Surgical anatomy of the vaginal vault.

AIM: Vaginal vault (VV) surgery should be a key part of surgery for a majority of pelvic organ prolapse (POP). The surgical anatomy of the VV, the upper most part of the vagina, has not been recently subject to a dedicated examination and description. METHODS: Cadaver studies were performed in (i) 10 unembalmed cadaveric pelves (observation); (ii) 2 unembalmed cadaveric pelves (dissection); (iii) 5 formalinized hemipelves (dissection). The structural outline and ligamentous supports of the VV were determined. Further confirmation of observations in post-hysterectomy patients were from a separate study on 300 consecutive POP repairs, 46% of whom had undergone prior hysterectomy. RESULTS: The VV is equivalent to the Level I section of the vagina, measured posteriorly from the top of the posterior vaginal wall (apex or highest part of the vagina) to 2.5 cm below this point. It comprises the anterior fornix (through which cervix protrudes or is removed at hysterectomy), posterior fornix and two lateral fornices. Before hysterectomy, the posterior aspects of the cervix and upper vagina are supported by the uterosacral (USL) and cardinal ligaments (CL), the distal segments of which fuse together to form a cardinal-uterosacral ligament complex (cardinal utero-sacral complex), around 2-3 cm long. Post---hysterectomy, there is some residual USL support to the anterior fornix but the posterior fornix has no ligamentous support and is thus more vulnerable to prolapse. CONCLUSION: Effective management of VV prolapse will need to be part of most POP repairs. Enhanced understanding of the surgical anatomy of the vaginal vault allows more effective planning of those POP surgeries.

Surgical anatomy of the vaginal introitus.

AIM: The vaginal introitus is the entrance to the vagina, encompassing the anterior and posterior vestibules and the perineum. The surgical anatomy of the vaginal introitus, the lowest level of the vagina, has not been subject to a recent comprehensive examination and description. Vaginal introital surgery (perineorrhaphy) should be a key part of surgery for a majority of pelvic organ prolapse. METHODS: Cadaver studies were performed on the anterior and posterior vestibules and the perineum. Histological studies were performed on the excised perineal specimens of a cohort of 50 women undergoing perineorrhaphy. Included are pre- and postoperative studies which were performed on 50 women to determine the anatomical and histological changes achieved with a simple (anterior) perineorrhaphy. RESULTS: The vaginal introitus is equivalent to the Level III section of the vagina, measured posteriorly from the clitoris to the anterior perineum then down the perineum to the anal verge. The anterior and posterior vestibules, with nonkeratinizing epithelium, extend laterally to the keratinized epithelium of the labia minora (Hart's line). The anterior vestibule has six anatomical layers while the posterior vestibule has three. The perineum has an inverse trapezoid shape. Perineorrhaphy specimens were a mean 2.9 cm wide and 1.6 cm deep. They show squamous epithelium with loose underlying connective tissue. There were no important structures seen histologically, for example, ligaments or muscles. Microscopically, only 6 (12%) were completely normal with 44 (88%) showing minor changes including inflammation and scarring. Considerable anatomical benefits were achieved with such a perineorrhaphy including a 27.6% increase in the perineal length and a 30.8% reduction in the genital hiatus. CONCLUSION: An understanding of the anatomy and histology of the vaginal introitus can assist with performing a simple and effective perineorrhaphy, the main surgical intervention at the vaginal introitus.

Surgical anatomy of the mid-vagina.

