Serious complications and recurrences after retropubic vs transobturator midurethral sling procedures for 2682 patients in the VIGI-MESH register.

BACKGROUND: Midurethral slings are the gold standard for treating stress urinary incontinence, but their complications may raise concerns. Complications may differ by the approach used to place them. OBJECTIVE: This study aimed to compare serious complications and reoperations for recurrence after midurethral sling procedures when using the retropubic vs the transobturator route for female stress urinary incontinence. STUDY DESIGN: This analysis was of patients included in the French, multicenter VIGI-MESH register since February 2017 who received a midurethral sling for female stress urinary incontinence either by the retropubic or the transobturator route and excluded patients with single-incision slings. Follow-up continued until October 2021. Serious complications (Clavien-Dindo classification ≥ grade III) attributable to the midurethral sling and reoperations for recurrence were compared using Cox proportional hazard models including any associated surgery (hysterectomy or prolapse) and a frailty term to consider the center effect. Baseline differences were balanced by propensity score weighting. Analyses using the propensity score and Cox models were adjusted for baseline differences, center effect, and associated surgery. RESULTS: A total of 1830 participants received a retropubic sling and 852 received a transobturator sling in 27 French centers that were placed by 167 surgeons. The cumulative 2-year estimate of serious complications was 5.8% (95% confidence interval, 4.8-7.0) in the retropubic group and 2.9% (95% confidence interval, 1.9-4.3) in the transobturator group, that is, after adjustment, half of the retropubic group was affected (adjusted hazard ratio, 0.41; 95% confidence interval, 0.3-0.6). The cumulative 2-year estimate of reoperation for recurrence of stress urinary incontinence was 2.7% (95% confidence interval, 2.0-3.6) in the retropubic group and 2.8% (95% confidence interval, 1.7-4.2) in the transobturator group with risk for revision for recurrence being higher in the transobturator group after adjustment (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-2.9); this surplus risk disappeared after exclusion of the patients with a previous surgery for stress urinary incontinence. CONCLUSION: The transobturator route for midurethral sling placement is associated with a lower risk for serious complications but a higher risk for surgical reoperation for recurrence than the retropubic route. Despite the large number of surgeons involved, these risks were low. The data are therefore reassuring.

Perceived health status after mid-urethral sling revision in 287 women from the VIGI-MESH registry: A cross-sectional study.

OBJECTIVE: To evaluate the health status and recovery of women after mid-urethral sling (MUS) revision in response to complications. DESIGN: Cross-sectional study using a questionnaire sent to women from a registry. SETTING: Twenty-two French surgical centres. POPULATION: A total of 287 women from the VIGI-MESH registry responded, having undergone MUS revision for complications. METHODS: Our sample of women were compared against a representative set of French women taken from the Eurostat database. Multivariate analysis was performed to identify clinical predictors for successful MUS revision. A qualitative analysis was carried out on free-text comments. MAIN OUTCOME MEASURES: Health status, defined by the Minimum European Health Module, and recovery, assessed by Patient Global Impression of Improvement. RESULTS: The response rate was 76% (287/378), with 49% of the women (141/287, 95% CI 43%-55%) reporting good health status, which was 8 points lower than that expected from the comparator French set (57%, 95% CI 55%-58%). Overall, 53% (147/275, 95% CI 47%-59%) of the women reported feeling much better after MUS revision. Just over one-third (35%, 95/275, 95% CI 29%-40%) of respondents reported poor health with little or no improvement. Multivariate analysis showed that being operated on for pain at revision was associated with worse self-perceived health than being operated on for exposure (OR 0.36, 95% CI 0.14-0.95); women with pre-existing comorbidity reported a poorer health status following MUS revision (OR 0.22, 95% CI 0.13-0.38). CONCLUSIONS: Our results suggest that half of the women recovered good health status after MUS revision, whereas a proportion appeared to be seriously affected by an MUS complication despite the revision.

The impact of pregnancy and childbirth on stress urinary incontinence in women previously submitted to mid-urethral sling: A systematic review and metanalysis.

