Patient Impression of Improvement 1 year After Sacrospinous Hysteropexy Versus Vaginal Hysterectomy in Women with Pelvic Organ Prolapse Stage 2 or Higher.

INTRODUCTION AND HYPOTHESIS: Patient-reported outcomes are relevant outcomes in studies on pelvic organ prolapse (POP) surgery, as anatomical recurrence alone does not have a significant correlation with perceived improvement. In the present study, the patient's impression of improvement after 1 year is studied after vaginal hysterectomy (VH) versus sacrospinous hysteropexy (SSH) in large cohorts from daily clinical practice. We hypothesize that there is no difference between the groups. METHODS: This is a secondary analysis on prospectively collected data in a multicenter cohort of patients who underwent VH or SSH for symptomatic POP. All patients had a POP-Q stage ≥ 2 in at least one compartment at baseline and were treated with VH or SSH between 2002 and 2019. The primary outcome was the patient-reported score on the patient global impression of improvement index (PGI-I) 1 year after surgery. The secondary outcome was a composite outcome of surgical success, defined as the absence of recurrent POP beyond the hymen with bothersome bulge symptoms and/or repeat surgery. RESULTS: A total of 378 women (196 VH and 182 SSH) were included. The median score on the PGI-I did not differ between VH and SSH. At 1 year post-operatively, 77 women after VH (73%) and 77 women after SSH (75%) considered their condition (very) much improved (p = 0.86). There was no difference in composite outcome of surgical success (126 out of 137 women [92%] after VH, 118 out of 125 women [94%] after SSH; p = 0.44). CONCLUSIONS: Our study shows that there was no difference in the type of surgery, VH or SSH, with regard to the patient's impression of improvement 1 year postoperatively in a large cohort from daily clinical practice.

Patient's preference for sacrospinous hysteropexy or modified Manchester operation: A discrete choice experiment.

OBJECTIVE: To investigate women's preference for modified Manchester (MM) or sacrospinous hysteropexy (SH) as surgery for uterine prolapse. DESIGN: Labelled discrete choice experiment (DCE). SETTING: Eight Dutch hospitals. POPULATION: Women with uterine prolapse, eligible for primary surgery and preference for uterus preservation. METHODS: DCEs are attribute-based surveys. The two treatment options were labelled as MM and SH. Attributes in this survey were treatment success ( levels SH: 84%, 89%, 94%; levels MM: 89%, 93%, 96%), dyspareunia (levels: 0%, 5%, 10%), cervical stenosis (levels: 1%, 6%, 11%) and severe buttock pain (levels: 0%, 1%). A different combination of attribute levels was used in each choice set. Women completed nine choice sets, making a choice based on attribute levels. Data were analysed in multinomial logit models. MAIN OUTCOME MEASURES: Women's preference for MM or SH. RESULTS: 137 DCEs were completed (1233 choice sets). SH was chosen in 49% of the choice sets, MM in 51%. Of all women, 39 (28%) always chose the same surgery. After exclusion of this group, 882 choice sets were analysed, in which women preferred MM, likely associated with a labelling effect, i.e. description of the procedure, rather than the tested attributes. In that group, MM was chosen in 53% of the choice sets and SH in 47%. When choosing MM, next to the label, dyspareunia was relevant for decision-making. For SH, all attributes were relevant for decision-making. CONCLUSIONS: The preference of women for MM or SH seems almost equally divided. The variety in preference supports the importance of individualised healthcare.