AIM: The mid-vagina (MV) represents Level II of the vagina. The surgical anatomy of the MV has not been recently subject to a comprehensive examination and description. MV surgery involving anterior and posterior colporrhaphy represents a key part of surgery for a majority of pelvic organ prolapse (POP). METHODS: Literature review and surgical observations of many aspects of the MV were performed including MV length and width; MV shape; immediate relationships; histological analysis; anterior and posterior MV prolapse assessment and anterior MV surgical aspects. Unpublished pre- and postoperative quantitative data on 300 women undergoing posterior vaginal compartment repairs are presented. RESULTS: The MV runs from the lower limit of the vaginal vault (VV) to the hymen. Its length is a mean of 5 cm. Its shape in section overall is a compressed rectangle. Its longitudinal shape is created by its anterior and posterior walls being inverse trapezoid in shape. Histology comprises three layers: (i) mucosa; (ii) muscularis; (iii) adventitia. MV prolapse staging uses pelvic organ prolapse quantification (POP-Q). Anterior MV prolapse can be quantitatively assessed using POP-Q while posterior MV prolapse can be assessed with POP-Q or PR-Q. Around 50% of both cystocele and rectocele are due to VV defects. POP will increase anterior MV width and length. Native tissue anterior colporrhaphy is the current conventional repair with mesh disadvantages outweighing advantages. Posteriorly, Level II (MV) defects are far smaller (mean 1.3 cm) than Level I (mean 6.0 cm) and Level III (mean 2.9 cm). CONCLUSION: An understanding of the surgical anatomy of the MV can assist anterior and posterior colporrhaphy. In particular, if VV support is employed, the Level II component of a posterior repair should be relatively small.

Posterior vaginal compartment repairs: Does vaginal vault (level I) fixation significantly improve the vaginal introital (level III) repair?

INTRODUCTION: Limited data exist associating vaginal vault and introital defects before and after posterior repairs (PR). We hypothesize: (i) a positive association between the size of vaginal vault and introital defects preoperatively; and (ii) a positive association between the reduction of these defects postoperatively if vault fixation (sacrospinous colpopexy-SSC) is used with the PR. METHODS: In a cross-sectional study of 300 consecutive PRs, the following were measured pre- and immediately postoperatively: (i) from POP-Q: genital hiatus (GH-Level III); (ii) from PR-Q: perineal gap (PG-Level III), posterior vaginal vault descent (PVVD-Level I). The data for introital defects (GH, PG) were separated according to the need for vault fixation using a SSC due to a larger vaginal defect (PVVD over 5 cm). RESULTS: Mean (SD) preoperative GH and PG were both significantly larger in the SSC versus no SSC group: GH (3.73 [0.94] vs 3.36 [0.83] cm, P = 0.01); PG (2.91 [1.0] vs 2.61 [0.91] cm, P = 0.05). SSC performed with the PR (84%); not performed (16%) cases. The mean (SD) postoperative reduction in GH (antero-posterior) was significantly (29%-P = 0.002) greater-1.1 (0.69) cm (29.5%) in the SSC group and 0.77 (0.49) cm (22.9%) in the no SSC group. The decrease in the PG (transverse) was greater by 11% (0.05). CONCLUSIONS: Levels I and III defects are associated with PRs; preoperatively larger vaginal vault (PVVD over 5 cm) and larger introital defects (GH, PG). Postoperatively, vault fixation resulted in significantly greater reduction in the introital defects. SUMMARY: Vaginal vault fixation (SSC) significantly improves the vaginal introital repair.

What if there were no tapes?

It is possible that the controversy involving prostheses implanted into women with pelvic floor problems might result in the majority of, or even all such products being restricted, banned or withdrawn in certain jurisdictions. A clear distinction between "tapes" for urinary incontinence and "mesh" for prolapse has been made in the enquiries and subsequent rulings in Australia and New Zealand. Transvaginal "mesh" will be unavailable with the range of "tapes" much more restricted in those countries from January 2018. The Chair of the all-party parliamentary group on surgical mesh implants in the United Kingdom was reported as describing the New Zealand announcement as "hugely significant" and "it's precisely what we've been calling for the UK." The title of this article has changed from a hypothetical piece to a potential reality review. Where does that leave the clinicians treating stress urinary incontinence (SUI) and the large number of female sufferers? "Tapes" (synthetic midurethral slings-MUS) have become very popular over the last 20 years since their original development and introduction in Scandanavia. Evidence-based medicine has shown their advantages over previous surgeries, in terms of ease of use, safety and efficacy. This article outlines the options which countries potentially rejecting the use of tapes, must now resort to for women with SUI. Those countries considering such action need the note of caution that none of the options are as good as tapes.

