Impact of Weight Gain on Surgical Outcomes and Quality of Life among Women after Sling Surgeries.

STUDY OBJECTIVE: To investigate the impact of body weight gain after sling surgeries on outcomes in women with stress urinary incontinence. DESIGN: A single-center, retrospective study. SETTING: Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taiwan. PATIENTS: A total of 248 women who underwent sling surgeries from 2010 to 2015 were reviewed. Patients who gained more than 10% body weight were compared with those with stable body weight. INTERVENTIONS: Midurethral sling surgery with single-incision, transobturator, or retropubic slings. MEASUREMENTS AND MAIN RESULTS: Objective success was defined as no urine leakage during the stress test in the filling phase of urodynamic studies. De novo overactive bladder (OAB) was defined as the appearance of urgency, frequency, and/or nocturia, with or without urinary incontinence after midurethral sling surgery persisting after 6 months. Quality of life evaluations included the short forms of the Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7. A total of 248 women who underwent sling surgeries and had complete weight measurement and evaluation data before and after the surgeries were included, of whom 47 gained body weight, and 201 had a stable body weight. The median follow-up duration was 18 months (range, 6-47 months). There were no significant differences in surgical outcomes between the 2 groups regarding objective cure rate (86% vs 87%, p = .834), 1-hour pad test (4.5 ± 17.8 vs 3.6 ± 18.6 g, p = .770), or postoperative quality of life (Urogenital Distress Inventory-6: 1.9 ± 2.8 vs 2.8 ± 3.2, p = .122; Incontinence Impact Questionnaire-7: 1.8 ± 3.9 vs 2.6 ± 4.3, p = .307). A trend toward increased de novo OAB rate was observed, although this finding was not adequately powered. CONCLUSION: Weight gain after sling surgeries did not influence surgical outcomes, but there was a nonsignificant trend toward increased OAB in the weight gain group. It may be beneficial to counsel patients with regard to body weight maintenance after sling surgeries.

Evaluation of efficacy and safety of single-incision sling versus transobturator sling in women with stress incontinence and intrinsic sphincter deficiency.

INTRODUCTION AND HYPOTHESIS: Urethral intrinsic sphincter deficiency (ISD) is associated with severe urine leakage and a higher risk of sling failure. The aim of this study is to evaluate the efficacy and safety of single-incision slings (SISs) versus transobturator slings (TOSs) in such patients. METHODS: Patients who had stress incontinence and ISD who underwent SIS or TOS procedures from 2010 to 2017 were retrospectively reviewed. The objective and subjective cure rates and surgical adverse events were compared between different slings. Objective cure was defined as no stress urine leakage with a comfortably full bladder. Subjective cure was determined by the patient's satisfaction. Incontinence-related symptom distress and quality of life were evaluated using the short forms of the Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7). RESULTS: Among 111 patients, 37 underwent SIS and 72 underwent TOS with a median follow-up of 21 (range: 12-72) months and 24 (range: 14-84) months (p = 0.265). For both groups, the UDI-6, IIQ-7, and 1-h pad test all significantly improved after surgery (all p < 0.001). The objective and subjective cure rates were comparable after SIS and TOS procedures (objective: 76% vs. 76%, p = 0.837; subjective: 78% vs. 83%, p = 0.212). There were no significant differences in adverse events, except SISs had a shorter surgery time (16.4 ± 9.3 vs. 27.3 ± 12.4 min, p = 0.020) and lower postoperative visual analog scale pain score (1.3 ± 1.1 vs. 3.9 ± 1.4, p < 0.001). CONCLUSION: SISs and TOSs had similar surgical results in women with stress incontinence and ISD after at least 1 year of follow-up. However, SISs had a shorter operation time and lower postoperative pain than TOSs.

The Prevalence of Vaginal Flatus in Women With Pelvic Floor Disorders and Its Impact on Sexual Function.