Location and motion of vaginal pessaries in situ in women with successful and unsuccessful pessary treatment for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The objective was to compare the location and motion of pessaries between women with pelvic organ prolapse (POP) with a successful (fitting) and unsuccessful (non-fitting) pessary treatment on dynamic magnetic resonance imaging (dMRI). METHODS: A cross-sectional exploratory study of 15 women who underwent a mid-sagittal dMRI of the pelvic floor at rest, during contraction and during Valsalva with three different types of pessaries. The coordinates of the pessaries cross section, inferior pubic point (IPP) and sacrococcygeal junction (SCJ) were obtained and the location (position, orientation) and the motion (translation and rotation) were calculated. Differences between the groups and between the pessaries within the groups were compared. RESULTS: Nine women with a fitting pessary and 6 women with a non-fitting pessary were selected. In the non-fitting group, the pessaries were positioned more caudally and rotated more in clockwise direction and descended more, but not significantly, during Valsalva compared with the fitting group. The Falk pessary was positioned more anteriorly in the fitting group and more cranially in the non-fitting group compared with the ring and ring with support pessary. CONCLUSIONS: A non-fitting pessary was positioned more caudally at rest; on Valsalva, it rotated more clockwise and moved more caudally, suggesting that the dynamic characteristics of the pessary might play an important role in its effectiveness. Findings of this study serve as a basis for the development of new pessary designs.

Usage of a Web-Based eHealth Intervention for Women With Stress Urinary Incontinence: Mixed Methods Study.

BACKGROUND: Stress urinary incontinence (SUI) is highly prevalent among women and has an impact on physical and mental well-being. eHealth with pelvic floor muscle training (PFMT) has shown to be effective in reducing complaints. The usage and nonusage attrition of eHealth for SUI is unknown, but knowledge about users and their usage patterns is crucial for implementation purposes. OBJECTIVE: This study aimed to evaluate how an eHealth intervention for SUI was used and by whom, explore reasons for nonusage attrition, and determine what factors are associated with usage. METHODS: In this observational, mixed methods study, women with SUI independently registered to a web-based eHealth intervention, Baas over je blaas, a translation of the Swedish internet program Tät-treatment of stress urinary incontinence. Log-in data were collected during 3-month access to the website, and surveys were sent at baseline. Participants were divided into three user groups (low, intermediate, and high) and were compared based on sociodemographic and incontinence-related characteristics. Nominal logistic regression analysis was used to study factors associated with eHealth usage. Qualitative content analysis was used for open-ended questions about nonusage attrition and about facilitators of and barriers to eHealth usage. RESULTS: Participants (n=561) had a mean age of 50.3 (SD 12.1) years, and most of them (340/553, 61.5%) had never visited a health care professional for SUI before. Most users were low users (295/515, 57.3%), followed by intermediate users (133/515, 25.8%) and high users (87/515, 16.9%). User groups differed significantly in age (48.3, SD 12 years; 52.1, SD 11.6 years; and 55.3, SD 10.9 years; P<.001) and in their expected ability to train the pelvic floor muscles (7.5, SD 1.4; 7.7, SD 1.4; and 8.1, SD 1.5 for low, intermediate, and high users, respectively; P=.006). Nonusage attrition was mainly caused by problems in integrating PFMT into everyday life. High age (>50 years), previous PFMT, and high expected ability to train the pelvic floor muscles are associated with high usage. Facilitators for eHealth usage were the clear explanation of exercises and the possibility of self-management. Barriers were its noncommittal character and the absence of personal contact. CONCLUSIONS: eHealth fulfills a need for women with SUI who have never received treatment. Those who discontinued prematurely did so mainly because it was difficult to integrate the training schedule into their everyday lives. High eHealth usage was more likely for women aged >50 years, with previous PFMT, and with high expectations about their ability to train the pelvic floor muscles. Knowledge of these user characteristics can guide clinicians and correct their misunderstandings about the suitable target population for this intervention. Furthermore, strategies for reinforcing expectations and self-efficacy are important to upscale eHealth usage, together with paying attention to people's need for personal contact. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/13164.

Does three-dimensional anatomy improve student understanding?