INTRODUCTION: There is no guideline or clinical consensus concerning the mid-urethral sling (MUS) operation for stress urinary incontinence (SUI) and future pregnancies. The aim of this systematic review and metanalysis is to evaluate the impact of pregnancy and of delivery on SUI in women who previously sustained a MUS surgery. METHODS: We performed a systematic review and meta-analysis, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, and selected seven publications for inclusion in the analysis. RESULTS: Recurrence of SUI after childbirth in women previously submitted to MUS was 22% (95% confidence interval [CI]: 18.0%-26.0%; I2 = 0%) while the reintervention rate for SUI the 5% (95% CI: 2.0%-8.0%; I2 = 47.34%) in the included studies. There was not statistically significant difference between women who delivered (both vaginally and by caesarian section) or not after MUS in SUI recurrence (RR 1.01, 95% CI 0.73-1.40; p = 0.96 and I2-test of 41% p = 0.18) and in SUI reintervention (RR 1.45, 95% CI 0.91-2.30; p = 0.12 and I2-test of 0% p = 0.38) with homogeneity among studies. There was no difference between women who delivered vaginally or by caesarian section both for recurrence of SUI (RR 1.24, 95%CI 0.77-2.01; p = 0.37 and I2-test of 0% p = 0.60) and reintervention (RR 1.61, 95% CI 0.76-3.42; p = 0.22 and I2-test of 0% p = 0.47). BMI ≥ 30 kg/m2, urinary incontinence (UI) before and during pregnancy emerged as risk factors for postpartum UI relapse. CONCLUSION: Childbirth do not affect SUI relapse or reintervention in women previously submitted to MUS. In the same population of patients, no difference was highlighted concerning the mode of delivery for the outcome SUI relapse or reintervention. Previous MUS surgery may not be an appropriate indication for cesarean birth in subsequent pregnancy.

Vaginal Hysterectomy and Pelvic Organ Prolapse: History and Recent Developments.

INTRODUCTION AND HYPOTHESIS: Vaginal hysterectomy (VH) was described as far back as 120 CE. However, it was not till the mid-1900s when reconstructive procedures were introduced to mitigate the risk of, or treat, pelvic organ prolapse in relation to VH. Furthermore, routine hysterectomy, particularly VH, has long been advocated in prolapse surgery. However, this indication is now questionable. METHODS: Literature review to provide an overview of current evidence and experts' opinion regarding the relationship between VH and pelvic organ prolapse. The review presents a historical perspective on the role of VH in the management of pelvic organ prolapse, the current debate on the usefulness of the procedure in this context, a practical guide on operative techniques used during VH and the impact of recent surgical developments on its use. RESULTS: Vaginal hysterectomy is a well-established technique that is still superior to laparoscopic hysterectomy for benign gynecological disease, although more surgically challenging. However, it is possible that some contemporary techniques, such as vaginal natural orifice transluminal endoscopic surgery, may overcome some of these challenges, and hence increase the number of hysterectomies performed via the vaginal route. Although patients should be counselled about uterine-sparing reconstructive surgery, vaginal hysterectomy continues to be a major surgical procedure in reconstructive pelvic floor surgery. CONCLUSIONS: Therefore, it is prudent to continue to train residents in vaginal surgical skills to ensure that they continue to provide safe, cost-effective, and comprehensive patient care.

Midterm complications after primary obstetrical anal sphincter injury repair in France.