The vaginal vestibule: assessing the case for an anterior and posterior division.

The vaginal vestibule has not been the subject of a dedicated journal article. Recent terminology has suggested its division into anterior and posterior components. The case for this division has not yet been assessed. Both components extend laterally from the hymen to the junction with the labia minora. The posterior vaginal vestibule is proposed to extend from the posterior aspect of the hymen to the anterior edge of the perineum whilst the anterior vestibule extends from the posterior aspect of the hymen to just below the clitoris. Anatomical considerations (differing layers) might firstly support the above division. The posterior vestibule, by necessity, is far more flexible with the superficial aspect (approximately 1.5 cm), anatomically and histologically, comprising skin and subcutaneous tissue, with perineal musculature deep to this. In turn, it is more likely to be subject to obstetric and surgical considerations than the anterior vaginal vestibule. Obstetric trauma, in particular, would tend to create defects, particularly at its posterior margin. Many dermatological and microbiological considerations may be common to both anterior and posterior vestibule. Any dermatological condition of the vestibule can result in sexual dysfunction and can be complicated by secondary muscular spasm. Congenital anomalies will differ anteriorly and posteriorly. Multiple considerations can be identified to support the case for division of the vaginal vestibule into anterior and posterior components. Neurourol. Urodynam. 36:979-983, 2017. © 2016 Wiley Periodicals, Inc.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction.

INTRODUCTION: The terminology for anorectal dysfunction in women has long been in need of a specific clinically-based Consensus Report. METHODS: This Report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted on Committee by experts in their fields to form a Joint IUGA/ICS Working Group on Female Anorectal Terminology. Appropriate core clinical categories and sub classifications were developed to give an alphanumeric coding to each definition. An extensive process of twenty rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for anorectal dysfunction, encompassing over 130 separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific anorectal investigations and imaging (ultrasound, radiology and MRI) has been included whilst appropriate figures have been included to supplement and help clarify the text. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible. CONCLUSION: A consensus-based Terminology Report for female anorectal dysfunction terminology has been produced aimed at being a significant aid to clinical practice and a stimulus for research. Neurourol. Urodynam. 36:10-34, 2017. © 2016 Wiley Periodicals, Inc., and The International Urogynecological Association.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction.

Introduction and hypothesis There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report. Methods This Report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology, and nursing were invited to comment on the paper. Results A Terminology Report on the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically based, with the most common symptoms, signs, assessments, diagnoses, and treatments defined. Clarity and ease of use have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated, but will be required to keep the document updated and as widely acceptable as possible. Conclusion A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced, aimed at being a significant aid to clinical practice and a stimulus for research.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction.

INTRODUCTION AND HYPOTHESIS: The terminology for anorectal dysfunction in women has long been in need of a specific clinically-based Consensus Report. METHODS: This Report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted on Committee by experts in their fields to form a Joint IUGA/ICS Working Group on Female Anorectal Terminology. Appropriate core clinical categories and sub classifications were developed to give an alphanumeric coding to each definition. An extensive process of twenty rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for anorectal dysfunction, encompassing over 130 separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific anorectal investigations and imaging (ultrasound, radiology and MRI) has been included whilst appropriate figures have been included to supplement and help clarify the text. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible. CONCLUSIONS: A consensus-based Terminology Report for female anorectal dysfunction terminology has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction.

INTRODUCTION AND HYPOTHESIS: There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report. METHODS: This Report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology, and nursing were invited to comment on the paper. RESULTS: A Terminology Report on the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically based, with the most common symptoms, signs, assessments, diagnoses, and treatments defined. Clarity and ease of use have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated, but will be required to keep the document updated and as widely acceptable as possible. CONCLUSION: A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced, aimed at being a significant aid to clinical practice and a stimulus for research.

An International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP).

INTRODUCTION: The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report. METHODS: This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 year) review is anticipated to keep the document updated and as widely acceptable as possible. CONCLUSION: A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research.