We aim to provide an overview of the various digital three-dimensional visualizations used for learning anatomy and to assess whether these improve medical students' understanding of anatomy compared to traditional learning methods. Furthermore, we evaluate the attitudes of the users of three-dimensional visualizations. We included articles that compared advanced newer three-dimensional anatomy visualization methods (i.e., virtual reality, augmented reality, and computer-based three-dimensional visualizations) to traditional methods that have been used for a long time (i.e., cadaver and textbooks) with regard to users' understanding of anatomy. Of the 1,148 articles identified, 21 articles reported data on the effectiveness of using three-dimensional visualization methods compared to two-dimensional methods. Twelve articles found that three-dimensional visualization is a significantly more effective learning method compared to traditional methods, whereas nine articles did not find that three-dimensional visualization was a significantly more effective method. In general, based on these articles, medical students prefer to use three-dimensional visualizations to learn anatomy. In most of the articles, using three-dimensional visualization was shown to be a more effective method to gain anatomical knowledge compared to traditional methods. Besides that, students are motivated and interested in using these new visualization methods for learning anatomical structures. Clin. Anat. 32:25-33, 2019. © 2019 Wiley Periodicals, Inc.

Recurrence risk is associated with preoperatively advanced prolapse stage: Is there a difference between women with stage 2 and those with stage 3 or 4 cystocele?

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) recurrence after surgery is a major problem. POP that is more advanced preoperatively is associated with a higher risk of recurrence postoperatively. We hypothesized that women with a stage 2 cystocele differ from those with a stage 3 or 4 cystocele. The aim of this study was to compare the baseline characteristics of women with mild and those with more advanced cystocele. METHODS: Patients had participated in one of two multicenter prospective cohort studies on women undergoing conventional anterior colporrhaphy without previous POP surgery. This was a secondary analysis of these data. Women with a preoperative cystocele stage 2 were compared with women with a stage 3 or 4 cystocele. Logistic regression models were employed to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Two hundred and sixty-nine women were assessed, of whom 132 (49.1%) had an advanced cystocele. Only older age was significantly associated with advanced cystocele preoperatively, with an OR of 1.07 (95% CI 1.04-1.10). There were no significant differences between women with advanced or stage 2 cystocele in body mass index, vaginal deliveries, assisted delivery, positive family history of POP, concurrent rectocele, concurrent uterine of vaginal vault prolapse, major levator ani muscle defects, or levator hiatal area. CONCLUSIONS: Women with advanced cystocele were significantly older than women with stage 2 cystocele. This raises the question whether it would be favorable to perform POP surgery in an earlier stage, i.e., at a younger age, in order to prevent POP recurrence.

Accuracy of augmented reality-guided needle placement for pulsed radiofrequency treatment of pudendal neuralgia: a pilot study on a phantom model.

Background: Pudendal neuralgia (PN) is a chronic neuropathy that causes pain, numbness, and dysfunction in the pelvic region. The current state-of-the-art treatment is pulsed radiofrequency (PRF) in which a needle is supposed to be placed close to the pudendal nerve for neuromodulation. Given the effective range of PRF of 5 mm, the accuracy of needle placement is important. This study aimed to investigate the potential of augmented reality guidance for improving the accuracy of needle placement in pulsed radiofrequency treatment for pudendal neuralgia. Methods: In this pilot study, eight subjects performed needle placements onto an in-house developed phantom model of the pelvis using AR guidance. AR guidance is provided using an in-house developed application on the HoloLens 2. The accuracy of needle placement was calculated based on the virtual 3D models of the needle and targeted phantom nerve, derived from CBCT scans. Results: The median Euclidean distance between the tip of the needle and the target is found to be 4.37 (IQR 5.16) mm, the median lateral distance is 3.25 (IQR 4.62) mm and the median depth distance is 1.94 (IQR 7.07) mm. Conclusion: In this study, the first method is described in which the accuracy of patient-specific needle placement using AR guidance is determined. This method could potentially improve the accuracy of PRF needle placement for pudendal neuralgia, resulting in improved treatment outcomes.

