Effect of pelvic floor status on the outcome of pelvic organ prolapse surgery.

Pelvic organ prolapse (POP) is a common diagnosis with an incidence in the population of up to 50%. POP causes restrictions in everyday life and reduces patients' quality of life. Therapy is either conservative in the form of physiotherapy or the use of different types of pessaries, possibly. in case of inappropriateness or failure of conservative treatment, an operative solution is chosen. Avulsion injury of the levator ani muscle (MLA) is a strong factor in the development of POP. Some patients undergo repeated surgeries for POP, negatively impacting their quality of life. Studies show that the stage of POP and avulsion injury is associated with an increased risk of recurrence after index prolapse surgery. Ultrasound diagnosis of MLA injuries might help in predicting the risk of recurrence. Assessment of pelvic floor function is crucial for the success of surgical management of POP.

Timing of caesarean section and its impact on levator ani musle avulsion at the first subsequent vaginal birth - a pilot study.

OBJECTIVE: The aim of this multicentric observational study was to explore the impact of the timing of cesarean section (SC) on levator (MLA - levator ani musle) avulsion at the first subsequent vaginal birth. METHODS: All women after term vaginal birth following a cesarean section (VBAC) for their second delivery at the Departments of Gynecology and Obstetrics, Faculty of Medicine, Charles University and University Hospital in Pilsen and the 1st Faculty of Medicine, Charles University and General Hospital in Prague, between 2012 and 2016 were identified. Hospital database and surgical notes were used to collect basic characteristics of the patients including the indication and course of their previous delivery. These women were divided into two groups according to indication of prior SC in the previous delivery to women with elective SC and acute SC. All participants were invited for a 4D pelvic floor ultrasound to assess levator trauma. Levator avulsion and the levator hiatus area were assessed off-line from the stored pelvic floor volumes. Data were statistically assessed. RESULTS: A total of 356 women had a VBAC for their second delivery during the study period. Of these, 152 (42.7%) attended the ultrasound examination and full data were available for 141 women for statistical analyses. These were further divided into 80 women after acute SC and 61 women after elective SC. The levator avulsion rate was higher in the elective SC subgroup, but the difference was not significant (26.3 vs. 41.0%, P = 0.0645). No statistical differences in urogenital hiatus enlargement and ballooning were observed. CONCLUSION: VBAC is associated with a significantly higher rate of levator ani avulsion compared to the first vaginal birth in nulliparous women. However, it seems that risk of levator ani avulsion doesnt depend on the timing of SC in previous labor. More studies are needed to confirm the results of this pilot study.

Laparoscopic removal of intravesically inserted transobturator tape.

INTRODUCTION AND HYPOTHESIS: The aim of this video is to provide a step-by-step description of our approach to the surgical management of intravesically localized transobturator tape after previous failure of repeated cystoscopic tape resection. METHODS: This video presents a patient with tape erosion to the urinary bladder after repeated cystoscopic tape resection, recurrent stone formation, and repeated lithotripsy, with recurrent urinary tract infections and overactive bladder (OAB) with urgency incontinence. RESULTS: During the laparoscopy procedure tape was identified in the left obturator muscle, cut near the obturator muscle, and dissected up to the bladder wall. Afterward, a vertical 2-cm incision was made in the bladder wall, the stone was removed, and the rest of the tape was dissected from the bladder wall. A two-layer suture of the bladder wall was performed. The postoperative course was uneventful. In follow-up visits 3 and 6 months after surgery the patient was continent with no symptoms of OAB. CONCLUSIONS: Cystoscopic resection of protruded mesh is inadequate in many cases. In such cases the mesh should be removed from the urinary bladder wall completely. Laparoscopy allows minimally invasive complete removal of the tape, combining resection of the extravesical and intravesical parts of the tape.

Is the fixation of single incision TVT-S tape as good as that of transobturator tape? An ultrasound study of randomized trial results.

