Anterior-apical Transvaginal Mesh (Calistar-S) for Treatment of Advanced Urogenital Prolapse: Surgical and Functional Outcomes at 1 Year.

INTRODUCTION AND HYPOTHESIS: Calistar-S is a single-incision synthetic mesh kit that addresses apical and anterior compartment prolapse. The aims of this study were to evaluate the short-term objective and subjective outcomes at the 1-year follow-up. The secondary objectives were to evaluate quality of life and lower urinary tract symptoms (LUTS) outcomes, as well as surgical complications. METHODS: Records of 108 patients with symptomatic advanced pelvic organ prolapse (stages III and IV) who underwent prolapse surgery using the Calistar-S system from June 2018 to August 2022 were reviewed. The primary outcome was the objective cure of anterior and apical prolapse < stage 1, and the subjective cure was the negative response to questions 2 and 3 of the Pelvic Organ Prolapse Distress Inventory-6. Secondary outcomes measured quality of life, the presence of lower urinary tract symptoms, and complications. RESULTS: A total of 101 patients were evaluated. The overall objective cure rate is 97% and the subjective cure rate is 92.1%. Good outcomes were seen in all three compartments. Secondary outcomes show significant improvement in all validated questionnaires. Persistence and de novo urinary incontinence were 15.2% and 18.2% post-operatively. There is one case of bladder injury and one case of vaginal mesh exposure. CONCLUSIONS: The Calistar-S System is a safe and efficient method for treating advanced-stage POP. We observed good anatomical results and subjective relief with a minimal complication rate. LUTS have also been positively affected, showing a high success rate. Additional studies are needed to establish the long-term efficacy of this system.

A Roadmap for Training in Urogynecology: IUGA International Initiative.

INTRODUCTION AND HYPOTHESIS: Training in urogynecology is an important mission of the International Urogynecological Association (IUGA). Promoting official training programs in countries around the world is an integral part of this mission. METHODS: The IUGA established the Fellowship Development Committee to develop a roadmap to assist countries to develop a professional training program in urogynecology. Two focus groups were created: the curricula topics focus group and the survey focus group. The curricula topics focus group is aimed at developing a list of subjects that can be the basis for a training syllabus. The survey focus group is aimed at understanding the main steps and the difficulties in establishing an official training program by interviewing representatives from both accredited and non-accredited countries and developing a roadmap for an official training program recognized by the local authorities. RESULTS: The fellowship development committee included 13 members. The curricula topics focus group developed a format for the description of each included topic. Each topic had to include a description of the required related skills and procedures. Two curricula topics lists were created: one for basic training and a second for advanced training. The survey focus group conducted two table discussions with representatives from countries with accredited training programs and countries without accredited training programs. The comments of these meetings were summarized in documents submitted to the IUGA board of directors. CONCLUSION: The fellowship development committee studied the main hurdles to developing an official training program in urogynecology. The roadmap document should form the basis of the IUGA international initiative to assist countries around the world to develop an official training program in urogynecology recognized by the local authority.

Voiding Dysfunction in Patients With Advanced Pelvic Organ Prolapse and Bladder Outlet Obstruction Following Pelvic Reconstructive Surgery: Urodynamic Profile and Predictive Risk Factors.

STUDY OBJECTIVE: To determine the outcome of voiding function 1 year after pelvic reconstructive surgery (PRS) in women with bladder outlet obstruction (BOO). DESIGN: Retrospective cohort study. SETTING: Tertiary referral hospital. PATIENTS: A total of 1894 women underwent PRS for advanced pelvic organ prolapse (POP) stages 3 to 4 with urodynamic findings of BOO. INTERVENTIONS: PRS. MEASUREMENTS: The primary outcome measured was the resumption of normal voiding function, defined clinically with multichannel urodynamic testing at 1 year postoperatively. The secondary outcomes were to identify the different risk factors for persistence voiding dysfunction (VD) 1 year after PRS. MAIN RESULTS: A total of 431 women with Pelvic Organ Prolapse Quantification stages 3 and 4, urodynamic study of maximum urinary flow rate ≤15 mL/s, and detrusor pressure at maximum flow ≥20 cm H2O were included. Resumption of normal voiding function was found in 91% (n = 392 of 431), whereas 9% (n = 39 of 431) remained to have VD 1 year postoperatively. Those with persistent VD, 20.5% (n = 8 of 39) remained having urodynamic diagnosis of BOO. Univariate and multivariate logistic regression revealed factors associated with postoperative VD were pre-operative maximal cystometric capacity ≥500 mL and postvoid residual volume ≥200 mL. CONCLUSION: VD may persist in women with BOO after PRS, particularly in those with preoperative maximal cystometric capacity of >500 mL and postvoid residual volume >200 mL.

