Vaginal packing after vaginal hysterectomy: systematic review and recommendations.

INTRODUCTION AND HYPOTHESIS: Vaginal packing is often used after vaginal hysterectomy to reduce the risk of haemorrhagic and infectious complications, but the procedure may impair spontaneous bladder emptying and necessitate permanent bladder catheterization, which itself increases the risk of urinary infection, patient bother, delayed discharge, and increased costs. This systematic review was aimed at assessing the complications and outcomes associated with vaginal packing after vaginal hysterectomy. METHODS: We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, using the Population, Interventions, Comparators, Outcomes, and Study design (PICOS) framework to define eligibility. Following data synthesis and subgroup analyses, we assessed the certainty of evidence according to GRADE guidance and formulated a clinical recommendation. RESULTS: The review included four clinical trials (involving 337 participants). These provided no clear evidence that vaginal packing led to clinically meaningful reductions in adverse effects, such as vaginal bleeding, hematoma formation, or postoperative vaginal cuff infection. Overall, the intervention produced no clear benefit regarding the predefined outcomes. CONCLUSIONS: Routine vaginal packing after vaginal hysterectomy had no clear benefit on outcomes. We therefore advise against this procedure.

Study protocol for improving mental health during pregnancy: a randomized controlled low-intensity m-health intervention by midwives at primary care centers.

BACKGROUND: Pregnancy-related anxiety and depression has received considerable attention worldwide. Mental health problems in pregnant women already since early weeks of gestation may have important consequences to the fetus. The necessity for more effective health care pathways, including some early interventions that reduce the overall burden of the childbearing situation appears a key factor for a successful birth and care of the baby. The few studies focalized in interventions, are focused on delivery and postpartum, without taking into account the whole maternity process. Current literature recommends the use of interventions based on new technologies for the treatment of mood disorders, already during the prenatal period. There have been scarce well-designed intervention studies that test technological low-intensity interventions by midwives to address pregnant women's mental health, diminishing anxiety and depression during pregnancy. METHODS/DESIGN: Adult pregnant women (weeks 12-14 of gestation) will be recruited and screened from different primary care centers in Catalonia, Spain. Women who pass the initial mental screening will be randomly allocated to the relaxation virtual reality intervention or control group. The intervention aims to improve mental state of pregnant women during pregnancy, work through breathing, mindfulness and muscle relaxation techniques. Women in the control group will receive standard care offered by the public funded maternity services in Catalonia. The primary outcome measures will include the Edinburg Postnatal Depression (EPDS), State Trait Anxiety Inventory (STAI), Symptom Checklist-90 (SCL-90), and the Cambridge Worry Scale (CWS) instruments. Secondary outcome measures will include the Temperament and Character Inventory-Revised (TCI-R) and the Whooley and Generalized Anxiety Disorder-2 (GAD-2) questions. Routinary pregnancy monitoring measures will be also evaluated. DISCUSSION: This study aims to test the efficacy of a low-intensity, midwife-led e-health intervention based on new technologies to work on women's anxiety and depression during pregnancy. We hypothesize that low-intensity mental health intervention during pregnancy, using an e-health (virtual reality) as a support tool, will be effective in reducing of anxiety, depressive symptoms, and improving satisfaction with pregnancy follow-up. TRIAL REGISTRATION: Clinical Trials ID NCT05756205.

What do female university students know about pelvic floor disorders? A cross-sectional survey.

INTRODUCTION AND HYPOTHESIS: Pelvic floor dysfunction (PFD) is common in women but few seek medical attention. Poor recognition of the condition as pathological and unawareness of treatments may account for low consultation rates. METHODS: This cross-sectional study was based on an online survey that was responded to in February and March 2020 by 768 female university students. Knowledge of PFD was assessed using the Prolapse and Incontinence Knowledge Questionnaire (PIKQ). Descriptive and inferential analyses were performed using IBM-SPSS (V26.0). RESULTS: Respondents had poor knowledge of PFD and especially of pelvic organ prolapse. Health science students (n = 531; 69.1%) obtained significantly higher scores (p < 0.001) than other students (n = 237; 30.9%). Those who had received information on how to perform pelvic floor muscle training were more likely to score higher than those who had not received previous information. CONCLUSIONS: While health science students have better knowledge of PFD than other students, university students in general are little aware of PFD. Most students considered the issue of PFD to be important and wanted more information. Our findings may be useful in planning strategies to raise women's awareness of PFD and its prevention and treatment.