INTRODUCTION: TVT-Secur (TVT-S) was the first single-incision sling available on the market and was soon found to have less efficacy than mid-urethral slings. Our aim was to assess the position and tape descent following TVT-O and TVT-S H in a U procedure and, based on this evaluation, to find the possible reason for lower TVT-S surgery efficacy. METHODS: We conducted an ultrasound study of a randomised trial with a 3-year follow-up that took place between 2007 and 2009 and included 197 women with urodynamic stress urinary incontinence. Of these, 67 were allocated to receive the TVT-O procedure, 64 to TVT-S in the H position, and 65 in the U position. Patients underwent a complete urogynaecological and ultrasound examination. The positions of the bladder neck and the tape after surgery were assessed and the data obtained compared between groups. RESULTS: Our primary study showed a significantly higher rate of positive stress tests in the TVT-S groups compared to the TVT-O group. After surgery, there was no difference between the position of the tape at rest and at maximal Valsalva between the groups. In TVT-O patients, the mean length of the upper tape margin descent increased from 6 mm on the 1st day after surgery to 9 mm 3 months after surgery and remained stable afterwards. For TVT-S patients, there was a further increase of up to 15 mm in tape descent after 3 months. CONCLUSIONS: Our results show that the lower efficacy of TVT-S might be due to inadequate fixation and increasing tape descent.

Obstetric anal sphincter injury and anal incontinence.

OBJECTIVE: The aim of our study is to clarify the problems of OASI (obstetric anal sphincter injuries) and anal incontinence and prevention of this injury. METHODS: Review of articles in peer reviewed journals with the usage of Google Scholar function and PubMed. CONCLUSION: OASI is a severe injury which is more commonly associated with assisted vaginal delivery. This injury cannot be fully prevented, but its incidence can be averted by the usage of selective mediolateral episiotomy, or by other precautionary moves in high risk patients. The treatment of anal incontinence after OASI requires a complex approach and thorough examination. At first delivery, OASI is not a stern indication for caesarean section in accordance with current state of knowledge.

Impact of residual defect of anal sphincter on patients quality of life

AIM: The aim of this retrospective study is to correlate the presence of residual anal sphincter defect with the quality of life of patients after vaginal delivery complicated with obstetrical anal sphincter injury. STUDY GROUP AND METHODS: Patients diagnosed with obstetrical anal sphincter injury are dispensed at our urogynecological unit, with a mean follow-up period of 37 months. Two investigators blinded to the results of clinical symptoms evaluated archived ultrasound volumes taken for the presence of residual anal sphincter defects that were later correlated with the St. Mark's Incontinence Score. RESULTS: The group comprises of 181 patients diagnosed with an obstetrical anal sphincter injury who underwent ultrasound examination of anal sphincter at three post-partum months. The questionnaires were completed by 118 patients (65.2% of all patients). A residual sphincter defect was diagnosed in seven cases (5.9%). In the group with residual defects, fecal urgency (lack of ability to defer defecation) was present in 57.1%. In the group without residual anal sphincter defects, fecal urgency was present in 12.6%. This difference is significant (< 0.001) with the contingency coefficient 0.291. CONCLUSIONS: In conclusion, the presence of residual anal sphincter defect increases the probability of fecal urgency.

Colpocleisis with a skin flap.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse is a common problem affecting up to 50% of women over the age of 50. The various methods of reconstructive pelvic organ prolapse surgery have been reported to be associated with long-term recurrence rates of up to 50%. METHODS: Management of patients with repeated failure of different surgical procedures is often challenging. Obliterative surgery can be an option for women with a POP-Q stage 2 or larger genital prolapse who are not sexually active. The video of the procedure shows how to address enterocele with frail and puffy vaginal epithelium of the posterior vaginal wall after unsuccessful surgery procedures by employing a perineal skin flap. The repeated enterocele was treated by using a skin flap during a LeFort colpocleisis, and Labhard perineoplasty was added. RESULTS: In some patients obliterative surgery may fail, especially those with recurrent POP. The use of a perineal skin flap in reoperation of POP is a possible solution for surgical treatment of recurrent enterocele with poor quality of the posterior vaginal wall. This patient's postoperative course was uneventful. At her follow-up visit 2 months later an examination revealed excellent healing. CONCLUSION: Obliterative surgery can be an option for women with large prolapses who are not sexually active and do not plan to be so in the future. Le Fort with perineal skin flap and Labhard high perineoplasty is one possible surgical technique which can treat recurrent pelvic organ prolapse in older patients where previous procedures have failed.

Surgical management of recurrent urethrovaginal fistula with a skin island flap.