Polypropylene anterior-apical single-incision UPHOLD-LITE mesh surgery in women with severe pelvic organ prolapse: Outcome at 53 months follow up.

BACKGROUND AND PURPOSE: We present this current study to complement with mesh inlays plausible benefits (UPHOLD-LITE System) on available long-term study amidst FDA's concern on mesh complications. This study aims to assess the medium-term outcomes of UPHOLD-LITE system for treatment of advanced pelvic organ prolapse (POP) and its complications, and lower urinary tract symptoms. METHODS: This is a retrospective case series of 53 months follow-up of 123 consecutive patients who underwent UPHOLD-LITE system. Objective outcome measures the anatomical correction of prolapse with POP-Q ≤ Stage 1. Subjective outcome was patient's feedback to questions 2 and 3 of POPDI-6. Secondary outcome measures the quality of life, presence of lower urinary tract symptoms and complications. Quality of life is assessed by validated questionnaires on Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire 7 (IIQ-7), Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12 (PISQ-12) at 1 and 3 years post-operatively. RESULTS: Objective outcome at 1 and 3 years was at 96.7 % and 95.4 % respectively. The subjective cure was 95.1 % and 91.6 %. Five-year cumulative cure rate maintained at 87.2 %. Secondary outcomes observed improvement on UDI-6, IIQ-7, POPDI-6 and PISQ-12 postoperatively. Bladder outlet obstruction improved while de novo urodynamic stress incontinence (USI) increased slightly post surgically. Mesh erosion rate was 0.8 %. CONCLUSION: The UPHOLD-LITE system demonstrated good medium term anatomical correction of apical and anterior prolapse, with good subjective cure and improved quality of life. Whilst complication rate was low, slight increase in de novo USI was observed.

Use of low-intensity extracorporeal shock wave therapy in the management of interstitial cystitis/bladder pain syndrome patients: A thirty case study in a tertiary medical center.

INTRODUCTION: Low-energy extracorporeal shock wave therapy (LiESWT) is a new potential treatment for intractable interstitial cystitis/bladder pain syndrome (IC/BPS), and this paper will evaluate its therapeutic effects on IC/BPS. MATERIALS AND METHODS: This prospective clinical trial enrolled 30 women who have been diagnosed with IC/PBS to receive LiESWT treatment at an intensity of 0.25 mJ/mm2 and a frequency of 3 pulses/second, for a total of 3000 pulses within 8 weeks. And we assessed questionnaires (including O'Leary-Sant Interstitial Cystitis Symptom Index (ICSI)), 3-day voiding diary, and urodynamic study at the following intervals: 4 weeks of LiESWT (W4), 8 weeks of LiESWT (W8), 1-month follow-up (F1), 3-month follow-up (F3) after LiESWT, and 1 year follow-up (F12). RESULTS: The primary outcome of questionnaires showed significant improvement of symptoms compared to baseline (W0), especially on ICSI(12.87 ± 3.44 before treatment and 7.87 ± 5.27 at F12, p < 0.05). 3-day voiding diary also revealed significant decrease in daytime voiding frequency (15.57 ± 5.22 times before treatment and 10.70 ± 4.21 times at F1, p < 0.05) and significant increase on average voiding volume (95.85 ± 35.30 mL before treatment and 161.27 ± 74.21 mL at F1, p < 0.05). However, there were no significant differences in all parameters of the urodynamic study. CONCLUSION: LiESWT can mitigate pain and lower urinary tract symptoms and improve the quality of life in IC/PBS patients, but does not increase the maximal cystometric capacity.

Correlation between overactive bladder and detrusor overactivity: a retrospective study.