Laparoscopic Davydov vs. laparoscopic Vecchietti neovaginoplasty in women with Mayer-Rokitansky-Küster-Hauser syndrome; a systematic review and meta-analysis.

OBJECTIVE: To summarize the available evidence on the laparoscopic Davydov and Vecchietti methods to create a neovagina and to compare these techniques with a focus on neovaginal length, sexual function, operative time, and complications. DESIGN: A systematic electronic search up to August 2022 using PubMed and Embase is performed. SETTING: Not applicable. PATIENTS: Women with Mayer-Rokistansky-Küster-Hauser syndrome. INTERVENTIONS: All published clinical studies concerning the laparoscopic Davydov and laparoscopic Vecchietti procedures as a surgical technique to create a neovagina in women with Mayer-Rokistansky-Küster-Hauser syndrome were obtained. The guidelines for the preferred reporting items for systematic reviews and meta-analysis were followed. The following data were extracted: operative time, hospital stay, major early complications (within 3 months postsurgery), dilation therapy, neovaginal length, vaginal discharge, vaginal stenosis, time to sexual activity, sexual satisfaction, penetrative sexual activity, dyspareunia, score on the Female Sexual Function Index (FSFI), and duration of follow-up. The Newcastle Ottawa Scale was used to assess the quality of articles. MAIN OUTCOME MEASURES: Neovaginal length, FSFI scores, operative time, and complications. RESULTS: A total of 1,163 articles were identified, of which 33 studies were included in this systematic review. Of these, 12 studies (380 patients) are related to the Davydov method, 19 studies (1,126 patients) to the Vecchietti method, and 2 articles concern both. There is clinical heterogeneity and variety in the quality of the studies. Eighteen studies were included in the meta-analyses. The mean neovaginal length 12 months after the Davydov method is 8.3 cm (95% confidence interval [CI] 8.1-8.6), vs. 8.7 cm (95% CI 7.2-10.3) after the Vecchietti method. The mean FSFI score after the Davydov method is 28.9 (95% CI 26.8-31.1), compared with 27.5 (95% CI 25.0-30.1) after the Vecchietti method. The operative time of the Davydov method is 126 minutes (95% CI 109-143), compared with 40 minutes (95% CI 35-45) of the Vecchietti method. CONCLUSIONS: The operations yield comparable neovaginal length, sexual function, and complication rates. The mean FSFI scores indicate no sexual dysfunction in either group. The operative time of the Davydov method is significantly longer. There is no superiority shown for one of the surgical techniques in functional terms.

Lessons learned from the experiences of patients with chronic pelvic pain syndrome (CPP syndrome) with a multidisciplinary consultation: a qualitative study.

INTRODUCTION: Chronic pelvic pain syndrome is a complex multifactorial condition with an increasing prevalence probably due to a rising awareness. Chronic pelvic pain syndrome is pain in the pelvic area and often accompanied with complaints in other organ systems of the lesser pelvis. Patients with chronic pelvic pain syndrome who present at our center are evaluated in a standardized care pathway with an integrated multidisciplinary consultation. The team works in a single center and consists of gynecologists, pain specialists, urologists, a pelvic floor physiotherapist and a psychologist. The aim of this interview study is to evaluate the value of the multidisciplinary consultation from the patient's perspectives. METHODS: In a qualitative study, we evaluated the experiences and perspectives of patients with chronic pelvic pain syndrome concerning the multidisciplinary consultation at the Radboud University Medical Center. Semistructured interviews were conducted with patients with chronic pelvic pain syndrome who attended a multidisciplinary consultation between 2019 and 2022. All interviews were transcribed verbatim, coded and analyzed via ATLAS.ti with the conventional content analysis. RESULTS: Data saturation was reached after seven interviews, followed by three confirmative interviews. In total, 10 patients (22-76 years) participated in the study. Three relevant themes were identified in the interviews: the deleterious effects of pain on overall health, the importance of the design of the multidisciplinary consultation, and the performance of healthcare professionals (knowledge, skills and interaction with patients and colleagues). Participants suggested that although the consultation did not improve their pain experience, there was value in having a comprehensive assessment of their disease. Patients preferred the consultation to occur at the beginning of the care. Additionally, they acknowledged the performance of healthcare providers and having their complaints recognized. However, some participants suggested the need for additional attention to mental health issues during the multidisciplinary consultation. DISCUSSION: Even though patients did not perceive the multidisciplinary consultation to improve their pain experience, they appreciated the sense of recognition by this team. CONCLUSION: A multidisciplinary consultation is of value from the patients' perspective. A suggestion for improvement emerged where the multidisciplinary consultation should occur at the beginning of the patient journey.