BACKGROUND: Vaginal flatus is involuntarily passing gas from the vagina. Women seldom voluntarily report it, and related data are limited. AIM: To investigate the prevalence of vaginal flatus in women with pelvic floor disorders and its impact on sexual function. METHODS: This was an observational study involving women who visited a urogynecologic clinic in a tertiary medical center. Patients were asked about their experience of vaginal flatus. Other evaluations included urodynamics, genital prolapse stage, and quality-of-life questionnaires, including the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Urogenital Distress Inventory, and Incontinence Impact Questionnaire. OUTCOMES: Clinical characteristics, vaginal anatomic landmarks, stage of prolapse, urodynamic parameters, and quality-of-life scores were compared between women with and without vaginal flatus. RESULTS: Among 341 women, 118 (35%) reported vaginal flatus, which was more common in those who were younger (a mean age of 49.3 ± 9.2 years; range 25-74 years vs 49.3 ± 9.2 years; range 25-74 years, P < .001) and sexually active (98% vs 55%, P < .001). Women with vaginal flatus had significantly worse sexual function (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, 16.3 ± 15.9 vs 30.9 ± 8.0, P < .001) and incontinence-related quality of life (Urogenital Distress Inventory, 23.4 ± 10.5 vs 17.8 ± 8.9, P = .039; Incontinence Impact Questionnaire, 25.5 ± 14.5 vs 17.2 ± 12.5, P = .012). For frequency and bother, 48 of 116 (46%) women reported often or always having symptoms during sexual activity, 5 of 34 (15%) when performing daily activities, and 4 of 31 (12%) when exercising, and 70 of 116 (60%) felt least moderate bothersome during sexual activity compared with 2 of 34 (5%) when performing daily activities and 6 of 31 (18%) when exercising. CLINICAL IMPLICATIONS: Vaginal flatus is prevalent in women with pelvic floor disorders, particularly in those who are younger and sexually active. STRENGTHS & LIMITATIONS: The strength of this study is to evaluate the sexual function with validated questionnaires. The lack of data after pelvic floor management is the major limitation. CONCLUSIONS: Among women with pelvic floor disorders, those with vaginal flatus reported poorer sexual function. Routine counseling should be considered for these patients. Lau H-H, Su T-H, Chen Y-Y, et al. The Prevalence of Vaginal Flatus in Women With Pelvic Floor Disorders and Its Impact on Sexual Function. J Sex Med 2021;18:487-492.

Estrogen for the prevention of recurrent urinary tract infections in postmenopausal women: a meta-analysis of randomized controlled trials.

INTRODUCTION AND HYPOTHESIS: Recurrent urinary tract infections (rUTIs) are commonly encountered in postmenopausal women. Optimal non-antimicrobial prophylaxis for rUTIs is an important health issue. The aim of this study was to evaluate the use of estrogen in the prevention of rUTIs versus placebo. METHODS: Eligible studies published up to December 2019 were retrieved through searches of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. We included randomized controlled trials of estrogen therapies versus placebo regarding the outcomes of preventing rUTIs. Changes in vaginal pH and estrogen-associated adverse events were also analyzed. RESULTS: Eight studies including 4702 patients (2367 who received estrogen and 2335 who received placebo) were identified. Five studies including 1936 patients evaluated the use of vaginal estrogen, which resulted in a significant reduction in rUTIs (relative risk, 0.42; 95% CI, 0.30-0.59). Three studies including 2766 patients evaluated the outcomes of oral estrogen in the prevention of UTIs and showed no significant difference in the number of rUTIs compared to treatment with placebo (relative risk, 1.11; 95% CI, 0.92-1.35). Two studies reviewed changes in vaginal pH and showed a lower pH (mean difference, -1.81; 95% CI, -3.10--0.52) after vaginal estrogen therapy. Adverse events associated with vaginal estrogen were reported, including vaginal discomfort, irritation, burning, and itching. There was no significance increase in the vaginal estrogen group (relative risk, 3.06; 95% CI, 0.79-11.90). CONCLUSIONS: Compared with placebo, vaginal estrogen treatment could reduce the number of rUTIs and lower the vaginal pH in postmenopausal women.

Changes in Female Sexual Function After Vaginal Mesh Repair Versus Native Tissue Repair for Pelvic Organ Prolapse: A Meta-Analysis of Randomized Controlled Trials.