INTRODUCTION: The primary objective of this study is to determine the prevalence of overactive bladder (OAB) and detrusor overactivity (DO) in female patients who were referred for urodynamic study (UDS) because of lower urinary tract symptoms (LUTS). The secondary objective is to determine the subjective and objective differences between female OAB patients with and without DO. MATERIALS AND METHODS: All female patients who underwent UDS for LUTS between June 2016 and September 2019 were retrospectively reviewed. Personal history, medical history, physical examination, and validated questionnaires were collected. One-hour pad test and multichannel urodynamic study was performed. All statistical analyses were conducted by SAS 9.4. P-value < 0.05 was considered statistically significant. RESULTS: A total of 4184 female patients underwent UDS because of LUTS between June 2016 and September 2019; 1524 patients were analyzed for OAB or DO. The occurrence of OAB was 36.4%. The overall incidence of DO in OAB patients was 15.5%; 9.5% of all patients had DO findings on UDS, and 4.6% were incidental findings. There were significant differences among mean age, parity, ICIQ-UI SF, OABSS, POPDI-6, and all UDS parameters (except for maximal urethral pressure and pressure transmission ratio) between patients with and without DO. In patients with DO, there were no significant differences among age, parity, and BMI with or without OAB symptoms. However, there were significant differences among mean OABSS, ICIQ-UI SF, UDI-6, POPDI-6, IIQ-7, and pad test. CONCLUSIONS: Patients with DO are associated with older age, increased parity, greater urine leakage, and worse storage and micturition functions on UDS. Combinations of subjective and objective measurements are better predictive models for OAB patients.

A time-frame comparison study of surgical volume shifts on female primary stress urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate the surgical volume shifts for primary female stress urinary incontinence (SUI) over a 20-year period (1999-2018) in Taiwan. METHODS: This was a retrospective cohort study based on Taiwan's National Health Insurance Research Database. We divided the time-frame into four periods: first period (1999-2003), second period (2004-2008), third period (2009-2013), and fourth period (2014-2018). The variables included major surgical types for SUI (retropubic urethropexy, pubovaginal sling, midurethral sling, etc.), surgeon gender, specialty, surgical volume (high ≥30, median 5-29, low <5), and hospital accreditation level. Reoperation rates within 1 year were analyzed as an outcome measurement. RESULTS: A total of 51,018 patients were identified. Major surgical types increased significantly during the first three periods and slightly decreased during the fourth period. The proportion of surgical volume shifted from high- to medium-, and low-volume, but it reversed during the fourth period. The proportion of SUI surgeries decreased in medical centers, whereas it increased in regional and local hospitals. The proportion of SUI surgeries by female surgeons increased. Similar phenomena occurred in MUS. As for surgeon specialty, major surgical types were performed by gynecologists and urologists equally, whereas MUS were performed more by gynecologists than by urologists. Unexpectedly, 1-year reoperation rates were higher in high-volume surgeons. CONCLUSIONS: The surgical trend of SUI surgeries shifted from high- to medium-, and low-volume surgeons, medical centers to regional and local hospitals during the study periods. This implied surgical skills and performance spreading, which may have a great influence on patient and healthcare provider choice of treatment.

Immunochemical and urodynamic outcomes after polypropylene mesh explant from the pelvic wall of rats.

INTRODUCTION AND HYPOTHESIS: To analyze the immunochemical and urodynamic outcomes after partial versus complete excision of transvaginal polypropylene mesh (PPM) from pelvic walls of rats. METHODS: Forty-eight female Sprague-Dawley (SD) rats were randomly distributed into seven groups: control, mesh total removal 60 days (M-T 60D), mesh total removal 180 days (M-T 180D), mesh partial removal 60 days (M-H 60D), mesh partial removal 180 days (M-H 180D), sham 60 days (Sham 60D), and sham 180 days (Sham 180D). In the mesh groups, PPM was inserted and partially (0.3 × 0.3 cm) or completely removed 30 days later. In the Sham group, the space between the vagina and bladder was dissected without placing or removing the synthetic mesh at day 1 and day 30 later. Urodynamic studies, immunochemical analysis, and Western blot were done at days 60 and 180. RESULTS: The M-T 60D voiding pressure was significantly decreased compared to the Sham 60D and M-H 60D. The voiding interval of M-T 60D was significantly shorter than that of M-H 60D. In the M-T 60D and M-T 180D groups, the leak point pressure was significantly less than in their corresponding sham groups. IL-1 and TNF-α were significantly more intense in M-T 60D compared to M-H 60D and Sham 60D. NGF was significantly greater in M-T 60D compared to Sham 60D. There were no significant differences in MMP-2 and CD-31s throughout the group. CONCLUSION: Total mesh excision incites a host inflammatory response and transitory lower urinary tract dysfunction. Despite the good outcomes after total excision, the invasiveness and surgical risk associated with repeated procedures should not be underestimateded.