Use of an Intrauterine Foley Probe for Ultrasound-Assisted Hysteroscopic Resection of Complete Uterine Septum.

STUDY OBJECTIVE: To demonstrate our technique for hysteroscopic resection of the complete uterine septum. DESIGN: Step-by-step description and demonstration of the procedure using pictures and video (educational video). The video was approved by our hospital's Ethical Committee. SETTING: Uterine malformations represent a rare, yet usually asymptomatic condition that can be associated with poor obstetric outcomes. The European Society for Gynaecological Endoscopy(ESGE)/European Society of Human Reproduction and Embryology (ESHRE)classification is widely accepted for the description of female genital tract anomalies. Treatment of the uterine septum should be considered if fertility is desired, with hysteroscopic resection the gold standard procedure. INTERVENTION: A patient with a U2bC2V1 malformation according to the ESGE/ESHRE classification was treated with hysteroscopy. The procedure was performed in the operating room under general anesthesia using a 9-mm hysteroscope with a bipolar cutting loop. Surgery began with resection of the vaginal septum with monopolar electrosurgery until the cervix was visualized. A Foley probe was placed in 1 uterine hemicavity, and then hysteroscopy on the other hemicavity was performed. Transrectal ultrasound guidance was used to identify the limits of the septum and thereby enhance the safety of the procedure. Resection of the septum started in the upper part until the Foley probe was seen, then continued downward until internal cervical orifice was reached. In the hysteroscopic follow-up after 3 months, we visualized a small residual septum that was resected to fully restore the uterine cavity and improve the patient's obstetric outcomes. The procedure was completed without complications, and a second-look hysteroscopy showed a normal uterine cavity. CONCLUSION: The combination of real-time ultrasound guidance and placement of an intrauterine balloon through the cervix may increase safety during the procedure by providing clear visualization of the uterine cavity and septum border during resection.

Adherence to pelvic floor muscle training with or without vaginal spheres in women with urinary incontinence: a secondary analysis from a randomized trial.

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle training (PFMT) is widely recommended as first-line therapy for women with urinary incontinence. However, adherence to PFMT decreases over time, and information regarding barriers to PFMT is scarce. The primary aim of our study was to investigate whether a vaginal spheres device helped improve adherence to PFMT. The secondary aim was to assess determinants of adherence and the association with treatment outcome. METHODS: This was a secondary analysis of a randomized trial with a 6-month follow-up in women with urinary incontinence (UI) in whom we evaluated adherence to PFMT, performed either with (spheres group) or without (control group) vaginal spheres. The Morisky-Green Questionnaire (MGQ) was used to assess adherence, defined as the extent to which participants corresponded to the agreed recommendations; participants were classified as adherent or nonadherent according to their responses. Efficacy of PFMT was assessed using the International Consultation on Incontinence Questionnaire Short Form scale (ICIQ-SF). RESULTS: Seventy women were enrolled and data from 65 (35 treated and 30 controls) were suitable for analysis. There were no significant differences in adherence to treatment between groups at the end of follow-up (33.3 % in controls and 42.9 % in spheres). The largest group of nonadherent women in both arms were those who mainly forgot to do the exercises. ICIQ-SF results between adherent and nonadherent women did not differ significantly [mean 0.55, 95 % confidence interval (CI) 1.13-2.25]. No significant difference was observed between women who attained greater and lesser improvement in UI after treatment (4.5 %; 95 % CI -11.7 to 20.6). CONCLUSIONS: In patients with UI, vaginal spheres as an adjunct to PFMT did not increase adherence to pelvic muscle exercises. Lack of persistence appeared to be due to forgetfulness and did not seem to be influenced by the efficacy of PFMT.

