Surgical management of pudendal nerve entrapment after sacrospinous ligament fixation.

OBJECTIVE: To analyse the efficacy of sacrospinous ligament (SSL) suture removal on the reduction of pain symptoms in the case of suspected pudendal nerve entrapment after sacrospinous ligament fixation (SSLF). DESIGN: Retrospective cohort study. SETTING: Tertiary referral centre, the Netherlands. POPULATION: A cohort of 21 women having their SSLF sutures removed because of SSLF-related pain symptoms. METHODS: Clinical record review. MAIN OUTCOME MEASURES: The primary outcome was reduction of pain after SSL suture removal. Secondary outcome measures were time interval between suture placement and suture removal, complete suture removal, adverse events and recurrence of pelvic organ prolapse (POP). RESULTS: A total of 21 women underwent SSL suture removal for severe and/or persistent pain, which was confirmed on clinical examination: 95% of the women (20/21) reported pain reduction after suture removal, and 57% reported complete pain relief. The time interval between suture placement and suture removal was at a median of 414 days (range 8-1855 days). Sutures could be completely removed in 86% of cases (18/21). One woman had excessive blood loss (520 ml) without blood transfusion. At 6-8 weeks after surgery, 10% of the women (2/21) had renewed symptomatic POP, stage ≥ 2, for which additional POP surgery was indicated. CONCLUSIONS: When performed by an experienced clinician, SSL suture removal is feasible and efficacious, with low morbidity. In addition, the risk of recurrent POP in the short term appeared to be low. TWEETABLE ABSTRACT: The surgical removal of sacrospinous ligament sutures is safe and efficacious for pain relief, even remote from initial placement.

Cystourethroscopy following midurethral slings: is it always necessary?

Midurethral slings are the mainstay of treatment for stress urinary incontinence. The role of cystourethroscopy to detect lower urinary tract injury following retropubic midurethral slings is well-established; however, its role following transobturator or single-incision sling placement remains controversial. Some advocate "routine" whereas others advocate for "selective" cystourethroscopy. This paper reviews the arguments for and against cystourethroscopy to detect lower urinary tract injury following transobturator and single-incision slings.

Agreement between palpation and transperineal and endovaginal ultrasound in the diagnosis of levator ani avulsion.

INTRODUCTION AND HYPOTHESIS: Our aim was to estimate agreement between transperineal and endovaginal ultrasound in assessing levator ani biometry and avulsion in nullipara and primipara women and determine agreement between levator avulsion palpation and ultrasound. METHODS: This longitudinal cohort study assessed 269 nullipara women at 36 weeks gestation and 191 primipara women 13 weeks postpartum. Women underwent levator palpation, and avulsion was diagnosed if no attachment to the pubic bone was felt. Subsequently, 3/4D transperineal and 3D endovaginal ultrasound were performed. A standardized protocol was used to perform measurements at rest. Levator avulsion was diagnosed on endovaginal ultrasound at rest if >50 % was avulsed and on transperineal tomographic ultrasound imaging at maximum contraction if the central three slices were avulsed. Levator avulsion was analyzed by two independent, blinded investigators. A third investigator resolved discrepancies. Intraclass correlation coefficient and limits of agreement were calculated for each time point. RESULTS: Intraclass correlation coefficient for levator urethra gap was 0.44-0.54, hiatus area 0.76-0.79, transverse diameter 0.51-0.59, anteroposterior diameter 0.70-0.72. Levator thickness correlated poorly. Endovaginal ultrasound measurements were generally smaller; however limits of agreement were acceptable for hiatus measurements. Overall agreement between both ultrasound techniques in diagnosing levator avulsion was 95 %; correlation 0.72 [95 % confidence interval (CI) 0.67-0.76]. Agreement between palpation and transperineal ultrasound was 92 % (kappa = 0.34), and between palpation and endovaginal ultrasound was 92 % (kappa = 0.37). CONCLUSIONS: Transperineal and endovaginal ultrasound can both be used to analyze hiatus area and anteroposterior diameter with the patient at rest and to diagnose levator avulsion. Palpation correlates only fairly with both methods.