Explorative Identification of Anatomical Parameters Associated with Successful Pessary Fitting in Pelvic Organ Prolapse Using Dynamic Magnetic Resonance Imaging.

Background: Pelvic organ prolapse (POP) affects many women and is often managed with pessary treatment, yet predicting the success of fitting remains challenging. This study aims to identify anatomical parameters associated with successful and unsuccessful pessary treatment using dynamic magnetic resonance imaging (dMRI). Methods: A cross-sectional study in Maastricht University Medical Centre (MUMC+), the Netherlands. Sixteen women with a cystocele and/or descensus uteri minimal POP-Q stage 2, using pessary treatment, were included. All women underwent a dynamic MRI of the pelvic floor at rest, during contraction and on Valsalva. The anatomical parameters evaluated included various lengths and angles. The association between the anatomical parameters and pessary fitted is assessed using partial least squares regression. The predictive accuracy was tested using cross-validation based on the partial least squares model with the most important variables. Results: Seven of the sixteen women (43.8%) were in the non-fitting group (due to movement, rotation or expulsion of the pessary), and nine women (56.3%) were in the fitting group. Participants in the non-fitting group had a significantly lower body mass index (BMI). Variables such as total vaginal length (TVL) and certain angles were highly predictive of pessary fitting success, with variable importance of projection (VIP) scores indicating their importance. The prediction models showed accuracies ranging from 53.3% to 80.0%. Conclusions: In this explorative study, TVL, cervical length (CL), sacrococcygeal angle and pubococcygeal angle were key variables associated with pessary fitting success. These findings offer valuable insights for optimizing pessary fitting procedures and the development of new pessaries.

Anatomy in the daily practice of the gynecologist, essential or just window dressing?

Traditionally, anatomy was one of the basic pillars of medical training. However, due to the expansion of medical science and medical knowledge in general, anatomy teaching has steadily declined and the way anatomy is taught has changed. These changes go hand in hand with growing literature about a perceived and proven lack of anatomical knowledge. While anatomy is important for all doctors, these developments seem to be more worrying for surgical residents. At the same time, little is known about how clinicians use anatomy in daily practice. The primary aim of this study was to increase understanding of the role of anatomy in the daily practice of gynecologists. An explorative qualitative study was performed to answer the question "What is the tangible utility of solid anatomical knowledge in the daily practice of the gynecologist"? Semi-structured interviews with gynecologists and obstetrics and gynecology (ObGyn) residents from Belgium and the Netherlands were held and the responses were analyzed using a phenomenographic inductive coding approach. Anatomical knowledge was important and used for technical skills and non-technical achievements in the daily practice of gynecologists, and three themes were distinguished. Specifically, anatomical knowledge was important and used (1) for daily activities, (2) for the feeling of self-efficacy, and (3) to gain a respected name as a doctor. These findings are discussed in light of (perceived) insufficient anatomical knowledge, and recommendations are made for the postgraduate education of ObGyn doctors.

Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study.