BACKGROUND: Incidence of complications following obstetrical anal sphincter injury (OASI) during vaginal delivery are poorly defined. They are only studied in high level maternities, small cohorts, all stages of perineal tear or in low-income countries. The aim of our study was to describe complications after primary OASI repair following a vaginal delivery in all French maternity wards at short and midterm and to assess factors associated with complication occurrence. METHODS: We conducted a historical cohort study using the French nationwide claim database (PMSI) from January 2013 to December 2021. All women who sustained an OASI repair following a vaginal delivery were included and virtually followed-up for 2 years. Then, we searched for OASIS complications. Finally, we evaluated factors associated with OASIS complication repaired or not and OASIS complication repairs. RESULTS: Among the 61,833 included women, 2015 (2.8%) had an OASI complication and 842 (1.16%) underwent an OASI complication repair. Women were mainly primiparous (71.6%) and 44.3% underwent an instrumental delivery. During a follow-up of 2 years, 0.6% (n = 463), 0.3% (n = 240), 0.2% (n = 176), 0.1% (n = 84), 0.06% (n = 43) and 0.01% (n = 5) of patients underwent second surgery for a perineal repair, a fistula repair, a sphincteroplasty, a perineal infection, a colostomy and a sacral nervous anal stimulation, respectively. Only one case of artificial anal sphincter was noticed. Instrumental deliveries (OR = 1.56 CI95%[1.29;1.9]), private for-profit hospitals (OR = 1.42 [1.11;1.82], reference group "public hospital"), obesity (OR = 1.36 [1;1.84]), stage IV OASIS (OR = 2.98 [2.4;3.72]), perineal wound breakdown (OR = 2.8 [1.4;5.48]), ages between 25 and 29 years old (OR = 1.59 [1.17;2.18], refence group "age between 13 and 24 years old") and 30 and 34 years old (OR = 1.57 [1.14; 2.16], refence group "age between 13 and 24 years old") were factors associated with OASIS complication repairs. CONCLUSIONS: Maternal age, stage IV OASIS, obesity, instrumental deliveries and private for-profit hospitals seemed to predict OASIS complications. Understanding factors associated with OASIS complications could be beneficial for the patient to inform them and to influence the patient's follow-up in order to prevent complications, repairs and maternal distress.

Urodynamic Profile and Impact of Surgery in Women Affected by Deep Infiltrating Endometriosis: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the impact of deep infiltrating endometriosis (DIE) on bladder function and the possible impact of surgical resection. DATA SOURCES: A systematic literature research was performed using the PubMed/MEDLINE and EMBASE database (last search date: April 30, 2024). METHODS OF STUDY SELECTION: We included studies that evaluated the urodynamics (UDS) findings in women affected by DIE before submission to surgery. Following epidemiological designs were considered suitable: randomized control trials, observational prospective or retrospective studies, and case series. Metanalysis was performed using Jamovi Software version 2.3.28 (Sydney, Australia), according to PRISMA 2020 guidelines. Nine publications were included. TABULATION, INTEGRATION, AND RESULTS: Nine studies, including 574 women affected by DIE and submitted to urodynamic assessment, were included. In women affected by DIE, preoperative detrusor overactivity (DO) was reported in 15% (95% confidence interval [CI] 3, 26; I2 = 93.9%, p <.001), preoperative voiding dysfunction in 21% (95% CI 12, 29; I2 = 78.1%, p <.001) and preoperative low maximum cystometry capacity was shown in 18% (95% CI -2, 38; I2 = 97.2%, p <.001). An abnormal bladder sensation was recorded in 39% of patients (95% CI 18, 60; I2 = 86%, p <.001), low preoperative bladder compliance was reported in 35% of patients (95% CI 30, 40; I2 = 0%, p = .66) and preoperative painful bladder filling was showed in 37% of the evaluated population (95% CI 27, 48; I2 = 0%, p = .58). No difference between preoperative and postoperative UDS detrusor overactivity was reported (odds ratio [OR] 0.45; 95% CI -0.10, 1.0, I2 = 0%; p = .66). Moreover, no difference in preoperative and postoperative voiding dysfunction was reported (OR 0.0; 95% CI -0.76, 0.76, I2 = 49.6%; p = .12). CONCLUSION: Abnormal urodynamic findings before surgery are prevalent in women with DIE. Surgery seems not to affect UDS outcomes in women affected by DIE. However, heterogeneity among included studies may limit the generalizability of our findings.

Self-care of vaginal pessary for pelvic organ prolapse: a systematic review and meta-analysis.