AIM: To evaluate changes in female sexual function after transvaginal mesh (TVM) repair versus native tissue repair for pelvic organ prolapse. METHODS: Eligible studies, published through November 2017, were retrieved through searches of ClinicalTrials.gov, MEDLINE, Embase, and Cochrane Review databases and associated bibliographies. We included randomized control trials of transvaginal prolapse surgery with either mesh repair or native tissue repair regarding the outcomes of sexual function, de novo and postoperative dyspareunia with a minimum of 3 months of follow-up. RESULTS: Seventeen trials including 2,976 patients (1,488 with TVM repair and 1,488 with native tissue repair) were identified. There was no significant difference in postoperative dyspareunia after TVM repair versus native tissue repair (risk ratio [RR] = 1.07; 95% confidence interval [CI] = 0.76-1.50). Likewise, there was no significant difference in de novo dyspareunia after TVM repair versus native tissue repair (RR = 0.91; 95% CI = 0.52-1.61). There was also no significant difference in the short form Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire score after TVM mesh repair versus native tissue repair (mean difference = 0.26; 95% CI = -1.34 to 1.85). CONCLUSION: Sexual function and de novo and postoperative dyspareunia were similar between the patients who underwent TVM repair and those who underwent native tissue repair. Liao S-C, Huang W-C, Su T-H, et al. Changes in Female Sexual Function After Vaginal Mesh Repair Versus Native Tissue Repair for Pelvic Organ Prolapse: A Meta-Analysis of Randomized Controlled Trials. J Sex Med 2019;16:633-639.

Treatment strategy for urinary frequency in women.

The purpose of this paper is to discuss the differential diagnosis of the underlying etiologies of urinary frequency and the treatment strategies for urinary frequency in women. Urinary frequency is a symptom, a sign, and a condition of uncertainty and of multifactorial cause. Common causes of urinary frequency include psychosocial, medical, sexual, urological, gynecologic, endocrine, and pharmacological in origin. Hence, treatment of symptoms and possible cures need a high-level plan or strategy to overcome the multifactorial etiology. Proper investigation of the chief complaint, history and physical examinations, is needed to evaluate urinary frequency. Pregnancy test, wet smear, urinalysis, midstream urine culture, frequency-volume charts, cystourethroscopy, urodynamics, and genitourinary imaging are the basic routine of office investigations. These tools promote the accuracy of the differential diagnosis of the underlying cause of urinary frequency. It is then often helpful to adopt an algorithmic approach to the management of this complaint. Treatment of urinary frequency might be empirical, and it remains a clinical challenge to gynecologists. To cure the disease, it is important to listen to the patient and consider the condition in all its aspects and use proven techniques.

Validation of a Mandarin Chinese version of the pelvic organ prolapse/urinary incontinence sexual questionnaire IUGA-revised (PISQ-IR).

INTRODUCTION AND HYPOTHESIS: Sexual dysfunction has a high prevalence in women with pelvic organ disorders. Until recently, there has been no single one questionnaire translated or validated that can evaluate the sexual function of patients with a pelvic floor disorder, either for sexually active or inactive women. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire IUGA-Revised (PISQ-IR) was developed to fill this gap. The aim of this study was to translate and validate the Mandarin Chinese version of PISQ-IR for global use. METHODS: This study was conducted with a sample of 106 patients. The PISQ-IR was translated and back-translated by two bilingual urogynecological specialists, and the Mandarin Chinese version was approved by the PISQ-IR Working Group of the International Urogynecological Association (IUGA). Its reliability was assessed using test-retest reliability and internal consistency, and its criterion validity was assessed in relation to other currently valid Chinese questionnaires. Both exploratory and confirmatory factor analyses were assessed. RESULTS: The mean age of the participants was 52 ± 10.6 years. The Cronbach alpha value for each subscale ranged from 0.65 to 0.84 and from 0.6 to 0.83 for the sexually active and inactive groups, respectively. The convergent validity test showed that the value of each subscale was positively correlated with those of other questionnaires (P < 0.05). Exploratory and confirmatory factor analysis illustrated both good factor extraction and model fit. CONCLUSION: This study demonstrated the Mandarin Chinese version of PISQ-IR is a valid, reliable and condition-specific instrument to assess sexual function in sexually active or inactive women with a pelvic floor disorder.