INTRODUCTION AND HYPOTHESIS: A urethrovaginal fistula is a possible rare complication of tension-free vaginal tape procedures. Surgical management of these fistulas is sometimes complicated, and failure can occur. The operation is difficult when the defect between the urethra and the vagina is larger or scarred, so surgical intervention and the preferred technique are controversial. METHODS: The patient was referred to our department, where the first operation was performed to address the urethrovaginal fistula by the transvaginal and transabdominal approach with interposed omentum. This initial repair failed, resulting in a large urethrovaginal fistula with minimal redundant anterior vaginal wall to provide a tension-free closure. This video presentation describes the second operation-transvaginal repair of a large recurrent urethrovaginal fistula using the skin island flap technique. RESULTS: The video of the procedure shows how to address a recurrent urethrovaginal fistula by employing a skin flap. An examination during the patient's follow-up visit 3 months later revealed excellent healing and persistent stress urinary incontinence (SUI). Six months after the fistula repair, the patient underwent a bulking agent procedure. CONCLUSIONS: The skin island flap procedure allowed the larger defect to heal, though it did not address the SUI, which was later treated by application of a bulking agent.

What is the optimal length for single-incision tape?

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the length of adjustable single-incision midurethral tape (SIMS; Ajust), which is needed to fix this tape to the obturator membrane. From these data, we can deduce the optimal length of the SIMS. METHODS: For this study, we employed the intra-operative data of patients included in a single-center randomized trial comparing the efficacy of Tension free vaginal tape obturator (TVT-O) and Ajust. The length of the Ajust tape was calculated using the formula: total length of the tape minus the length of the stylet used for the tape lock, minus the length of the lock minus the width of the two anchors. The length of the obturator tape was calculated using the formula: total tape length minus the snipped parts of the tape. The correlation coefficient of the tape length to basic biometric parameters, such as height, weight, and body mass index, was calculated. RESULTS: For this study, data from 50 women from each group, TVT-O and Ajust, were used. The mean length of the Ajust tape inside the body is 11.6 cm (SD 0.9), with a minimum length of 9.6 cm and a maximum length of 14.6 cm. The mean length of TVT-O tape inside the body is 20.3 cm (SD 2.1), with a minimum of 14.8 cm and a maximum length of 24.5 cm. CONCLUSIONS: This study demonstrates that to achieve continence it is necessary to use different lengths of single-incision tape. Inappropriate SIMS length could cause failure related to the tape itself and not to the TVT technique.

Effect of severity of urinary incontinence on quality of life in women.

AIMS: While the effect of different types of incontinence on the quality of life (QoL) has been clearly documented, the information about the impact of incontinence severity on QoL in women is lacking. Therefore, we investigated whether increasingly severe degrees of incontinence were linearly correlated with poorer QoL. METHODS: We included 391 incontinent women and 81 continent volunteers in the study and assessed them in accordance with routine clinical practice. A 24 h pad-weight test was used to objectively quantify the incontinence severity. We then stratified participants according to incontinence type and severity and assessed correlations between incontinence severity and Patient Perception of Bladder Condition (PPBC), International Consultation on Incontinence short-form questionnaire (ICIQ-SF), and King's Health Questionnaire (KHQ) quality of life scores in the entire study population and in individual groups according to incontinence type. RESULTS: Minimal incontinence was associated with significant negative impact on QoL, as measured by all quality of life assement tools. There were nonlinear correlations between scores on individual questionnaires and daily leakage volumes. Stress urinary incontinence had a weaker impact on quality of life than urge or mixed incontinence, as measured by PPBC (P < 0.0001), KHQ part 1 (P < 0.0001), and KHQ part 2 (P < 0.001). Stress urinary incontinence also had a weaker impact on QoL than mixed incontinence as measured by ICI-Q (P = 0.007). CONCLUSIONS: This study demonstrated that even mild urinary leakage significantly reduces the QoL, while subsequent increase in the degree of incontinence has only minimal additional effect. There was no linear correlation between incontinence severity and QoL.

Are the same tapes really the same? Ultrasound study of laser-cut and mechanically cut TVT-O post-operative behavior.