INTRODUCTION: There is no evidence about the efficacy of self-care of vaginal pessary in women with symptomatic pelvic organ prolapse (POP). The aim of this systematic review and meta-analysis is to assess the adherence to pessary treatment among women who engage in self-management of their pessary. METHODS: We performed a systematic review and meta-analysis, according to PRISMA 2020 guidelines, and selected seven publications for inclusion in the analysis. RESULTS: Pooled continuation rate of self-cared vaginal pessary was the 76% (95%CI: 66-85%) with a I2-test of 93.3% (p < 0.001). Pooled conversion to POP surgery was the 12% (95%CI: 1-23%) with a I2-test of 96% (p < 0.001). Continuation rate was not statistically different between women who were treated by self-care and non-self-care management of vaginal pessary (RR 1.11, 95%CI 0.96-1.27; p = 0.15), with a related I2-test of 37% (p = 0.21). CONCLUSION: Self-care vaginal pessary management presented a high continuation rate in women affected by pelvic organ prolapse at a long follow-up. The rate of conversion to surgical management of POP was low. No significant difference in continuation rate were highlighted between women who adopted the self-care or the clinical-based management of pessary.

The anatomy of the sacrospinous ligament: how to avoid complications related to the sacrospinous fixation procedure for treatment of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Historically, the sacrospinous ligament (SSL) has been used to treat POP in order to restore the apical compartment through a posterior or an anterior vaginal approach. The SSL is located in a complex anatomical region, rich in neurovascular structures that must be avoided to reduce complications such as acute hemorrhage or chronic pelvic pain. The aim of this three-dimensional (3D) video describing the SSL anatomy is to show the anatomical concerns related to the dissection and the suture of this ligament. METHODS: We conducted a research of anatomical articles about vascular and nerve structures located in the SSL region, in order to increase the anatomical knowledge and show the best placement of sutures to reduce complications related to SSL suspension procedures. RESULTS: We showed the medial part of the SSL to be most suitable for the placement of the suture during SSL fixation procedures, in order to avoid nerve and vessel injuries. However, nerves to the coccygeus and levator ani muscle can course on the medial part of the SSL, the portion of the SSL where we recommended to pass the suture. CONCLUSIONS: Knowledge of the SSL anatomy is crucial and during surgical training it is clearly indicated to stay far away (almost 2 cm) from the ischial spine to avoid nerve and vascular injuries.

vNOTES Hysterectomy: What about Obese Patients?

STUDY OBJECTIVE: To compare the surgical outcomes of hysterectomy by vaginal natural orifice transluminal endoscopic surgery (vNOTES) for patients with body mass index (BMI) <30 and BMI ≥30. DESIGN: A retrospective cohort study. SETTING: A French teaching hospital. PATIENTS: All patients who underwent a vNOTES hysterectomy from February 2020 to January 2022 were included (N = 200). The vNOTES approach was chosen for all patients requiring a hysterectomy, unless the procedure was for endometriosis or cancer (except grade 1 endometrioid adenocarcinoma). INTERVENTIONS: Patients were categorized into 2 groups based on their BMI (<30 or ≥30 kg/m2). The population characteristics, surgical outcomes, and hospitalization outcomes were compared. The main outcome was the intraoperative conversion rate. Secondary end points were blood loss, operative time, perioperative and postoperative complications, and same-day surgery management. MEASUREMENTS AND MAIN RESULTS: A total of 146 patients were included in the BMI <30 group, and 54 patients in the BMI ≥30 group. There was no statistical difference between obese and nonobese patients concerning intraoperative conversion (p = .150), with 4 cases occurring in the BMI <30 group (2.74%) and 4 occurring in the BMI ≥30 group (7.41%). Operative times were longer in obese patients (115.93 min [±55.28] vs 79.78 min [±40.38], p <.001). There was no significant difference in blood loss (p = .337) or perioperative and postoperative complications (p = .346 and p = .612, respectively). The ability to complete the surgery as a same-day procedure was no different between obese and nonobese patients (p = .150). CONCLUSION: The results concerning intraoperative conversion and perioperative and postoperative complications show that vNOTES hysterectomies seem to be feasible for obese patients. When same-day surgery was decided before surgery, no more obese than nonobese patients were converted to conventional hospitalization. Further studies are needed to confirm these observations.

Comparing vNOTES Hysterectomy with Laparoscopic Hysterectomy for Large Uteri.