Changes in urodynamic measurements and bladder neck position after single-incision trans-vaginal mesh for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Stress urinary incontinence (SUI) is common in patients with pelvic organ prolapse. This study hypothesized that SUI may be persistent, de novo, or even cured in women after Elevate™ mesh repair alone and that SUI is associated with urodynamic changes and bladder neck position. METHODS: This secondary analysis included a study cohort of 100 women who underwent Elevate repair. All of them underwent multi-channel urodynamic measurements, 1-h pad test, and bead chain urethrocystography to measure the bladder neck position pre-operatively and at 3 months post-surgery. RESULTS: Fifty-five women with pelvic organ prolapse were continent and 45 had concomitant SUI. Of the 55 continent women, 19 (35%) had de novo SUI after mesh repair surgery and 5 (9%) subsequently underwent anti-incontinence surgery. Of the 45 incontinent women, 11 (24%) became dry after mesh repair without additional anti-incontinence surgery. Of the remaining 34 (76%) with persistent SUI, 15 (33%) underwent subsequent anti-incontinence surgery. Patients with de novo and persistent SUI had a greater decrease in maximal urethral closure pressure (MUCP) after mesh repair (p = 0.03 and 0.01 respectively). Those cured of SUI also had decreased MUCP (p = 0.12), but the bladder neck position while straining was significantly more elevated after mesh repair (p < 0.01) compared with those with persistent SUI. CONCLUSIONS: Elevate mesh reinforcement significantly decreases post-operative MUCP, which is associated with SUI, but can elevate the bladder neck position. Correcting a hyper-mobile urethra is associated with treatment of the concomitant SUI.

Changes in sexual function of women with refractory interstitial cystitis/bladder pain syndrome after intravesical therapy with a hyaluronic acid solution.

INTRODUCTION: Intravesical instillation with a hyaluronic acid (HA) solution is an effective treatment for interstitial cystitis/bladder pain syndrome (IC/BPS), but its impact on sexual functioning of patients is not known. AIM: The aim of this study was to evaluate the changes in sexual function of women with refractory IC/BPS who underwent a second-line intravesical HA therapy. METHODS: A total of 103 women diagnosed with refractory IC/BPS were enrolled in this prospective, multicenter study. Sexual function was evaluated using the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-9). Bladder-related symptoms and bother were assessed by the Interstitial Cystitis Symptom Index (ICSI) and Interstitial Cystitis Problem Index (ICPI), and a pain visual analog scale (VAS), respectively. Data were analyzed with univariate methods or multivariate logistic regression analysis accordingly. MAIN OUTCOMES MEASURES: Changes in PISQ-9, ICSI, ICPI, and pain VAS scores after treatment were assessed. RESULTS: Mean age and duration of symptoms was 43.6 ± 11.8 and 5.1 ± 5.0 years, respectively. ICSI, ICPI, and pain VAS scores were significantly (P < 0.001) improved after 1 month and 6 months of treatment. Of the 87 (84.5%) sexually active women evaluated, PISQ-9 total scores improved significantly (P < 0.001) from the baseline (mean 18.9 ± 6.4), after 1 month (20.4 ± 5.8), and 6-months (21.5 ± 5.6) of treatment. Significantly improved PISQ-9 items included "dyspareunia" (P < 0.001) and "negative reactions" (P = 0.015) during sexual intercourse, and "intensity" (P < 0.001) of sexual orgasms. After a logistic regression analysis, we found that a baseline PISQ-9 score was negatively correlated with the duration of IC/BPS symptoms (P = 0.022). Meanwhile, the changes in PISQ-9 scores were positively correlated with the reduction in ICSI scores after treatment (P = 0.045). CONCLUSIONS: Intravesical HA is an effective treatment for refractory IC/BPS. A longer duration of IC/BPS symptoms may be a predictor of poor sexual function. However, intravesical HA may improve sexual function along with the reduction of IC/BPS symptoms.

Single-incision mesh repair versus traditional native tissue repair for pelvic organ prolapse: results of a cohort study.