INTRODUCTION AND HYPOTHESIS: TVT-O production has been modified to laser cutting from mechanical cutting. We compared the behavior of laser and mechanically cut tension-free vaginal tape-obturator (TVT-O) using ultrasound at various time points after surgery. METHODS: This is a retrospective analysis of clinical and ultrasound data from two previously reported randomized controlled trials with TVT-O. Behavior of mechanically cut TVT-O implanted in January 2007 to November 2009 and laser-cut TVT-O implanted in May 2010 to May 2012 was assessed by ultrasound at day 1, the 2nd week, the 3rd month, and the 1st and 2nd years post-operatively. Bladder neck and tape margins positions were described by coordinates in the orthogonal system calculated from polar coordinates. Tape mobility was measured as a change in the upper and lower tape margin position from rest to maximal Valsalva. Comparison of 2-year subjective and objective surgery outcomes was also performed. RESULTS: In total, 68 mechanically cut and 50 laser-cut TVT-Os were implanted. Follow-up data were available from 49 and 45 women respectively. No differences in any baseline characteristics or bladder neck mobility were observed. Significantly lower tape mobility was observed on day 1 and week 2 after mechanically cut TVT-O, although subsequent mobility was comparable to laser-cut TVT-O. The subjective and objective surgery outcomes were comparable. CONCLUSIONS: Although without clinical significance, early postoperative behavior of the mechanically cut and laser-cut TVT-O tapes differs. The less stiff, mechanically-cut TVT-O loosens within 2 weeks of implantation, whereas the stiffer, laser-cut TVT-O keeps its tension.

Variability in practice patterns in stress urinary incontinence and pelvic organ prolapse: results of an IUGA survey.

INTRODUCTION AND HYPOTHESIS: Members of the International Urogynecological Association (IUGA) come from different geographic locations and practice settings. A member survey regarding practice patterns provides valuable information for practitioners and researchers alike, and allows the IUGA to discover areas to focus on education and information dissemination. METHODS: A questionnaire was developed by the IUGA Research and Development committee and distributed electronically to IUGA surgeons. Answers were analyzed in reference to demographics, geographic distribution, and academic affiliation. RESULTS: Five hundred sixty-four members answered the questionnaire, representing a 28 % response rate, and closely reflecting the geographic distribution of IUGA membership. Preferred surgical treatment for uncomplicated SUI was the mid-urethral trans-obturator sling (49.7 %). Vaginal mesh was mainly used for repair of recurrent POP (20.4 %). Pessary use was offered "always" or "frequently" by 61.5 %, with no difference in academic affiliation, but significant differences based on region of practice. Compared to practitioners in non-academic centers, those with academic affiliation utilized Urodynamic studies (UDS) and Magnetic Resonance Imaging (MRI) more frequently in the evaluation of POP. Regions of practice significantly influenced the majority of practice patterns, with the highest impact found in the use of robotic assistance. CONCLUSIONS: Many practice patterns in the evaluation and treatment of POP and SUI depend on academic affiliation and geographic location. Practice patterns are not always based on most recent evidence-based data.

TVT ABBREVO: cadaveric study of tape position in foramen obturatum and adductor region.

INTRODUCTION AND HYPOTHESIS: The aim of the study was to describe fixation of the TVT ABBREVO and establish whether the tape penetrates through obturator muscles and membrane (obturator complex) into the adductor region and, if so, how far it penetrates. METHODS: Eight formalin-embalmed female cadavers were used to simulate TVT ABBREVO surgery (totalling 16 insertions). Following tape insertion, dissection was performed and ends of the tape were identified. In cases of penetration, the length of tape penetrating into the adductor region was measured. RESULTS: Of the 16 cases, the tape ended in the obturator membrane in eight, in the internal obturator muscle in one, and penetrated through the obturator membrane into the external obturator muscle in five, where it remained. In two cases, it penetrated through the obturator internus muscle, obturator membrane and obturator externus muscle into the group of thigh adductors; one penetration was by 3 mm and the second by 10 mm. No contact with the obturator nerve or its branches was noted in any case. CONCLUSIONS: No TVT contact with the obturator nerve was noted; tape penetrated into the adductor region in two of the 16 cases.