STUDY OBJECTIVE: Our study aimed to compare conventional laparoscopic hysterectomies (LHs) with vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies performed for patients with large uteri (weight >280 g) at our institution, which underwent a change in practice from conventional LH to vNOTES for large uteri. DESIGN: Retrospective cohort. SETTING: French tertiary university hospital. PATIENTS: Two cohorts: the last 54 patients who underwent vNOTES hysterectomy and the last 52 patients who underwent conventional LH for large uteri. INTERVENTION: Baseline characteristics and surgical outcomes were assessed, including uterine weight, mode of delivery for previous pregnancies, history of abdominal surgery, indication for hysterectomy, associated procedures, operative time (OT), complications, volume of intraoperative bleeding, and length of postoperative hospital stay. MEASUREMENTS AND MAIN RESULTS: Both groups were comparable, with a mean uterine weight of 586.4 ± 289.2 g in the laparoscopy group compared with 686.7 ± 374.6 g in the vNOTES group. There was a significant decrease in the OT in the vNOTES group with a median of 99 minutes (66.5-138.5 minutes) compared with 171 minutes (131-208 minutes) in the laparoscopy group, p <.001. The length of hospital stay was also decreased in the vNOTES group with a median of 0.5 nights compared with 2 nights in the laparoscopy group, p <.001. More patients were managed in an ambulatory setting in the vNOTES group (50% vs 3.7%, p <.001). Our study did not find any significant difference in terms of bleeding or the number of conversions to another surgical approach. The frequency of intraoperative and postoperative complications was very low. CONCLUSION: Compared with the laparoscopic approach, vNOTES hysterectomy for large uteri (>280 g) is associated with decreased OT, a shorter hospital stay, and increased performance in the ambulatory setting.

Urinary and sexual impact of pelvic reconstructive surgery for genital prolapse by surgical route. A randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: The main objective of the study was to evaluate the rates of de novo stress urinary (SUI) and postoperative dyspareunia after both sacrocolpopexy/hysteropexy (SCP) and vaginal mesh surgery. METHODS: A prospective, multicenter, randomized, open-label study with two parallel groups treated by either SCP or Uphold Lite vaginal mesh was carried out. Study participants were ≥ 50 and < 80 years old patients with Pelvic Organ Prolapse Quantification (POP-Q) stage ≥2 who were considered eligible for reconstructive surgery and who were sexually active with no dyspareunia and free from bothersome SUI at presentation. Women were assessed before surgery and at 4-8 weeks and 11-13 months after using validated measures including POP-Q, Pelvic Floor Disability Index (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR), and Patient Global Impression of Improvement (PGI-I). Data were also collected for health economics evaluation. RESULTS: Of the required sample of 156 women, 42 women (19 SCP and 23 vaginal mesh) were only recruited owing to the discontinuation of vaginal mesh worldwide. The median follow-up was 376 days. The rates of bothersome de novo SUI were similar in the SCP and Uphold vaginal mesh groups (15.79 vs 15.00%, OR 0.95 [95% CI 0.22-4.14]). Among 30 sexually active patients at follow-up, the rates of women reporting de novo dyspareunia "usually or always" were 6.7% after SCP vs 13.3% after vaginal mesh (p = 1). Health economics evaluation showed a cost saving of 280€ in favor of the Uphold vaginal mesh technique, but no significant difference in the total cost (2,934.97€ for SCP vs 3,053.26€ for Uphold vaginal mesh). CONCLUSIONS: Bothersome de novo SUI and de novo dyspareunia occurred in approximately 15% and 23% of our study cohorts, with no significant difference between sacrocolpopexy/hysteropexy and anterior/apical vaginal mesh surgery. However, these results should be interpreted with caution owing to the small sample size.

Is V-NOTES Hysterectomy as Safe and Feasible as Outpatient Surgery Compared with Vaginal Hysterectomy?

