and the results compared to those of the preoperative period. Subjective satisfaction was scored using the Patient Global Impression of Improvement (PGI-I) questionnaire. RESULTS: POP-Q measurement results before and after surgery, an objective indicator of surgery, the Ba and C scores improved significantly from 2.1 ± 1.2 preoperatively to -2.0 ± 1.1 postoperatively (P <.01), and from 0.3 ± 1.3 preoperatively to -4.3 ± 1.1 postoperatively (P <.01), respectively. In PGI-I questionnaire, the numbers of patients who awarded scores of 1 and 2 (evidencing high-level symptom improvement) were 33 at 1 month (76.7%), 30 at 3 months (69.8%), and 28 (65.1%) at 12 months. When respondents awarding 3 points (a little improvement) were included, the numbers rose to 38 (88.4%) at 1 and 3 months and 35 (81.4%) at 12 months, indicating satisfaction with symptom improvement. There were no critical complications during and after surgery, but complications such as de novo stress urinary incontinence that lower patient satisfaction occurred in some cases. CONCLUSION: Robot-assisted paravaginal repair and sacrocolpopexy can be safely performed in patients with cystocele-predominant pelvic organ prolapse and good surgical results can be expected with excellent effects.

Outcomes of a fixed skeletonised mini mesh implant for pelvic organ prolapse repair with uterine preservation.

Mesh repair of pelvic organ prolapse (POP) is complicated, causing erosions, postoperative pain and surgical failure. We hypothesised that reducing the mesh size and fixating it would result in significant cure rates and reduce complication rates. Here, we present the effectiveness of mini mesh implants in POP reconstruction. Sixty women who underwent repair of stage III and IV apical prolapse with cystocele or rectocele using skeletonised mesh implant Seratom PA MR MN® were evaluated. Anatomical outcomes were assessed using modified POP-quantification (POP-Q) staging and functional outcomes were self-reported by patients - one and three months post-operatively. Apical support with anterior and/or posterior colporrhaphy was performed, resulting in 96.6% success rate. Follow-up conducted one and three months post-operatively revealed significant improvement on the modified POP-Q (p < .001) and no complaints of dyspareunia. Para-vesicular fixation using a skeletonised mini mesh implant is feasible and effective in POP repair and has low surgical complication risk.Impact StatementWhat is already known on this subject? Mesh repair for pelvic organ prolapse (POP) is currently under scrutiny as it may result in erosions, postoperative pain, and surgical failure.What do the results of this study add? The use of an apical support with mini-mesh implants resulted in a 96.6% (58/60) success rate and excellent outcomes at 1- and 3-month follow-up.What are the implications of these findings for clinical practice and/or further research? Reconstruction using skeletonised and fixated mini-mesh implants may be safe and effective for POP treatment.

Vaginal Patch Plastron for cystocele repair at the time of vaginal prosthesis bashing: A technical note (with video).

Native tissue cystocele repair has been the cornerstone of prolapse surgery, especially since the learned societies warned clinicians and patients about serious mesh related complications and recommend a vaginal route without prosthesis in first intention. Surgical techniques mainly consist in anterior colporraphy, vaginal patch plastron and para vaginal repair. However, in case of vaginal patch plastron, the vagina left in contact with the bladder is a material of much better quality than colporraphy alone. The multiplication of native tissues, generating post-operative fibrosis, associated with anchorage on a strong ligamentous structure, allows to expect better outcomes compared to anterior colporraphy. Indeed, vaginal plastron corrects median cystoceles with a vaginal strip as well as lateral cystoceles thanks to bilateral paravaginal suspension. Thereby, vaginal patch plastron appears to be a good compromise between the 3 autologous techniques with median and paralateral repair We aimed to describe the surgical technique of the vaginal patch plastron for vaginal native tissue repair for cystocele.

Preperitoneal laparoscopic lateral repair in pelvic organ prolapse - a novel approach.