Effect of vaginal spheres and pelvic floor muscle training in women with urinary incontinence: a randomized, controlled trial.

AIMS: To compare the efficacy and safety of Kegel exercises performed with or without, vaginal spheres as treatment for women with urinary incontinence. METHODS: Multicentre parallel-group, open, randomized controlled trial. Women were allocated to either a pelvic floor muscle-training program consisting of Kegel exercises performed twice daily, 5 days/week at home, over 6 months with vaginal spheres, or to the same program without spheres. The primary endpoint was women's report of urinary incontinence at 6 months using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF). Secondary outcome measures were the 1 hr pad-test, King's Health Questionnaire (KHQ) and a five-point Likert scale for subjective evaluation. Adherence was measured with the Morisky-Green test. RESULTS: Thirty-seven women were randomized to the spheres group and 33 to the control group. The primary endpoint was evaluated in 65 women (35 in the spheres group vs. 30 controls). ICIQ-UI-SF results improved significantly at 1-month follow-up in the spheres group (P < 0.01) and at 6 months in the controls. The 1 hr pad-test improved in the spheres group but not in the control group. No significant differences were found in the KHQ results or in the subjective evaluation of efficacy and safety. Adherence was higher in the spheres group but differences were not significant. Mild transient side effects were reported in four patients in the spheres group and one in the control group. CONCLUSIONS: Both treatments improved urinary incontinence but women who performed the exercises with vaginal spheres showed an earlier improvement. Vaginal spheres were well tolerated and safe.

Comparison of a human acellular dermal matrix and a polypropylene mesh for pelvic floor reconstruction: a randomized trial study in a rabbit model.

Non-absorbable polypropylene (PP) meshes have been widely used in surgical reconstruction of the pelvic floor disorders. However, they are associated with serious complications. Human acellular dermal matrices (hADM) have demonstrated safety and efficacy in reconstructive medicine, but their suitability and efficacy at vaginal level is not known. This study compares the biological performance of PP mesh and a newly developed hADM. 20 rabbits were randomized to receive the hADM graft or the PP mesh. Grafts were surgically implanted in the abdominal wall and vagina. After 180 days, grafts were explanted and evaluated. The vaginal mesh extrusion rate was higher in the PP group (33% vs. 0%, p = 0.015). Full integration of the vaginal grafts was more frequent in the hADM group, where 35% of the grafts were difficult to recognize. In the PP group, the vaginal mesh was identified in 100% of the animals (p = 0.014). In PP group, the infiltrates had a focal distribution and were mostly located in the internal part of the epithelium, while in the hADM group, the infiltrates had a diffuse distribution. Additionally, the hADM group also presented more B-lymphocytes and less T-lymphocytes. Biomechanical analysis showed that hADM had lower resistance to stress. Moreover, PP mesh stiffness and elasticity were higher. Then, hADM is associated with fewer clinical complications, as well as better tissue integration. However, it shows greater incorporation into the surrounding native tissue, especially in the vaginal location, undergoing a reduction in its biomechanical properties 6 months after implantation.

Rabbit as an animal model for the study of biological grafts in pelvic floor dysfunctions.

The aims of this study were to evaluate the feasibility of the New Zealand White (NZW) rabbit for studying implanted biomaterials in pelvic reconstructive surgery; and to compare the occurrence of graft-related complications of a commercial polypropylene (PP) mesh and new developed human dermal matrix implanted at vaginal and abdominal level. 20 white female NZW rabbits were randomized into two groups, experimental group (human acellular dermal matrices-hADM-graft) and control group (commercial PP graft). In each animal, grafts were surgically implanted subcutaneously in the abdominal wall and in the vaginal submucosa layer for 180 days. The graft segments were then removed and the surgical and clinical results were analyzed. The main surgical challenges during graft implantation were: (a) an adequate vaginal exposure while maintaining the integrity of the vaginal mucosa layer; (b) to keep aseptic conditions; (c) to locate and dissect the breast vein abdominal surgery; and (d) to withdraw blood samples from the ear artery. The most abnormal findings during the explant surgery were found in the PP group (33% of vaginal mesh extrusion) in comparison with the hADM group (0% of vaginal graft extrusion), p = 0.015. Interestingly, macroscopic observation showed that the integration of the vaginal grafts was more common in the hADM group (40%) than in the PP group, in which the vaginal mesh was identified in 100% of the animals (p = 0.014). The NZW rabbit is a good model for assessing materials to be used as grafts for pelvic reconstructive surgery and vaginal surgery. Animals are easily managed during the procedures, including surgical intervention and vaginal mucosa approach. Additionally, hADM is associated with fewer clinical complications, as well as better macroscopic tissue integration, compared to PP mesh.