STUDY OBJECTIVE: The vaginal approach is the reference surgical route to perform hysterectomy for benign pathologies. Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) is a new technique that would overcome the limitations of vaginal surgery by allowing a complete exploration of the peritoneal cavity and a constant visual control of the adjacent structures. The aim of this study is to assess the V-NOTES technique compared with vaginal hysterectomy (VH). DESIGN: A retrospective cohort study. SETTING: French teaching hospital. PATIENTS: The first 50 V-NOTES hysterectomies were included successively and compared with the last 50 VH performed from March 2019 to November 2020. The study concerned all patients requiring hysterectomy unless it was for endometriosis or cancer (except for grade 1 endometrioid adenocarcinoma). INTERVENTIONS: The baseline characteristics and the surgical outcomes were compared. The main outcome assessed was the performing of outpatient surgery. Secondary end points were uterine weight and intraoperative and postoperative complications. MEASUREMENTS AND MAIN RESULTS: The rate of outpatient surgery did not differ between the 2 surgical techniques (p = .23). The success rate of outpatient management was 77% in the V-NOTES group versus 75% in the VH group (p = .85). There was no difference in surgical outcomes between the 2 groups, except for the rate of salpingectomies or adnexectomies, which was significantly higher in the V-NOTES group, with 100% of patients undergoing one of these procedures, compared with 60% of patients in the vaginal route group (p < .001). There were 2 cases of re-admission in the month following the intervention in the vaginal group and 0 cases in the V-NOTES group. CONCLUSION: Hysterectomy by V-NOTES can be performed as a safe and adequate alternative to VH. This surgical route is a good candidate for outpatient management. However, more studies need to be conducted to confirm these findings.

Change over time in the surgical management of pelvic organ prolapse between 2008 and 2014 in France: patient profiles, surgical approaches, and outcomes.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is a common pathological condition that may require surgical management. Several surgical treatment options are possible, and practice varies from one center to another. The objective of the present study was to describe the surgical management and outcomes of POP in France from 2008 to 2014. METHODS: We performed a retrospective cohort study of all patients operated on for POP from 2008 to 2014, according to the French national hospital discharge summary database. Patient characteristics, surgical approaches, concomitant hysterectomy and/or incontinence surgery, the length of stay, the proportion of day-case operations, and patient outcomes were analyzed. RESULTS: We analyzed 310,938 hospital stays with POP surgery between 2008 and 2014; 130,908 (42%) of the operations took place in hospitals performing more than 100 prolapse surgical procedures per year. The proportion of day-case operations was low, but rose significantly from 1.2% to 4.6% during the study period. More than half of the operations featured a vaginal approach. The proportions of operations with concomitant hysterectomy or urinary incontinence surgery fell from 41.0% to 36.1% and from 33.0% to 25.8% respectively. The proportions of laparoscopic procedures increased. The mortality rate was stable (0.07% for all years). CONCLUSIONS: The number of patients undergoing POP surgery remained stable from 2008 to 2014. The proportion of laparoscopic procedures increased (in parallel with the rising proportion of day-case operations) and the proportion of procedures with concomitant hysterectomy or incontinence treatment decreased.

How we do an anterior sacrospinous ligament fixation for vaginal vault prolapse.

Since 2019, all vaginal mesh implants were removed from the market. Since, surgeons have only the autologous technique left to treat prolapse by vaginal route. The anterior sacrospinofixation is an alternative technique to treat vaginally apical prolapses. We have divided the anterior sacrospinous ligament fixation technique into 10 surgical steps: exposure, infiltration, vaginal incision, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture (two passage in the SSL on each side, using a suture-capturing device), vaginal fixation, vaginal closure, sacrospinous ligament fixation and final closure. We have performed more than 50 ASSF. This technique is not very well known, and the surgeons are more used to approach the SSL by posterior way. We have included a video of the procedure and an anatomical drawing exhibiting the dissection of the SSL without eyes control. We also added tips and tricks to easily apprehend this new technique. The anterior approach seems to has several advantages compared to the traditional posterior technique. We want to share such a video on showing how to approach the paravesical fossa anteriorly without eyes control.

National survey of surgical practices: Sacropexy in France in 2019.