OBJECTIVES: The aim of this study is to present a novel approach for a paravaginal defect treatment. This extraperitoneal approach can be performed in patients with comorbidities and on obese patients. The main advantages are: not requiring the pneumoperitoneum and the Trendelenburg position and the avoidance of peritoneal adhesions. MATERIAL AND METHODS: This study presents the results in 27 patients with cystocele caused by a lateral defect pelvic organ prolapse quantification (POP Q) stage II or higher. The procedure was performed with a modified Richardson and Burch technique using a preperitoneal approach. Three follow-up examinations were conducted two, six weeks, and six months after the operation. A quality of life assessment was conducted before and after surgery using the short form of the PFIQ-7. RESULTS: All patients had a POP Q II cystocele and 59% had concomitant stress urinary incontinence. In all patients cystocele was reduce to asymptomatic POP Q stage I or 0. Mean operation time was approximately 80 minutes. In six months post-operation follow up, one case of recurrence was noted. The patients' quality of life revealed a statistical improvement from an average of 6.8 points before, to an average of 0.7 points after the operation (p < 0.05) in the PFIQ-7. CONCLUSIONS: Preperitoneal laparoscopic lateral repair is a relatively fast procedure and it is also feasible for obese women and for patients with a cardiopulmonary risk. Neither the Trendelenburg position nor the pneumoperitoneum are required. Postoperatively, the patients witnessed a reduction of the cystocele and complaints connected with their previous condition.

Predictors of occult stress urinary incontinence.

BACKGROUND: Causes for occult stress urinary incontinence (SUI) are poorly recognised. AIMS: To explore the mechanisms behind occult SUI. We hypothesised that cystocele type affects the risk of occult SUI. MATERIALS AND METHODS: We conducted a retrospective, cross-sectional study on 878 consecutive women assessed at a tertiary urogynaecologic clinic between July 2016 and November 2018. The population of this study consisted of 424 women with urodynamic stress incontinence. Women with previous anti-incontinence surgery were excluded. All women underwent a standardised interview, clinical examination and urodynamic testing. Translabial ultrasound was used to categorise cystoceles into Green type II (cystocele with open retrovesical angle) and Green type III (cystocele with intact retrovesical angle). We compared women with overt SUI to those with occult SUI (defined as stress incontinence only observed after prolapse reduction) for demographic characteristics, urodynamic findings and functional anatomy. Predictors for occult SUI were identified with a multivariable logistic regression model. RESULTS: Of 424 women, 362 (85%) had overt, and 62 (15%) occult SUI. There were 136 (32%) women who had a significant cystocele on imaging; 57 (42%) were classified as type II and 79 (58%) as type III. On multivariable regression, age and cystocele type were significantly associated with occult SUI. Odds for occult SUI was 10.9 times higher with type III (cystocele with an intact retrovesical angle) than with type II cystocele (cystocele with an open retrovesical angle; 95% CI 1.3-90.9). CONCLUSIONS: Cystocele type affects the risk of occult SUI. Type III cystocele (intact retrovesical angle) associates with occult SUI.

Prevalence of detrusor underactivity and bladder outlet obstruction in women with cystocele and changes in voiding function after cystocele repair.

PURPOSE: To evaluate the prevalence of detrusor underactivity (DU) and bladder outlet obstruction (BOO) in women with high-grade cystocele and the impacts of cystocele repair. METHODS: Between November 2010 and September 2018, women with ≥stage II cystocele were included. DU (detrusor pressure at maximum flow rate (PdetQmax) < 20 cmH2O, maximum flow rate (Qmax) < 15 mL/s, and bladder voiding efficiency < 90%) and BOO (PdetQmax ≥ 40 cmH2O and Qmax < 12 mL/s) were diagnosed by urodynamic study (UDS). Women who underwent cystocele repair were further analyzed with preoperative and postoperative comparisons. RESULTS: A total of 623 women were included. Forty-four (7%) and 17 (3%) women were diagnosed with DU and BOO, respectively. Among the 314 operatively treated women, a significant increase in DU (7% vs. 15%, p = 0.0007), especially in those with stage III cystocele, and a slightly decreased rate of BOO were noted postoperatively. UDS revealed that the postvoid residual volume, functional profile length, maximum urethral closure pressure (MUCP), and pressure transmission ratio at the MUCP decreased significantly, as did the pad weight. Nearly all lower urinary tract symptoms (LUTS) improved significantly, except nocturnal enuresis. Among bladder diary parameters, nocturia episodes, daytime frequency, urgency episodes, and incontinence episodes decreased significantly after the operation. CONCLUSION: The prevalence rates of DU and BOO in women with high-grade cystocele were 7% and 3%, respectively. After cystocele repair, the rate of DU increased. Most LUTS improved subjectively on questionnaires and objectively on UDS and bladder diary parameters after operation.