INTRODUCTION AND HYPOTHESIS: To compare the efficacy and safety of the Elevate™ anterior and posterior prolapse repair system and traditional vaginal native tissue repair in the treatment of stage 2 or higher pelvic organ prolapse. METHODS: A cohort study was conducted between January 2010 and July 2012. Patients who underwent transvaginal pelvic reconstruction surgery for prolapse were recruited. The primary outcome was anatomical success 1 year after surgery. The secondary outcome included changes in the quality of life and surgical complications. Recurrence of prolapse was defined as stage 2 or higher prolapse based upon the pelvic organ prolapse qQuantification system. RESULTS: Two hundred and one patients (100 in the Elevate™ repair group and 101 in the traditional repair group) were recruited and analyzed. The anatomical success rate of the anterior compartment was significantly higher in the Elevate™ repair group than in the traditional repair group (98 % vs 87 %, p = 0.006), but not for the apical (99 % vs. 6 %, p = 0.317) or posterior (100 % vs 97 %, p = 0.367) compartments after a median 12 months of follow-up. Both groups showed significant improvements in the quality of life after surgery with no statistical difference. Mesh-related complications included extrusion (3 %) and the need for revision of the vaginal wound (1 %). Those in the mesh repair group had a longer hospital stay (p = 0.04), operative time (p < 0.001), and greater estimated blood loss (p = 0.05). Other complications were comparable with no statistical difference. CONCLUSIONS: The Elevate™ prolapse repair system had a better 1-year anatomical cure rate of the anterior compartment than traditional repair, with slightly increased morbidity.

Impact of pelvic floor muscle training on sexual function in women affected by stress urinary incontinence.

Background: Pelvic floor muscle training can effectively improve pelvic floor muscle strength and activities; however, its impact on sexual function in women with stress urinary incontinence remains unclear. Aim: The study sought to investigate the impact of pelvic floor muscle training on pelvic floor muscle and sexual function in women with stress urinary incontinence. Methods: This was a retrospective observational study involving women who visited a urogynecologic clinic at a tertiary medical center. Patients with stress urinary incontinence without pelvic organ prolapse underwent pelvic floor muscle training programs that included biofeedback and intravaginal electrostimulation. Other evaluations included pelvic floor manometry, electromyography, and quality-of-life questionnaires, including the short forms of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, Urogenital Distress Inventory, and Incontinence Impact Questionnaire. Outcomes: Clinical characteristics, vaginal squeezing and resting pressure, maximal pelvic floor contraction, duration of sustained contraction, quality-of-life scores, and sexual function were compared between baseline and after the pelvic floor muscle training programs. Results: There were 61 women included in the study. The mean number of treatment sessions was 12.9 ± 6.3, and the mean treatment duration was 66.7 ± 32.1 days. The short forms of the Urogenital Distress Inventory (7.7 ± 3.8 vs 1.8 ± 2.1; P < .001) and Incontinence Impact Questionnaire (5.9 ± 4.3 vs 1.8 ± 2.0; P < .001) scores significantly improved after the pelvic floor muscle training program. In addition, all pelvic floor muscle activities significantly improved, including maximal vaginal squeezing pressure (58.7 ± 20.1 cmH2O vs 66.0 ± 24.7 cmH2O; P = .022), difference in vaginal resting and maximal squeezing pressure (25.3 ± 14.6 cmH2O vs 35.5 ± 16.0 cmH2O; P < .001), maximal pelvic muscle voluntary contraction (24.9 ± 13.8 µV vs 44.5 ± 18.9 µV; P < .001), and duration of contraction (6.2 ± 5.7 s vs 24.9 ± 14.6 s; P < .001). Nevertheless, the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire score demonstrated no significant improvement (28.8 ± 9.7 vs 29.2 ± 12.3; P = .752). Clinical Implications: Pelvic floor muscle training programs may not improve sexual function in women with stress urinary incontinence. Strengths and Limitations: The strength of this study is that we evaluated sexual function with validated questionnaires. The small sample size and lack of long-term data are the major limitations. Conclusion: Pelvic floor muscle training can improve pelvic floor muscle activities and effectively treat stress urinary incontinence; however, it may not improve sexual function.

The changes in bladder function and symptoms after robot-assisted sacrocolpopexy and transvaginal mesh surgery for pelvic organ prolapse.