INTRODUCTION AND HYPOTHESIS: Sacropexy is a reference surgical treatment for pelvic organ prolapse in women. The great variability in surgical techniques for this procedure is a source of bias that complicates analysis of the results of trials assessing it. Using the French guidelines issued in 2016 by the SCGP, AFU, SIFUD-PP, and CNGOF as a reference, we sought to inventory the surgical practices of the surgeons who perform these procedures. METHODS: In November 2018, a questionnaire about the technical aspects of this procedure was distributed by email to the French physicians performing it. It was distributed to members of several professional societies (CNGOF, SCGP, and SIFUD) and to gynecologists practicing in clinics owned by the ELSAN group. RESULTS: Of the 273 responders, 92% reported that they perform most operations laparoscopically. Overall, 83% of gynecologic surgeons used polypropylene prostheses (mesh); 38% routinely placed a posterior mesh, while the rest did so only in cases of clinical rectocele with anorectal symptoms. A concomitant hysterectomy was performed by 51% of respondents when the uterus was bulky and/or associated with substantial uterine prolapse. Finally, half the surgeons suggested the placement of a suburethral sling for women with stress urinary incontinence. CONCLUSIONS: Although practices are largely consistent with the most recent guidelines, surgical techniques vary widely between surgeons, both in France and internationally.

How we perform a posterior sacrospinous ligament fixation by the vaginal route.

Posterior sacrospinous fixation (SSF) was first described by Amreich in 1950 and then modified by Richter in 1968. The main difficulty of this technique is the pararectal approach with dissection under visual guidance. Our aim was to teach young surgeons to use this alternative technique for apical suspension and to facilitate the pararectal approach. We divide the sacrospinous ligament fixation technique into ten surgical steps: exposure, infiltration, vaginal incision, recto-vaginal dissection, pararectal dissection, SSL suture, vaginal fixation (with vaginal strips), vaginal closure, SSF and final closure. We have performed > 500 SSFs following the sacrospinous ligament fixation technique. Inexperienced surgeons are generally not comfortable with the dissection of the SSL. A video of the procedure with pararectal dissection, SSL identification and suturing clearly shown can help to perform this technique. The use of vaginal strips has been designed to help strengthen the vaginal part of the SSF. It is important to share such a video showing how to approach the pararectal fossa with a dissection under visual guidance. The aim is to help young surgeons better understand the surgical technique and dissection.

Complications and reoperation after pelvic organ prolapse, impact of hysterectomy, surgical approach and surgeon experience.

INTRODUCTION AND HYPOTHESIS: The surgical treatment of pelvic organ prolapse (POP) is associated with specific complications. Our primary objective was to assess the recurrence requiring reoperation after prolapse surgery, and our secondary objectives were to assess the early complications and secondary surgery for urinary incontinence. METHODS: Retrospective study of a population-based cohort of all hospital or outpatient stays including POP surgery from 2008 to 2014, using the French nationwide discharge summary database. We calculated the rates of hospital readmission following surgery as well as the rates of reoperation for recurrent prolapse and subsequent procedures performed for urinary incontinence. RESULTS: A total of 310,938 patients had undergone surgery for POP. Two hundred fourteen (0.07%) patients died, and 0.45% were admitted to an intensive care unit; 4.4% of the patients underwent surgery for the recurrence of prolapse. Concomitant hysterectomy in the first surgery was associated with a significantly lower risk of POP surgery recurrence: (hazard ratio (HR) [95% confidence interval (CI)] = 0.51 [0.49; 0.53]). A total of 1386 (2.5%) patients were readmitted to the hospital for early (30-day) complications of prolapse surgery. The most frequent reasons for early readmission were local infection (32.8%), hemorrhage (21.4%) and pain (17.2%). Risk factors for complications were obesity, hospitals with low levels of activity and associated incontinence surgery; 4.6% of the patients required secondary surgery for urinary incontinence; obesity was a risk factor (HR [95% CI] = 1.12 [1.01; 1.24]), and the vaginal route was a protective factor (odds ratio = 1.86 for laparoscopy, 1.44 for laparotomy and 1.25 for multiple approaches). CONCLUSIONS: POP surgery is associated with low rates of complication and recurrence. Complications occurred most commonly following combined surgeries for both prolapse and incontinence and in hospitals with low surgical volumes. Concomitant hysterectomy appears to be protective for the need for additional prolapse surgery, and the vaginal route leads to a lower frequency of secondary surgery for urinary incontinence.