INTRODUCTION AND HYPOTHESIS: This study aimed to determine the relationship of recurrent cystocele with avulsion of puborectalis muscle and other risk factors. METHODS: In this prospective observational cohort study, 245 women undergoing anterior colporrhaphy were invited for a 2-year follow-up visit consisting of a questionnaire, physical examination, and translabial 3D ultrasonography. Women with and without recurrent cystocele were compared to identify recurrence risk factors. RESULTS: Of the 245 women, 156 agreed to the follow-up visit (63.7%). Objective recurrence rate was 80 of 156 (51.3%). Seventeen of the 156 (10.9%) reported subjective recurrence. Risk factors for anatomical recurrence were complete avulsion of puborectalis muscle (OR, 2.4; 95% CI, 1.3, 4.7), advanced preoperative stage (OR, 2.0; 95% CI, 1.0, 4.1), family history of prolapse (OR, 2.4; 95% CI, 1.2, 4.9), and sacrospinous fixation (OR, 6.5; 95% CI, 2.0, 21.2). CONCLUSIONS: Risk factors for anatomical cystocele recurrence after anterior colporrhaphy were complete avulsion of puborectalis muscle, advanced preoperative stage, family history of prolapse, and sacrospinous fixation.

Anatomy (knowledge) in postgraduate obstetrics and gynaecology training: Is it sufficient enough?

BACKGROUND: Due to the importance, anatomy training is worldwide recognizable in virtually all undergraduate curricula and many postgraduate surgical curricula (Estai and Bunt, 2016; Older, 2004). The postgraduate curriculum of Obstetrics and Gynaecology (O&G) is such a surgical curriculum. It is a diverse branch of medicine and the role of anatomy in O&G is versatile. In the Netherlands nor in Europe the expectations of knowledge on anatomy are specified in the current training program, making trainees insecure about their performance in anatomy knowledge ("Better Education for Obsetrics and Gynaecology,"). Therefore, we recently performed a Delphi study to determine which anatomical structures should be taught to ensure safe and competent practice among general gynaecologists (Koppes et al., 2020). The aim of this study is the determination of the anatomical knowledge level in postgraduate training for O&G. Our hypothesis is that the trainees possess a good knowledge of anatomy and on average at least 80% of correct answers on core knowledge is shown. METHODS: A longitudinal knowledge analysis was performed under Dutch Trainees Obstetrics and Gynaecology. The anatomy questions of the annual progress tests from 2010 to 2019 were analysed. Anatomy questions were selected and assessed on relevance based on the previous performed Delphi study which identified 86 structures which are essential to perform safe and competent practice as a general gynaecologist. Scores on relevant anatomy questions were calculated. RESULTS: In 10-year 3136 trainees performed the annual progress test. 54 Anatomy related questions were asked on a total of 1637 questions (3.3%). Of these 54 questions, 38 (70%) were concerned as relevant questions. Overall 10-year score was 64.5%. CONCLUSIONS: The anatomy knowledge of trainees' Obstetrics and Gynaecology is insufficient. Our results are a step in the awareness of testing and improving anatomy knowledge of postgraduate O&G training.

What do we need to know about anatomy in gynaecology? An international validation study.

OBJECTIVE: International validation of the Dutch Delphi study about which anatomical structures should be taught to ensure safe and competent practice among general gynaecologists. STUDY DESIGN: Validation study with gynaecologists and trainees in gynaecology from academic, non-academic teaching and non-academic, non-teaching hospitals worldwide. The relevance of 123 items included in the Dutch Delphi study was scored on a Likert scale between 1 (not relevant) and 5 (highly relevant). Consensus was defined when ≥70 % of the panellist scored the item as relevant or very relevant and the average rating was ≥4. RESULTS: A total of 192 gynaecologists and trainees from seven countries (Belgium, Germany, Norway, Oceania, Sweden, United Kingdom and United States) completed the questionnaire. Of the 123 structures, 72 (58.5%) were internationally relevant. When the 72 relevant structures from the international Delphi study were compared with the 86 relevant structures from the Dutch Delphi study, 70 (81.4%) structures matched. CONCLUSIONS: This study identified 70 anatomical structures that should be taught for safe and competent practice of general gynaecologists based on national and international validation. The results of our study identify the learning needs (i.e., the content) for an international anatomy curriculum. The development of the curriculum (i.e., the form) can be determined by each country and used to standardize and guide postgraduate training in gynaecology. This is an important step in the era of international teaching and training.