Impact of intrinsic sphincter deficiency on mid-urethral sling outcomes.

INTRODUCTION AND HYPOTHESIS: Our primary objective was to study outcomes of patients with intrinsic sphincter deficiency (ISD) following mid-urethral slings (MUS) at 1-year. Our secondary objective was to delineate factors affecting success in these patients. METHODS: Six hundred eighty-eight patients who had MUS between January 2004 and April 2017 were reviewed retrospectively; 48 women were preoperatively diagnosed with ISD. All completed urodynamic studies and validated quality-of-life (QOL) questionnaires at baseline and 1 year. Primary outcomes were objective and subjective cure of stress incontinence, defined as no involuntary urine leakage during filling cystometry and 1-h pad test < 2 g and negative response to Urogenital Distress Inventory-6 Question 3. Ultrasound was performed to determine tape position, urethral mobility and kinking at 1 year. RESULTS: Women with ISD had significantly lower objective and subjective cure rates of 52.1% and 47.9%, respectively, compared to an overall of 88.2% and 85.9%. QOL scores significantly improved in those with successful surgeries. The sling type did not make a difference. Multivariate logistic regression identified reduced urethral mobility [OR 2.11 (1.24-3.75)], lower maximum urethral closure pressure (MUCP) [OR 1.61 (1.05-3.41)] and tape position [OR 3.12 (1.41-8.71)] to be associated with higher odds of failed slings for women with ISD. CONCLUSIONS: Although there are good overall success in women undergoing MUS, those with ISD have significantly lower cure rates at 1 year. Factors related to failure include reduced urethral mobility, low MUCP and relative tape position further away from the bladder neck. Optimal management of patients with ISD and reduced urethral mobility remains challenging.

Ultrasonography and clinical outcomes following anti-incontinence procedures (Solyx™ tape): a 3-year post-operative review.

INTRODUCTION AND HYPOTHESIS: Our primary objective was to study objective and subjective outcomes of patients with urodynamic stress incontinence (USI) following Solyx™ at 3-year follow-up. Our secondary objective was to evaluate ultrasonographic tape and bladder neck position and mobility. METHODS: Records of 88 women who received Solyx™ surgery between September 2015 and December 2017 were reviewed. Ultrasonographic sling evaluation was performed at 6 months and 3 years postoperatively. Primary outcomes were objective and subjective cure of stress incontinence, defined as no involuntary urine leakage during filling cystometry, 1-h pad test < 2 g and negative response to Urogenital Distress Inventory-6 Question 3. RESULTS: Subjective and objective cure rates at 3 years were 85.2% and 87.5%, respectively, with no complications reported. QOL improvements were maintained. Bladder neck position and mobility had no significant change between 6-month and 3-year follow-up. Tape position demonstrated significant shifts in the y-axis at both rest and Valsalva and in the x-axis at Valsalva between 6 months and 3 years; overall mobility was unchanged. Percentile of sling location remained unchanged at 60.1%, as did percentage of urethral kinking (67.9%) achieved. Risk factors for failure were bladder neck hypomobility postoperatively and no urethral kinking postoperatively. CONCLUSIONS: There was good sustained objective and subjective cure with improved QOL in women who underwent Solyx™ for USI at 3-year follow-up. Ultrasonographic evaluation showed a tape position shift upwards and backwards with unchanged tape and bladder neck mobility. Percentile of sling location and rates of dynamic kinking were maintained.

Beneficial effect of Bletilla striata extract solution on zymosan-induced interstitial cystitis in rat.

AIMS: Interstitial cystitis (IC) is a chronic pain syndrome that is characterized by suprapubic pain upon bladder filling. Bletilla striata, a well-known traditional Chinese herb with established efficacy in wound healing and anti-inflammation, was hypothesized to improve the symptoms of IC possibly though forming a physical barrier that could isolate the bladder tissue from irritants. This study was conducted to evaluate the beneficial effects of intravesical treatment with B. striata extract solution (BSES) on visceral pain and bladder function of rats with zymosan-induced IC. METHODS: Thirty female rats were randomly divided into control group, zymosan-induced cystitis rats treated with normal saline (Z + NS), and zymosan-induced cystitis rats treated with BSES (Z + BSES). All rats underwent evaluation for abdominal withdrawal reflex (AWR) scores to assess visceral hypersensitivity, cystometrography, and electromyogram (EMG) of both external urethral sphincter and bladder detrusor. Data were analyzed by one way analysis of variance. RESULTS: The Z + NS group had an increased visceral hypersensitivity as compared to control group. Rats treated with BSES (Z + BSES group) had decreased AWR scores and amplitude of bladder detrusor-EMG. Besides, BSES treatment improved overactive bladder with significant effects on the extend of micturition interval and increase of storage of urine. CONCLUSIONS: Intravesical instillation of BSES can significantly alleviate zymosan-induced visceral hypersensitivity and bladder overactivity associated with IC. This study suggested that intravesical instillation with BSES might be a promising treatment for IC.