OBJECTIVE: This study is aimed to compare the impact on bladder function and symptoms between robotic sacrocolpopexy (RSC) and transvaginal mesh surgery (TVM) in women with pelvic organ prolapse. MATERIALS AND METHODS: This prospective controlled study enrolled patients who received RSC or TVM at our hospital between March 2020 and June 2022. We compared preoperative and postoperative bladder function between two groups by using a questionnaire of lower urinary tract symptom (LUTs) for subjective assessment and urodynamic study for objective assessment. RESULTS: A total of 60 patients were enrolled, of whom 30 received RSC and 30 received TVM. In LUTs analysis, the RSC group had a higher risk of de novo stress urinary incontinence than the TVM group (33.3% vs. 3.3%, p = .007). Urodynamic studies showed that both groups had a deterioration in maximal urethral closure pressure postoperatively (RSC: 56.9 ± 17.1 vs. 44.2 ± 15.5 cmH2O; and TVM: 61.2 ± 29.4 vs. 47.6 ± 19.7 cmH2O, p < .01 and p = .03, respectively). The incidence of urodynamic stress incontinence was also significantly increased after RSC (33.3% vs. 76.7%, p = .01). The de novo urodynamic stress incontinence rate was 46.7% after RSC, which was not significantly different to the TVM group (26.7%, p = .16). In the TVM group, the incidence of voiding difficulty decreased after surgery (43.3% vs. 10.0%, p < .01), and urodynamic measurements revealed that the prevalence of urine retention decreased (43.3% vs. 16.7%, p < .01). In the RSC group, the incidence of incomplete emptying sensation decreased (36.7% vs. 13.3%, p = .04), and urodynamic measurements showed that none of the patients had bladder outlet obstruction, underactive detrusor, or urine retention after surgery. CONCLUSION: RSC and TVM are both beneficial to improve voiding function in women with pelvic organ prolapse. However, a deterioration in urethral function was observed and the de novo SUI rate was higher in the RSC group than in the TVM group.

A prospective study of transobturator tape as treatment for stress urinary incontinence after transvaginal mesh repair.

INTRODUCTION AND HYPOTHESIS: The transobturator suburethral sling is a common surgical treatment for stress urinary incontinence (SUI). In patients with incontinence after trocar-guided transvaginal mesh repair (Prolift), data on outcome remain limited. In the present study, we hypothesized that transobturator tape in such cases is assumed to be as effective as surgery alone. METHODS: This was a prospective analysis of outcomes of transobturator slings in women who had undergone transvaginal mesh repair and in those who underwent sling surgery alone (controls). Objective cure was defined as the absence of urinary leakage during the stress test at filling cystometry and a negative cough test during pelvic examination. The success rates were evaluated 3-6 months postoperatively. RESULTS: One hundred women were recruited for the study. Compared to the control group, women after transvaginal mesh repair had a significantly lower objective success rate (62 vs 86%, p = 0.005) and poorer bladder neck mobility (0.5 ± 0.8 vs 1.1 ± 0.5 cm, p = 0.001). CONCLUSIONS: The transobturator sling has lower objective success rate in women after transvaginal mesh that may be due to decreased bladder neck mobility. Patients with post-mesh repair SUI who opt for sling surgery should be informed of these less satisfactory outcomes during preoperative counseling.

Pressure-Volume Loop Analysis of Voiding Workload: An Application in Trans-Vaginal Mesh-Repaired Pelvic Organ Prolapse Patients.

Although trans-vaginal mesh (TVM) offers a successful anatomical reconstruction and can subjectively relieve symptoms/signs in pelvic organ prolapse (POP) patients, its objective benefits to the voiding function of the bladder have not been well established. In this study, we investigated the therapeutic advantage of TVM on bladder function by focusing on the thermodynamic workload of voiding. The histories of 31 POP patients who underwent TVM repair were retrospectively reviewed. Cystometry and pressure volume analysis (PVA) of the patients performed before and after the operation were analyzed. TVM postoperatively decreased the mean voiding resistance (mRv, p < 0.05, N = 31), reduced the mean and peak voiding pressure (mPv, p < 0.05 and pPv, p < 0.01, both N = 31), and elevated the mean flow rate (mFv, p < 0.05, N = 31) of voiding. While displaying an insignificant effect on the voided volume (Vv, p < 0.05, N = 31), TVM significantly shortened the voiding time (Tv, p < 0.05, N = 31). TVM postoperatively decreased the loop-enclosed area (Apv, p < 0.05, N = 31) in the PVA, indicating that TVM lessened the workload of voiding. Moreover, in 21 patients who displayed postvoiding urine retention before the operation, TVM decreased the residual volume (Vr, p < 0.01, N = 21). Collectively, our results reveal that TVM postoperatively lessened the workload of bladder voiding by diminishing voiding resistance, which reduced the pressure gradient required for driving urine flow.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence.