Posterior vaginal compartment repairs: Where are the main anatomical defects?

INTRODUCTION AND HYPOTHESIS: Traditionally, it has been believed that posterior vaginal compartment prolapse was largely due to defects in the rectovaginal fascia, with surgical repairs concentrating on addressing this defect. We aimed to determine the relative size of defects at the different vaginal levels (I-III) following a large number of posterior vaginal compartment repairs (PRs) to determine whether this traditional viewpoint is still appropriate. METHODS: In a cross-sectional study of 300 consecutive PRs, mostly following prior or concomitant hysterectomy, two sets of markers of posterior compartment prolapse were used to measure anatomical defects at levels I-III: (i) from Pelvic Organ Prolapse Quantification (POP-Q) system points C, Ap, Bp, and genital hiatus (GH), and from Posterior Repair Quantification (PR-Q) perineal gap (PG), posterior vaginal-vault descent (PVVD), midvaginal laxity (MVL)-vault undisplaced, and rectovaginal fascial laxity (RVFL). RESULTS: The largest defects were found at level I (PVVD: mean 6.0 cm; point C, mean minus 0.9 cm), and level III (PG, mean 2.9 cm; GH, mean 3.7 cm). Level II defects (MVL-vault undisplaced, mean 1.3 cm; RVFL, mean 1.1 cm; points Ap, Bp, both mean 1.0 cm) were relatively small. CONCLUSIONS: This study suggests that the defects found at surgery for posterior vaginal compartment prolapse were more frequent at the vaginal vault (level I) and vaginal introitus (level III) than at midvagina (level II). These findings should have implications for surgical planning.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP).

INTRODUCTION: The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report. METHODS: This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 year) review is anticipated to keep the document updated and as widely acceptable as possible. CONCLUSION: A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research.

An International Urogynecological Association (IUGA) / International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP).

INTRODUCTION: The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report. METHODS: This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus). RESULTS: A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 year) review is anticipated to keep the document updated and as widely acceptable as possible. CONCLUSION: A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research.

Perineorrhaphy quantitative assessment (Pe-QA).

INTRODUCTION AND HYPOTHESIS: Perineorrhaphy (Pe) has not been subject to a comprehensive perioperative quantitative assessment (QA). We wish to nominate such an assessment (Pe-QA) for any Pe, through testing the QA on the excision of the perineal gap (PG) at the time of posterior repair (PR). METHODS: At 50 consecutive PRs, the following measurements were taken pre- and postoperatively: (i) perineorrhaphy width (PW) equals PG [1]; (ii) perineorrhaphy depth (PD); (iii) perineal length (PL); (iv) midperineal thickness (MPT); (v) genital hiatus (GH) and (vi) total posterior vaginal length (TPVL). The total vaginal length was also measured. Surgical details deemed appropriate to each repair were recorded. RESULTS: The overall means and ranges (cm) were: (i) PW 2.9 (1.5-5.5); (ii) PD 1.6 (0.8-2.0); (iii) PL 2.9 (1.5-4.5); (iv) MPT 0.7 (0.4-1.1); (v) GH 3.9 (2.3-6.5); (vi) TPVL 9.2 (6.0-12.5). Excision of PG (100 % cases reducing PW and PD to zero) resulted in a mean 23.6 % increase in total vaginal length over that if the repair was commenced at the hymen, despite a 3.3 % decrease in the TPVL perioperatively. There was a mean 30.8 % reduction in the GH, a mean 27.6 % increase in the PL and a mean 57.1 % increase in the MPT. CONCLUSIONS: Pe and the anatomical results of such surgery can be subject to quantitative assessment allowing comparison studies between different forms of Pe and possibly other types of perineal surgeries.

Severe adolescent female stress urinary incontinence (SAFSUI): case report and literature review.