De novo detrusor overactivity and urgency after mid-urethral slings for urodynamic stress incontinence.

INTRODUCTION AND HYPOTHESIS: The objective was to identify incidence and risk factors of de novo urgency and detrusor overactivity (DO) following mid-urethral slings (MUS) in patients with urodynamic stress incontinence (USI) without urgency. METHODS: A total of 688 women between January 2004 and July 2017 were reviewed retrospectively. De novo urgency was established with a positive response to question 2 on the Urogenital Distress Inventory-6 questionnaire (UDI-6). Objective cure of USI is no involuntary urine leakage during filling cystometry and pad test < 2 g. Subjective cure of stress urinary incontinence (SUI) is defined as a negative response to question 3 on UDI-6. Multivariate logistic regression was used to identify risk factors for failure. RESULTS: Forty-four out of 688 women (6.4%) developed de novo urgency, with 16 out of 688 (2.3%) demonstrating de novo DO. Subjective cure for women with de novo urgency was significantly lower at 35 out of 44 (79.5%) compared with 556 out of 644 (86.3%) in those with no urgency (p < 0.001). Objective cure for women with de novo DO was significantly lower at 8 out of 16 (50%) compared with 599 out of 672 (89.1%) in those with detrusor stability (p < 0.001). Quality of life improved for all. Age ≥ 66 (OR, 1.23; 1.07), increased bladder sensation (OR, 4.18; 3.80), lower bladder capacity (OR, 5.28; 4.97), lower maximum urethral closure pressure (OR, 2.32; 5.20), and pad test > 100 g (OR, 1.08; 1.15) were independent risk factors for de novo urgency and DO. Diabetes (OR, 1.32) was an independent predictor of de novo urgency. CONCLUSION: Cure is significantly reduced in women who report symptoms of de novo urgency or demonstrate DO after MUS at 1 year. Independent risk factors include age ≥ 66, increased bladder sensation, lower bladder capacity, lower maximum urethral closure pressure, greater pad loss, and diabetes.

Immunochemical analysis on polypropylene mesh: does mesh size make a difference?

INTRODUCTION AND HYPOTHESIS: The aim of the study is to demonstrate the impact of the size of implanted mesh in relation to its immunohistochemical reaction implanted into animal models. METHODS: An experimental study utilizing 54 female Sprague Dawley (SD) rats was divided into five groups: control, sham, and study groups (mesh-small [M-S], mesh-medium [M-M], mesh-large [M-L]). The M-S group used a mesh size of 0.2 × 0.2 cm, the M-M group a mesh size of 0.5 × 0.5 cm, and the M-L a mesh size of 0.7 × 1.0 cm. The sham group underwent vaginal dissection with no mesh implantation. The rats were sacrificed using isoflurane overdose on days 7 and 30. The mesh with the surrounding vaginal and bladder wall tissues were removed and processed for histochemical and western blot analysis. RESULTS: There is a significant increase in IL-1 and TNF-α immunoreactivity in the M-M and M-L groups on day 7 when compared with the sham group with p values of 0.001 and < 0.001 respectively. M-L showed significantly higher immunoreactivity to TNF-α persisting until day 30. All study groups presented a significantly higher immunoreactivity to MMP-2 and NGF on day 7. However, reactivity to NGF does not persist to day 30 in all groups. Immunoreactivity to CD 31 on days 7 and 30 appears significantly greater in the M-M and M-L groups, with the reaction in the M-L group continuing until day 30. CONCLUSION: Mesh size is directly proportional to the inflammatory reaction in the host tissue. The prolonged inflammatory process leads to delayed tissue remodeling and angiogenesis, which could delay mesh-tissue integration.