BACKGROUND: Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI. OBJECTIVES: To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures. METHODS: Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO). SELECTION CRITERIA: The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus. RESULTS: The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI. CONCLUSIONS: Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

Minimal requirement in urogynecological knowledge for obstetrics and gynecology specialists.

OBJECTIVE: To investigate the current knowledge and practice patterns of obstetrics and gynecology (obs/gyn) physicians regarding the diagnosis, evaluation, and management of pelvic floor disorders (PFD) including stress urinary incontinence (SUI), pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTS). The knowledge related to urodynamic study (UDS) is also evaluated. MATERIALS AND METHODS: A 25-item questionnaire was developed and sent for the physician members who participated in the annual congress of Taiwan Association of Obstetrics and Gynecology (TAOG). Response to the questionnaire was voluntary and anonymous. The questionnaires were collected prior to the ending of the congress. RESULTS: 2000 copies of the questionnaire were sent and 1443 TAOG members responded. 86 poor respondents and 45 copies from urogynecologists were excluded. 1312 copies of the completed questionnaires were analyzed. 77.7% of the respondents were male physicians and 50.6% were over 55 years old. Up to 53.7% of the physicians had completed their residency training for over twenty years. Generally, around half of the respondents didn't reach well a level of well understanding regarding the various PFD. Most of the physicians would like to have further knowledge in urogynecological field for their daily practice. Regular delivery of updated information about various urogynecological diseases is mandatory. CONCLUSION: With the aging population worldwide, the need for management of PFD is increasing. The obs/gyn physician plays an important role in the primary evaluation and management of PFD. This study offered important information related to the current investigation, management, practice patterns and future expectation from obs/gyn physicians as references for the future continuing medical education programs.

Five-year results of no-fault compensation related to childbirth injuries in Taiwan.

OBJECTIVE: Increasing obstetric medical litigations had great impacts in health care system resulted in lower recruitment of residents and higher medical cost of defensive medicine in Taiwan. In order to reduce medical litigation, the "Childbirth Accident Emergency Relief Act" was implemented in June 2016. This study presented five-year results of a novel childbirth accident compensation system. MATERIALS AND METHODS: The purpose of the Relief Act was to establish a national relief system to ensure timely relief, reduce medical disputes, promote the partnership between patient and medical personnel. The compensations included maximal 2 million NTD for maternal death, maximal 0.3 million NTD for neonatal and fetal deaths, and 3, 2, and 1.5 million NTD for maternal or neonatal profound, severe, and moderate disabilities, respectively. Puerperal hysterectomy was included with maximal 0.8 million NTD compensation. RESULTS: Since June 30, 2016 to June 30, 2021, there were 1340 applications reviewed by Committee and 1258 were approved with total relief of 744.7 million NTD (26.6 million USD) with approve rate of 93.9%. It took an average of 109.8 days to start application from childbirth and 102.4 days to get compensation from application. 66.1% of accident victims agreed this system can restore doctor-patient relationship by immediate care and assistance from medical institutions. CONCLUSION: The Relief Act is the first government leading compensation system to establish a national relief system. It was enacted to reduce medical disputes, promote the partnership between patient and medical personnel, and enhance health and safety of women during childbirth. A no-fault compensation would be an efficient alternative disputes resolution to childbirth accidents.

Efficacy of Biofeedback and Electrostimulation-Assisted Pelvic Floor Muscle Training between Women with Mild and Moderate to Severe Stress Urinary Incontinence.