INTRODUCTION: Severe adolescent female stress urinary incontinence (SAFSUI) can be defined as female adolescents between the ages of 12 and 17 years complaining of involuntary loss of urine multiple times each day during normal activities or sneezing or coughing rather than during sporting activities. An updated review of its likely prevalence, etiology, and management is required. MATERIALS AND METHODS: The case of a 15-year-old female adolescent presenting with a 7-year history of SUI resistant to antimuscarinic medications and 18 months of intensive physiotherapy prompted this review. Issues of performing physical and urodynamic assessment at this young age were overcome in order to achieve the diagnosis of urodynamic stress incontinence (USI). Failed use of tampons was followed by the insertion of (retropubic) suburethral synthetic tape (SUST) under assisted local anesthetic into tissues deemed softer than the equivalent for an adult female. RESULTS: Whereas occasional urinary incontinence can occur in between 6 % and 45 % nulliparous adolescents, the prevalence of non-neurogenic SAFSUI is uncertain but more likely rare. Risk factors for the occurrence of more severe AFSUI include obesity, athletic activities or high-impact training, and lung diseases such as cystic fibrosis (CF). This first reported use of a SUST in a patient with SAFSUI proved safe and completely curative. Artificial urinary sphincters, periurethral injectables and pubovaginal slings have been tried previously in equivalent patients. CONCLUSIONS: SAFSUI is a relatively rare but physically and emotionally disabling presentation. Multiple conservative options may fail, necessitating surgical management; SUST can prove safe and effective.

Cardinal ligament surgical anatomy: cardinal points at hysterectomy.

INTRODUCTION AND HYPOTHESIS: The cardinal ligament (CL) still requires more precise anatomical mapping. We aim to elucidate the anatomy of the CL and the roles it plays in gynecological surgery. METHODS: Studies employed sharp dissection of 28 formalin-fixed cadaveric hemipelves and 10 unembalmed cadaveric hemipelves. RESULTS: The CL (total length averaging 10.0 cm) can be subdivided into three sections: a distal (cervical) section, on average 2.1 cm long, attached to the lateral aspect of the cervix (posteriorly, it was confluent with the attachment of the uterosacral [USL] ligament to form the cardinal-uterosacral confluence [CUSC]); an intermediate section, on average 3.4 cm long, running laterally (slightly posteriorly) from the cervix; a proximal (pelvic) section, relatively thick, triangular-shaped on cross-section, averaging 4.6 cm long, attached to the lateral pelvic sidewall, with its apex at the first branching of the internal iliac artery. Only the distal section is free of any significant neural or vascular component (ureter is in the intermediate section) and therefore safe for surgical use. The CUSC (first pedicle of a vaginal hysterectomy and later pedicle of an abdominal hysterectomy), if attached to the vaginal vault at hysterectomy has the potential for both lateral (CL) and supero-posterior (USL) surgical support. This pedicle would not be subsequently accessible for other surgeries. CONCLUSIONS: Suggested cardinal points at hysterectomy are: know the CL anatomy; the distal section (as part of the CUSC) can provide vaginal vault support; the intermediate and proximal sections are surgically dangerous.

Optimizing study design for interobserver reliability: IUGA-ICS classification of complications of prostheses and graft insertion.

INTRODUCTION AND HYPOTHESIS: Results of interobserver reliability studies for the International Urogynecological Association-International Continence Society (IUGA-ICS) Complication Classification coding can be greatly influenced by study design factors such as participant instruction, motivation, and test-question clarity. We attempted to optimize these factors. METHODS: After a 15-min instructional lecture with eight clinical case examples (including images) and with classification/coding charts available, those clinicians attending an IUGA Surgical Complications workshop were presented with eight similar-style test cases over 10 min and asked to code them using the Category, Time and Site classification. Answers were compared to predetermined correct codes obtained by five instigators of the IUGA-ICS prostheses and grafts complications classification. Prelecture and postquiz participant confidence levels using a five-step Likert scale were assessed. RESULTS: Complete sets of answers to the questions (24 codings) were provided by 34 respondents, only three of whom reported prior use of the charts. Average score [n (%)] out of eight, as well as median score (range) for each coding category were: (i) Category: 7.3 (91 %); 7 (4-8); (ii) Time: 7.8 (98 %); 7 (6-8); (iii) Site: 7.2 (90 %); 7 (5-8). Overall, the equivalent calculations (out of 24) were 22.3 (93 %) and 22 (18-24). Mean prelecture confidence was 1.37 (out of 5), rising to 3.85 postquiz. Urogynecologists had the highest correlation with correct coding, followed closely by fellows and general gynecologists. CONCLUSIONS: Optimizing training and study design can lead to excellent results for interobserver reliability of the IUGA-ICS Complication Classification coding, with increased participant confidence in complication-coding ability.