Mode of vaginal delivery: a modifiable intrapartum risk factor for obstetric anal sphincter injury.

The aim of this study was to analyze the comparative risks of this anal sphincter injury in relation to the type of intervention in vaginal delivery. We performed an observational, retrospective study of all vaginal deliveries attended at a tertiary university hospital between January 2006 and December 2009. We analyzed the incidence of obstetric anal sphincter injury for each mode of vaginal delivery: spontaneous delivery, vacuum, Thierry spatulas, and forceps. We determined the proportional incidence between methods taking spontaneous delivery as the reference. Ninety-seven of 4526 (2.14%) women included in the study presented obstetric anal sphincter injury. Instrumental deliveries showed a significantly higher risk of anal sphincter injury (2.7 to 4.9%) than spontaneous deliveries (1.1%). The highest incidence was for Thierry spatulas (OR 4.804), followed by forceps (OR 4.089) and vacuum extraction (OR 2.509). The type of intervention in a vaginal delivery is a modifiable intrapartum risk factor for obstetric anal sphincter injury. Tearing can occur in any type of delivery but proportions vary significantly. All healthcare professionals attending childbirth should be aware of the risk for each type of intervention and consider these together with the obstetric factors in each case.

Distancias anatómicas de la pelvis en relación con las técnicas quirúrgicas a través del foramen obturador / Anatomical distances among pelvic structures related to surgical techniques through the obturator foramen

Objetivo: Describir las distancias entre las principales estructuras óseas, vasculares, neurológicas y viscerales que son relevantes para guiar el paso de las agujas insertoras en las técnicas quirúrgicas a través del foramen obturador. Material y métodos: Se diseccionaron 6 hemipelvis femeninas de cadáver embalsamado, procedentes de donantes de cuerpo voluntarias del Departament de Ciències Morfològiques de la Universitat Autònoma de Barcelona (UAB). En la disección se hizo especial hincapié en la delimitación del agujero obturador y la localización de estructuras osteomusculoaponeuróticas y neurovasculares adyacentes. Resultados: Se midieron distintas distancias. Son especialmente relevantes las distancias en relación con la rama isquiopubiana, la espina ciática y el arco tendinoso del músculo elevador del ano, ya que constituyen las principales referencias para la cirugía. Conclusiones: Un buen conocimiento de la anatomía trae luz al paso a ciegas de los tunelizadores que utilizan el foramen obturador para acceder a la pelvis. Ello debe permitir una cirugía más segura y una mejor comprensión de los riesgos potenciales, cómo evitarlos y cómo tratar las complicaciones perioperatorias

Objective: To describe distances between the major bony, vascular, neurologic and visceral structures of importance when guiding trocar needles through the obturator foramen. Material and methods: Six embalmed female hemipelvises from voluntary donors were dissected at the Department of Anatomy of the Universitat Autònoma de Barcelona (UAB) School of Medicine. Special attention was paid to the obturator foramen and its neighboring bony, aponeurotic and muscular structures, and neurovascular bundles. Results: Several distances were collected. Distances in relation to the ischiopubic ramus, the ischial spine and the arcus tendineus of levator ani seemed to be particularly important, as they are the main landmarks for surgery. Conclusion: A good knowledge of anatomy illuminates the passage of trocar needles inserted through the obturator foramen as a route to enter the pelvic space. This knowledge improves safety, understanding of potential risks and how to avoid them, as well as the management of perioperative complications