Anterior-Apical Transvaginal Mesh (Surelift) for Advanced Urogenital Prolapse: Surgical and Functional Outcomes at 1 Year.

STUDY OBJECTIVE: To determine the objective and subjective outcomes of pelvic organ prolapse (POP) surgery using a modified Surelift system (Neomedic International, Barcelona, Spain) and to evaluate surgical complications and postoperative impact on quality of life (QOL) and lower urinary tract symptoms. DESIGN: Retrospective cohort study. SETTING: Tertiary-care university hospital. PATIENTS: Patients with symptomatic anterior or apical POP stage III and above. INTERVENTIONS: All patients underwent pelvic reconstructive surgery with a modified Surelift transvaginal mesh kit. MEASUREMENTS AND MAIN RESULTS: Eighty-three women who underwent pelvic reconstructive surgery with a modified Surelift for symptomatic anterior or apical prolapse stage III and above from April 2018 to January 2019 were reviewed retrospectively. All completed a 72-hour voiding diary, urodynamic study, and multiple validated QOL questionnaires at baseline and at between 6 and 12 months postoperatively. Descriptive statistics were used for demographics and perioperative data. Paired-samples t test and the McNemar test were applied for comparison of pre- and postoperative continuous and categoric data, respectively. The primary outcomes were the objective cure of POP, defined as anterior and apical prolapse Pelvic Organ Prolapse Quantification System ≤ stage I, and subjective cure on the basis of negative answers to Pelvic Organ Prolapse Distress Inventory 6. The objective and subjective cure rates at 1 year were 97.6% and 92.8%, respectively. There were significant improvements in QOL scores postoperatively. Although bladder outlet obstruction improved, de novo urodynamic stress incontinence and stress urinary incontinence were increased at 18.9% and 21.6%, respectively, at 1-year follow-up. The mesh extrusion rate was 4.8%. CONCLUSION: A modified Surelift has good objective and subjective cure rates at 1 year postoperatively with 4.8% mesh extrusion rate. There was significant improvement in lower urinary tract symptoms and QOL. De novo urodynamic stress incontinence at 6 months to 12 months was increased, but it was not sufficiently bothersome to warrant surgery.

Mid Urethral Slings for the Treatment of Urodynamic Stress Incontinence in Overweight and Obese Women: Surgical Outcomes and Preoperative Predictors of Failure.

PURPOSE: We evaluated mid urethral sling outcomes in overweight and obese patients compared to normal weight patients and identified risk factors for failure in this population. MATERIALS AND METHODS: Records of 688 women between January 2004 and July 2017 were retrospectively reviewed. Patients received urodynamic studies, 1-hour pad test, Urogenital Distress Inventory-6 and Incontinence Impact Questionnaire-7, and were divided into normal weight, overweight and obese. Objective cure at 1 year was defined as no involuntary urine leakage during filling cystometry and pad test less than 2 gm. Subjective cure was established by negative response to question 3 on Urogenital Distress Inventory-6. McNemar's test, chi-square test, Mann-Whitney U and Fisher's exact test were used for paired categorical variables. Independent samples t-tests and paired t-test were used for continuous parametric variables. Multivariate logistic regression was used to identify risk factors for failure. RESULTS: Objective and subjective cure in normal, overweight and obese patients was 91.4% and 89.1%, 87.5% and 86%, and 76% and 70.1%, respectively. There was no difference in surgical complications. Obese patients had worse quality of life scores preoperatively and postoperatively. Risk factors in obese patients with failed mid urethral sling included 66 years old or older (OR 2.02, 1.56-3.98), menopause (OR 4.21, 1.21-14.22), previous prolapse surgery (OR 4.57, 2.36-8.52), diabetes (OR 2.79, 1.61-5.99) and intrinsic sphincter deficiency (OR 5.06, 3.08-9.64). CONCLUSIONS: Obese women with mid urethral sling had lower objective and subjective cure at 1 year and worse quality of life scores compared to normal and overweight women. Risk factors for failure include age, diabetes, menopause, previous prolapse surgery and intrinsic sphincter deficiency.

Outcomes and failure risks in mid-urethral sling insertion in elderly and old age with urodynamic stress incontinence.