Improving the clinical prediction of detrusor overactivity by utilizing additional symptoms and signs to overactive bladder symptoms alone.

INTRODUCTION AND HYPOTHESIS: We attempted to improve the accuracy of the clinical diagnosis of detrusor overactivity (DO) by using other significant clinical parameters in addition to overactive bladder (OAB) symptoms alone. METHODS: One thousand one hundred and forty women attending for their initial urogynecological assessment, including urodynamics, due to symptoms of pelvic floor dysfunction, underwent a comprehensive clinical and urodynamic assessment. Multivariate logistic regression analysis of a wide range of clinical parameters was used in order to determine a model of factors most accurately predicting the urodynamic diagnosis of DO. Data were separated according to women without DO; women with DO. The analysis involved the stepwise building of an optimal clinical model for predicting DO. RESULTS: In multivariate analysis, the OAB symptoms of urgency incontinence, urgency and nocturia (not frequency) were significantly associated with DO. Their prediction of DO was not particularly accurate (sensitivity 0.64; specificity 0.67). The addition of other significant clinical parameter, i.e. absent symptoms of stress incontinence; lower parity (0-1); no signs of prolapse, to the diagnostic model, resulted in marginally improved accuracy (area under the ROC curve increased from 0.70 to 0.74). CONCLUSIONS: Overactive bladder symptoms alone are not accurate in predicting DO. Adding other significant clinical parameters to the model resulted in a small statistical advantage, which is not clinically useful. An accurate clinical diagnosis of DO in women would appear to remain elusive.

Posterior repair quantification (PR-Q) using key anatomical indicators (KAI): preliminary report.

INTRODUCTION AND HYPOTHESIS: Posterior vaginal compartment repairs (PR) have traditionally involved a subjective approach. We aim to quantify such repairs using key anatomical indicators (KAI). METHODS: At 50 consecutive PRs: perineal gap (PG); posterior vaginal vault descent (PVVD); mid-vaginal laxity (MVL-vault undisplaced/displaced); and recto-vaginal fascial laxity (RVFL) were measured. The total posterior vaginal length (TPVL) and from POP-Q, TVL, GH, Ap, Bp C, D were also measured. Surgical details deemed appropriate to each repair were recorded. RESULTS: A mean preoperative PG of 2.5 cm was reduced to 0.0 cm postoperatively by excision (100 % cases) with an average increase of 21.6 % in total vaginal length over that if the repair was commenced at the hymen. There was an average reduction of 25.0 % in the genital hiatus (GH). Mean PVVD was 5.3 cm overall; 6.4 cm for 31 out of 50 (62 %) undergoing sacrospinous colpopexy; 3.5 cm for 19 out of 50 (38 %) with no ligamentous vault fixation. An approximate "cut-off" for PVVD of 5 cm may assist with the differentiation of cases where vault fixation may be desirable. Up to 52 % (1.4/2.7 cm) of preoperative MVL displacement was due to vaginal vault descent. The MVL undisplaced (mean 1.3 cm) may better guide vaginal mucosal trimming. RVFL averaged just 0.8 cm with 22 out of 50 (44 %) RVFL being 0.5 cm or less, and not requiring any RVF plicatory sutures. CONCLUSIONS: It is possible to use KAI to assist the planning and execution of posterior vaginal compartment surgery. The PG, PVVD, MVL, and RVFL can indicate surgical measures in the perineum, vaginal vault, vaginal mucosa, and recto-vaginal space respectively.