The Level of Anatomical Knowledge, Hard to Establish: a Systematic Narrative Review.

Objective: This literature review aimed to gain more insight into the level of anatomical knowledge based on published measurements among medical students, residents, fellows, and specialists. Methods: We performed an extensive literature search in three online databases: Medline (using PubMed), Web of Science, and Education Resources Information Centre (ERIC). Results: A total of 30 relevant studies were found. In these studies, participants took different anatomy tests, and their mean/median scaled scores range from 22.5 to 82.4% on a 0 to 100% scale. Conclusion: This review provides an overview of what is known about measured anatomical knowledge. After critically reviewing the literature, we have to conclude that the existing literature confirms that anatomical knowledge is hard to establish, mainly due to the lack of standardisation.Further research should focus on ways to define and assess 'desired anatomical knowledge' in different contexts. In a next phase, we can discuss if anatomical knowledge is lacking and if interventions are needed.

Protocol for translabial 3D-ultrasonography for diagnosing levator defects (TRUDIL): a multicentre cohort study for estimating the diagnostic accuracy of translabial 3D-ultrasonography of the pelvic floor as compared to MR imaging.

BACKGROUND: Pelvic organ prolapse (POP) is a condition affecting more than half of the women above age 40. The estimated lifetime risk of needing surgical management for POP is 11%. In patients undergoing POP surgery of the anterior vaginal wall, the re-operation rate is 30%. The recurrence risk is especially high in women with a levator ani defect. Such defect is present if there is a partially or completely detachment of the levator ani from the inferior ramus of the symphysis. Detecting levator ani defects is relevant for counseling, and probably also for treatment. Levator ani defects can be imaged with MRI and also with Translabial 3D ultrasonography of the pelvic floor. The primary aim of this study is to assess the diagnostic accuracy of translabial 3D ultrasonography for diagnosing levator defects in women with POP with Magnetic Resonance Imaging as the reference standard. Secondary goals of this study include quantification of the inter-observer agreement about levator ani defects and determining the association between levator defects and recurrent POP after anterior repair. In addition, the cost-effectiveness of adding translabial ultrasonography to the diagnostic work-up in patients with POP will be estimated in a decision analytic model. METHODS/DESIGN: A multicentre cohort study will be performed in nine Dutch hospitals. 140 consecutive women with a POPQ stage 2 or more anterior vaginal wall prolapse, who are indicated for anterior colporapphy will be included. Patients undergoing additional prolapse procedures will also be included. Prior to surgery, patients will undergo MR imaging and translabial 3D ultrasound examination of the pelvic floor. Patients will be asked to complete validated disease specific quality of life questionnaires before surgery and at six and twelve months after surgery. Pelvic examination will be performed at the same time points. Assuming a sensitivity and specificity of 90% of 3D ultrasound for diagnosing levator defects in a population of 120 women with POP, with a prior probability of levator ani defects of 40%, we will be able to estimate predictive values with good accuracy (i.e. confidence limits of at most 10% below or above the point estimates of positive and negative predictive values).Anticipating 3% unclassifiable diagnostic images because of technical reasons, and a further safety margin of 10% we plan to recruit 140 patients. TRIAL REGISTRATION: Nederlands trial register NTR2220.

Pain after midurethral sling; the underestimated role of mesh removal.