INTRODUCTION AND HYPOTHESIS: To study the surgical outcomes and risk factors for failure of three types of mid urethral slings(MUS) surgeries in elderly and old age women with urodynamic stress incontinence(USI). METHODS: Three different types of MUS surgeries [single incision sling(SIS), trans-obturator tape(TOT), retro-public mid-urethral sling-tension-free vagina tape (TVT)]were performed among three age groups of women (young <64 yr, elderly 65-74 yr and old >75 yr) with USI. They were followed up for 1 year. RESULTS: Complete postoperative data was available for 688 women. After 1 year, overall objective cure rate was 88.2% and subjective cure rate was 85.9%. Among the young, elderly, and old age women objective cure rates were 91.0%, 80.6%, 66.7% and subjective cure rates were 89.2%, 77.6%, 58.3% respectively. Urodynamic parameters demonstrated flow rate, higher post-void bladder residual, smaller cystometric capacity, and lower maximum urethral closure pressure were significantly lower among old and elderly group. Subjectively, urinary distress inventory-6 (UDI-6) and incontinence impact questionnaire-7(IIQ-7) improved significantly in all groups with significant changes from baseline only in older women. Intrinsic sphincter deficiency(ISD) was found to be significantly associated with failure in older women. Other preoperative comorbidities were equally distributed among all the three age groups. The operative time, perioperative complications, and length of hospital stay showed no difference between the study groups. CONCLUSIONS: MUS surgery is safe for the young and aging patients with USI and demostrated significant improvement in its outcomes, but objective and subjective cure rates decreases with age. ISD was also found to be significantly associated with failure.

Outcomes of urodynamic mixed urinary incontinence and urodynamic stress incontinence with urgency after mid-urethral sling surgery.

INTRODUCTION AND HYPOTHESIS: Mixed urinary incontinence (MUI) is defined as symptomatic complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing or coughing. The paucity of research, especially on the surgical management of MUI, limits its best management. METHODS: This is a retrospective study to determine the outcomes of mixed urinary incontinence after mid-urethral sling surgery with two groups, urodynamic stress incontinence (USI) with urgency and urodynamic mixed urinary incontinence (MUI-UD; USI and detrusor overactivity [DO]). RESULTS: Ninety women (USI + urgency group) with preoperative USI and urgency and no demonstrable DO/DOI attained an objective cure of 82.2%, whereas the remaining 67 (MUI-UD group) women with both USI and DO/DOI were reported to have an objective cure of only 55.2%. Subjective cures were 81.1% and 53.7% respectively. The type of incontinence surgery does not affect postoperative outcomes in either of the groups. Demographic factors identified to have a significant negative effect on cure rates were postmenopausal status (p = 0.005), prior hysterectomy (p = 0.028), pre-operative smaller blafdder capacity (p = 0.001), and a larger volume of pre-operative pad test (p = 0.028). A lower mid-urethral closure pressure (MUCP) was significant with post-operative failure of treatment with MUI-UD group (68.8 ± 36.2 cmH2O vs 51.9 ± 24.7 cmH2O; p = 0.033). CONCLUSIONS: Although there is evidence for a good cure of the stress component of MUI, urodynamic investigation with its findings prior to management of MUI could have greater implications for selective patient centered counseling. Presence of DO or DOI on urodynamics resulted in poorer objective and subjective outcomes.

Time-frame comparison of hystero-preservation in the surgical treatment of uterine prolapse: a population-based nation-wide follow-up descriptive study, 2006-2013 versus 1997-2005.

INTRODUCTION AND HYPOTHESIS: The purpose of our study was to describe the surgical trend and time-frame comparison between 1997-2005 (1stperiod) and 2006-2013 (2nd period) of hystero-preservation for uterine prolapse, based upon a nationwide population-based National Health Insurance (NHI) claim data in Taiwan. METHODS: Women, who underwent primary surgeries for uterine prolapse, either uterine suspension with hystero-preservation or hysterectomy during 1997-2013, were identified from National Health Insurance Research Database (NHIRD).We analyzed the related variables including surgical types (hystero-preservation or hysterectomy), patient age and concomitant anti-incontinence surgery, surgeon age, gender, and service volume; and hospital accreditation level, and service volume. RESULTS: We identified a total of 46,968 inpatients, 6629 (14.11%) hystero-preservation group, and 40,339 (85.89%) hysterectomy group. Hystero-preservation significantly increased during the 17 year follow-up study period (1997 to 2013) (P value =0.0147). The overall surgeries for uterine prolapse increased among patients ≥70 years, with concomitant anti-incontinence surgery, surgeons ≥45 years, high volume surgeons, and hospitals. Multiple logistic regression revealed hysterectomy was less used in 2nd period (OR 0.45, 95%, confidence interval (CI) 0.43-0.48). Hysterectomy was more often used in patient aged ≥50 years, surgeon aged ≥45 years, and low volume hospitals. In case of concomitant anti-incontinence surgery (OR 0.48, CI 0.45-0.52), high volume surgeons (more than 30 surgeries) and hospitals (more than 73 surgeries) hystero-preservation was more often used. CONCLUSIONS: Time-frames, younger patients, concomitant anti-incontinence surgery, younger surgeons, and high volume surgeons and hospitals increase hystero-preservation for uterine prolapse. Surgeons and hospitals should be ready to respond to the wishes of female patients who want to preserve the uterus.