Comparison of the efficacy of tension-free vaginal tape obturator (TVT-O) and single-incision tension-free vaginal tape (Ajust™) in the treatment of female stress urinary incontinence: a 1-year follow-up randomized trial.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare the efficacy of the tension-free vaginal tape obturator (TVT-O) and single-incision tension-free vaginal tape (Ajust™) in the treatment of stress urinary incontinence in a randomized two-arm study with a 1-year follow-up. METHODS: This single-centre randomized trial compared the objective and subjective cure rates of TVT-O and Ajust using objective criteria (cough test) and subjective criteria (International Consultation on Incontinence Questionnaire short form, ICIQ-UI SF). The objective cure rate was defined as the number of patients with a negative cough stress test. Subjective cure was defined as no stress leakage of urine after surgery based on the ICIQ-UI SF. The primary outcome was to establish differences in objective and subjective cure rates between the TVT-O and Ajust groups. We also compared postoperative pain profiles using a visual analogue scale (VAS), improvement in quality of life using the ICIQ- UI SF and the Incontinence Quality of Life questionnaire, and overall satisfaction with the surgical procedure using a VAS and a five-item Likert scale. Inclusion criteria were age over 18 years, signed informed consent, and urodynamic stress urinary incontinence. Following a power calculation, 50 patients were enrolled into each group (Ajust and TVT-O). RESULTS: The mean follow-up after surgery was 445 days (SD 157.6 days) in the TVT-O group and 451.8 days (SD 127.6 days) in the Ajust group (p = 76.6 %). At 1 year, 47 patients were evaluated in the TVT-O group and 49 in the Ajust group. No differences in subjective cure rates or objective cure rates were observed. In the Ajust and TVT-O groups, the rates for no subjective stress leakage were 89.8 % and 91.5 %, respectively (p = 1.0, OR 1.22, 95 % CI 0.24 - 6.58), and the rates for a negative stress test were 89.8 % and 87.2 %, respectively (p = 0.76, OR 0.77, 95 % CI 0.17 - 3.32). In the Ajust group two patients reported de novo pain during sexual intercourse. CONCLUSIONS: After a 1-year-follow-up, no significant differences were found with regard to subjective and objective outcomes between the single-incision tape Ajust and TVT-O.

Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion.

INTRODUCTION AND HYPOTHESIS: This committee opinion paper summarizes available evidence about recurrent pelvic organ prolapse (POP) to provide guidance on management. METHOD: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development Committee was formed. The literature regarding recurrent POP was reviewed and summarized by individual members of the subcommittee. Recommendations were graded according to the 2009 Oxford Levels of Evidence. The summary was reviewed by the Committee. RESULTS: There is no agreed definition for recurrent POP and evidence in relation to its evaluation and management is limited. CONCLUSION: The assessment of recurrent POP should entail looking for possible reason(s) for failure, including persistent and/or new risk factors, detection of all pelvic floor defects and checking for complications of previous surgery. The management requires individual evaluation of the risks and benefits of different options and appropriate patient counseling. There is an urgent need for an agreed definition and further research into all aspects of recurrent POP.

Bleeding complication with the TVT-Exact procedure: a report of two cases.

Midurethral tension-free vaginal tapes (TVT), placed through the retropubic space or through the obturator foramina, are widely used for the surgical treatment of female stress urinary incontinence. Some complications are associated with retropubic tapes owing to the passage of the tape through the space of Retzius. One of the most frequent complications is bleeding, and if injury to major vessels is involved, this may be life-threatening. In 2010, the Gynecare TVT-Exact® Continence System was introduced onto the market, with a rigid trocar shaft measuring 3.0 mm in diameter. We have no clinical data regarding the complication rate, especially concerning bleeding, connected with this device; all data are related to the original size of the TVT inserter. The cases presented demonstrate that bleeding complications can occur with the TVT-Exact procedure.

Fixation of the Ajust minisling based upon cadaveric study.

INTRODUCTION AND HYPOTHESIS: The objective was to describe the fixation site of the anchor of the Ajust mid-urethral minisling. METHODS: This cadaveric study was based on a group of 11 formalin-embalmed bodies with legs positioned in 30° flexion and 30° abduction, and a group of five fresh-frozen bodies with legs positioned as normal during the procedure. The groups were later compared. The fixation site was dissected and described. The distance to the obturator bundle was considered as the primary safety parameter. To compare the groups of fresh-frozen bodies and formalin-embalmed bodies, the Student's t test and Mann-Whitney test were used. RESULTS: In the group of formalin-embalmed bodies the mean distance from the anchoring device to the obturator nerve was 4.23 cm. In 19 cases out of 22 the anchor was within the complex of the obturator membrane and obturator muscles. In the group of fresh frozen bodies the mean distance to the obturator nerve was 3.15 cm. In 9 cases out of 10 the anchor was in the complex of the obturator membrane and obturator muscles. CONCLUSION: The distance from the anchor to the obturator nerve was more than 2 cm in all cases. Correct placement in the obturator membrane was achieved in 65.6 % of cases. In 87.5 % of cases the anchor was placed within the complex of obturator membrane and obturator muscles.