BACKGROUND: To evaluate the efficacy of biofeedback and electrical stimulation-assisted pelvic floor muscle training (PFMT) between women with mild and moderate to severe stress urinary incontinence (SUI). METHODS: This retrospective cohort study was conducted at a single center from 2014 to 2021. We included 57 patients with urodynamically proven SUI who underwent a biofeedback and electrical stimulation-assisted PFMT. They were categorized into mild and moderate to severe SUI. One-hour pad test from 2 to 10 g was defined as mild SUI, and ≥11 g was defined as moderate to severe SUI. RESULTS: Fifty-seven patients were reviewed during the study period. Incontinence-related symptoms of distress, including the UDI-6, ISI, and VAS, all significantly improved in the mild SUI group (p = 0.001, p = 0.001 and p = 0.010, respectively), while only UDI-6 and VAS statistically improved in the moderate to severe SUI group (p = 0.027 and p = 0.010, respectively). There was significant improvement in IIQ-7 in the mild SUI group during serial treatments, but only in Session 6 in the moderate to severe SUI group. After 18 sessions of treatment, the UDI-6, ISI, and IIQ-7 scores showed significantly greater improvements in the mild SUI group compared to the moderate to severe SUI group (p = 0.003, p = 0.025, and p = 0.002, respectively). CONCLUSIONS: Although biofeedback and electrical stimulation-assisted PFMT is an effective treatment option for SUI, it is more beneficial for patients with mild SUI and a 1-h pad weight ≤ 10 g urine leak.

Modification of bladder thermodynamics in stress urinary incontinence patients submitted to trans-obturator tape: A retrospective study based on urodynamic assessment.

Importance: It needs to be clarified whether trans-obturator tape (TOT)-enhanced urethral resistance could impact the voiding function. Objective: Although TOT has been well-recognized for enhancing urethral resistance to restore continence in stress urinary incontinence (SUI) patients, whether the bladder's voiding functions adapt to the TOT-enhanced resistance has not been adequately investigated. This study thereby aimed to investigate whether TOT impacts the bladder's thermodynamic efficacy during the voiding phase. Design: A retrospective analysis of urodynamics performed before and after TOT was assessed. Setting: A tertiary referral hospital in Taiwan. Participants: A total of 26 female SUI patients who underwent urodynamic investigations before and after TOT. Main outcomes and measures: The area enclosed by the pressure-volume loop (Apv), which represents the work performed by the bladder during voiding, in a pressure-volume analysis established by plotting the detrusor pressure versus intra-vesical volume was retrospectively analyzed. Paired Student's t-tests were employed to assess the difference in values before and after the operation. Significance in difference was set at p < 0.05. Results: TOT increased Apv in 20 of 26 (77%) patients and significantly increased the mean Apv compared to the preoperative control (2.17 ± 0.18 and 1.51 ± 0.13 × 103 cmH2O-ml, respectively p < 0.01). TOT also increased the mean urethral resistance (1.03 ± 0.30 vs. 0.29 ± 0.05 cmH2O-sec/ml, p < 0.01) and mean voiding pressure (25.87 ± 1.72 and 19.30 ± 1.98 cmH2O p < 0.01) but did not affect the voided volume and voiding time. Moreover, the TOT-induced Apv increment showed a moderate correlation with the changes in urethral resistance and voiding pressure (both r > 0.5) but no correlation with changes in voided volume or voiding time. It is remarkable that the TOT-induced urethral resistance increment showed a strong correlation with changes in voiding pressure (r > 0.7). Conclusion and Relevance: The bladder enhances thermodynamic efficacy by adapting the voiding mechanism to increased urethral resistance caused by TOT. Further studies with higher case series and longer follow-ups should assess whether this effect could be maintained over time or expire in a functional detrusor decompensation, to define diagnostic criteria that allow therapeutic interventions aimed at its prevention during the follow-up. Clinical Trial Registration: (clinicaltrials.gov), identifier (NCT05255289).

Outcome of transvaginal pelvic reconstructive surgery with Prolift after a median of 2 years' follow-up.

INTRODUCTION AND HYPOTHESIS: This study seeks to analyze the medium- to long-term outcome of transvaginal pelvic reconstructive surgery using the Prolift™ system for pelvic organ prolapse. METHODS: Sixty-five patients who underwent pelvic floor reconstruction using Prolift™ were followed for 1 to 3 years postoperatively. Assessment included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7) scores. RESULTS: The overall anatomic success rate was 97% after a median of 24.5 months and 94% for the 34 women followed for more than 2 years. POP-Q stage, UDI-6, and IIQ-7 scores all improved significantly after surgery. Complications included one bladder perforation (1.5%) and one bowel perforation (1.5%), prolonged catheterization in four patients (6%), and mesh erosion in one (2%). Eight received blood transfusion (12%). CONCLUSIONS: Prolift™ surgery yielded a good anatomical outcome and satisfactory symptom improvement that appeared to be durable after 2 years.