Surgical Trends and Time Frame Comparison of Surgical Types of Hysterectomy: A Nationwide, Population-based 15-year Study.

STUDY OBJECTIVE: To investigate the surgical trends among different types of hysterectomy (abdominal, vaginal, laparoscopic, and subtotal) over a 15-year period in Taiwan. DESIGN: A retrospective cohort study. SETTING: A population-based National Health Insurance Research Database. PATIENTS: Women undergoing various types of hysterectomy for noncancerous lesions. INTERVENTIONS: Data for this study were extracted from the inpatient expenditures by admissions files of Taiwan's National Health Insurance Research Database from 1998 through 2012 and divided into three 5-year time frames: first (1998-2002), second (2003-2007), and third (2008-2012). The variables included types of hysterectomy, patient age, gynecologist age and sex, hospital accreditation level, and surgical volume. Chi-square and trend tests were used to examine the association between the variables. MEASUREMENTS AND MAIN RESULTS: A total of 329 438 patients who underwent various types of hysterectomy were identified; 306 257 were included in the study. During the 15-year period, 45% underwent total abdominal hysterectomy, 41% underwent laparoscopic hysterectomy (LH), 9.8% underwent vaginal hysterectomy, and 4.2% underwent subtotal abdominal hysterectomy. The frequency of LHs increased from 35.9% in the first period to 43.9% in the second period and remained at 44.2% in the third period. During the same time period, there was a decrease in the frequency of total abdominal hysterectomies. Typically, younger patients underwent LHs by gynecologists with large volume surgical practices and medical centers. CONCLUSION: This 15-year study describes an increase of LHs and subtotal abdominal hysterectomies over time and provides evidence of surgical trends and a paradigm shift of hysterectomies. Surgical skills and performance extended from high- to low-surgical volume gynecologists and from medical centers to regional and local hospitals. This shift may have a great influence on patient and health care provider choice of treatment.

Anterior-apical single-incision mesh surgery (uphold): 1-year outcomes on lower urinary tract symptoms, anatomy and ultrasonography.

INTRODUCTION AND HYPOTHESIS: Our primary objective is to determine the presence of SUI at 6-12 months after surgery. The secondary objective is to determine the objective and subjective outcomes of POP. METHODS: A retrospective study conducted between February 2015 and July 2016 at Chang Gung Memorial Hospital. The subjects had had symptomatic anterior or apical prolapse with stage III or IV and undergone pelvic reconstructive surgery using Uphold™ LITE. Patients completed a 3-day voiding diary, urodynamic study, real-time ultrasonography and validated quality-of-life questionnaires at baseline and 12-month follow-up. Primary outcome was the absence of USI. Secondary outcomes included the objective cure rate of POP, ≤ stage 1 at the anterior/apical vaginal wall, and the subjective cure rate, negative feedback to POPDI-6. RESULTS: Ninety-five women were eligible. Six were excluded because of incomplete data. The postoperative de novo USI and SUI were 22.7 and 19.7%, respectively. There was significant improvement of USI in patients who had MUS insertion (93.8%) and bladder outlet obstruction (96.7%). The objective and subjective cure rate for prolapse was 95.5 and 94.3%, respectively. POP-Q measurements pre- and postoperatively were significantly improved at all points except for Gh and Pb. There was a significant difference in the distance between the bladder neck to the distal end of the mesh during straining both at both the postoperative 3rd month and 1 year. CONCLUSIONS: Uphold™ mesh has a 20% incidence of de novo USI with acceptable objective and subjective cure rates at 1 year postoperatively. The de novo USI rate was high but not bothersome enough to require surgery.