INTRODUCTION: The primary aim of this study was to evaluate the results of midurethral sling (MUS) removal in women who have pain as their single complication of MUS. MATERIAL AND METHODS: We performed a retrospective chart study supplemented with a cross sectional questionnaire. Women who underwent MUS removal for pain as the solitary reason for removal between 2004 and 2018 were included. Primary outcome was change in pain levels assessed by the visual analogue scale (VAS) pain score (range 0-10). Secondary outcome was the recurrence of stress urinary incontinence (SUI). RESULTS: Twenty-six of 31 patients returned the questionnaire. Median medical file follow-up was 12 months (range 2-66) and 25 months (range 5-104) regarding questionnaires. VAS pain score dropped from 7.8 (SD 1.9) at baseline to 4.5 (SD 3.2) at follow-up (p <.00). Seven (23%) patients were pain-free. Patients undergoing partial vaginal resection (n = 6) had a VAS pain score decrease of 4.7 (p = .02) versus 2.7 (p = .02) for complete vaginal removal (n = 14). Twenty-three (89%) patients experienced SUI at follow-up, whereof 10 (45%) reported (almost) no incidents of SUI. CONCLUSIONS: MUS removal is a viable and safe option with a significant drop in VAS pain score in patients with chronic pain after MUS placement. A post-operative increase of SUI and a possible renewed wish for SUI treatment have to be considered. This should not be a reason to refrain from information and/or referral for surgical removal.

Association between levator ani avulsion and urinary incontinence in women: A systematic review and meta-analysis.

BACKGROUND: Urinary incontinence is a bothersome symptom. Although the relationship between stress urinary incontinence (SUI) and vaginal delivery is established, the pathology underlying SUI after vaginal birth remains to be elucidated. OBJECTIVES: To determine whether levator ani muscle avulsion predisposes for SUI in women. SEARCH STRATEGY: Pubmed and Embase were searched for terms and their variations "levator ani muscle avulsion" and "urinary incontinence", from inception until 5 November 2019. SELECTION CRITERIA: Inclusion criterion: studies describing the relationship between urinary incontinence and levator ani muscle avulsion in women at least 1 year after delivery. Exclusion criterion: studies only analyzing the urethral sphincter or hiatus dimensions. DATA COLLECTION AND ANALYSIS: Odds ratios were used and if not available, were calculated as means of data synthesis, adjusted odds ratios if presented by the study, random-effects model to compute a pooled estimate. RESULTS: Seven studies were included, accounting for 2388 women. Comparing women with and without levator ani muscle avulsion, the overall odds ratio for SUI is 0.87 (95% confidence interval 0.56-1.34), and after adjustment for possible confounders was 0.72 (95% confidence interval 0.40-1.30). CONCLUSION: There is no relationship between levator ani muscle avulsion and SUI in women.

What do we need to know about anatomy in gynaecology: A Delphi consensus study.

OBJECTIVE: Determination of the anatomical structures that should be taught to ensure safe and competent practice among general gynaecologists. STUDY DESIGN: A two-round Delphi survey, face-to-face meeting in focus groups and an individual interview. Participants were medical doctors and trainees from gynaecology, surgery, urology and radiology from academic, non-academic teaching and non-academic, non-teaching hospitals in the Netherlands. Relevant structures were collected from gynaecology surgery atlas based on most common gynaecological surgeries and diseases. These structures were supplemented and critically viewed in focus groups followed by a Delphi survey. In the Delphi survey gynaecologist and trainee's gynaecology from all over the Netherlands scored the items on a Likert scale between 1 (not relevant) and 5 (highly relevant). Consensus was defined when ≥ 70 % of the panellist scored the item as relevant or very relevant and the average rating was ≥ 4. Main outcome was clinically relevant anatomical structures. RESULTS: Consensus on 86 clinically relevant anatomical structures divided by nine categories. CONCLUSIONS: This study identified a core list of anatomical structures that are relevant to the safe and competent practice of general gynaecologists and that can be used to guide gynaecology postgraduate education. This is the first step in a much wider and complex process of becoming a competent gynaecologist.