Dynamic magnetic resonance imaging to quantify pelvic organ mobility after treatment for uterine descent: differences between surgical procedures.

INTRODUCTION AND HYPOTHESIS: Pelvic organ mobility is defined as the displacement of pelvic organs between rest and maximal straining. We hypothesized that pelvic organ mobility after vaginal sacrospinous hysteropexy (SSHP) might be increased compared with other surgeries for uterine descent, which may contribute to the high occurrence of postoperative cystocele after this surgery. Pelvic organ mobility and the vaginal axes after SSHP are compared with other surgical procedures for uterine descent: vaginal hysterectomy with uterosacral suspension (VH) and laparoscopic sacrohysteropexy (LSH). METHODS: In this prospective pilot study, 15 women were included (5 for each procedure). Six months postoperatively, POP-Q examination and dynamic MRI were performed and questionnaires were filled out regarding prolapse complaints. Pelvic organ mobility on MRI was defined as vertical displacement of pelvic organs at rest and maximal straining. The displacements and angles were measured using an image registration method. Furthermore, the angle of displacement of cervix/vaginal vault and vaginal axes were assessed. RESULTS: No anatomical recurrences of pelvic organ prolapse were found. No difference in pelvic organ mobility was demonstrated. After VH, a more posterior position of the upper vagina was found compared with SSHP and LSH. CONCLUSIONS: Based on these data, the higher recurrence risk in the anterior compartment after SSHP cannot be explained. Larger sample sizes, studying women with recurrence or de novo cystocele after SSHP or using an upright MRI scanner would be of interest to further assess the relationship between pelvic organ mobility and the occurrence of anterior vaginal wall prolapse.

Surgery for urinary incontinence in women: Report from the 6th international consultation on incontinence.

Urinary incontinence is a prevalent condition worldwide and causes a tremendous impact on a woman's quality of life. While conservative and non-surgical therapies are options for treatment, surgery for stress urinary incontinence (SUI) is common. Options include colposuspension, slings (pubovaginal and midurethral), and periurethral bulking. While evidence supports each of these options in the treatment of SUI, each is associated with various rates of success and unique adverse event profiles. Urgency urinary incontinence (UUI) is initially treated with behavioral modification and pharmacologic means, with surgery reserved for those with refractory symptoms or significant complications from medication use. At present, intravesical onabotulinumtoxinA injections, percutaneous tibial nerve stimulation, and sacral neurostimulation are all viable options for refractory UUI/overactive bladder. As with surgical interventions for SUI, each of these is, likewise, associated with unique outcomes and adverse event profiles. Herein, we summarize the findings and conclusions from the 6th International Consultation on Incontinence (ICI) regarding surgical treatment of urinary incontinence in women.

The anatomy of the sacral promontory: How to avoid complications of the sacrocolpopexy procedure.

Because of problems with vaginal meshes and the high rate of recurrences of native tissue repair, more and more surgeons treat pelvic organ prolapse with laparoscopic sacrocolpopexy. This surgery requires skilled surgeons. The first step of sacrocolpopexy is the dissection of tissues in front of the sacral promontory to reach the anterior longitudinal ligament. Some complications can occur during this dissection and the attachment of the mesh. This step is dangerous for surgeons because of the proximity of vessels, nerves, and ureters. The lack of knowledge of anatomy can lead to severe complications such as vascular, ureteral, or nerve injuries. These complications can be life-threatening. To show anatomic concerns when surgeons dissect and affix the mesh on the anterior longitudinal ligament, we have developed a video of the promontory anatomy. By reviewing anatomic articles about vessels, nerves, and ureters in this localization, we propose an educational tool to increase the anatomic knowledge to avoid severe complications. In this video, we show an alternative location for dissection and graft fixation when the surgeon believes that mesh cannot be fixed safely on the anterior surface of S1, as currently recommended.