A Case of Vesicovaginal Fistula After Transvaginal Mesh Surgery Cured by Placement of a Urethral Catheter With Low‐Pressure Intermittent Suction

ObjectivesPelvic organ prolapse (POP) is a cause of overactive bladder (OAB), and transvaginal mesh (TVM) surgery can improve the symptoms. Bladder wall thickness (BWT) is a useful and safe marker to evaluate bladder function in urinary disorders. The main purpose of this study is to clarify the relationship between BWT and changes in the OAB symptom score (OABSS) after TVM operation in patients with POP.MethodsBWT was measured by ultrasonography before and 6 months after surgery at three sites in the bladder: the anterior wall, trigone, and dome. Similarly, the OABSS was evaluated at the time of BWT measurement. Changes induced in BWT at each site and the mean BWT at all sites after TVM surgery were analyzed. Similarly, the relationship between presurgical BWT and the decrease in OABSS was investigated.ResultsTVM surgery improved OABSS in 30 patients (responders; 73.2%), while 11 patients were judged as nonresponders (26.8%). BWT at the anterior bladder wall and dome as well as the mean BWT at all three sites were significantly decreased by TVM surgery (P < .001). Similar trends were identified in OABSS responders; however, all markers showed no significant changes in OABSS nonresponders. All the BWT‐related markers before surgery were significantly lower in OABSS responders than in OABSS nonresponders.ConclusionsBWT at the bladder anterior wall and dome, but not the trigone, were decreased by TVM surgery. We conclude that presurgical BWT may be a useful marker to predict the improvement in OAB symptoms by TVM surgery in patients with POP‐related OAB.

Background/Aims: Postoperative urinary retention (POUR) is one of the most frequent complications of epidural anesthesia. This study aims to clarify risk factors of POUR and to estimate the appropriate timing of urethral catheter removal. Methods: Between September and December 2014, a retrospective cohort study was conducted on 120 patients who underwent epidural anesthesia and major abdominal surgery. To observe trends in incidence of POUR, we analyzed the order and interval of removal of epidural and urethral catheters using Cochran-Armitage trend test. Results: In this study, 40 patients were diagnosed with POUR (33.3%). Median removal of epidural catheters was 4 postoperative days in the POUR group and 3.5 postoperative days in the non-POUR group (p = 0.04). When the urethral catheter was removed before epidural catheter, incidence of POUR was comparatively greater (p < 0.001). There were no statistical differences in surgical fields, operation approach, epidural catheter levels, or epidural opioid use. No patients had urinary tract infections. Conclusion: We demonstrated that removal of urethral catheter before epidural catheter contributed to increasing trends in incidence of POUR. The optimal order and interval of removal of epidural and urethral catheters should be considered to avoid POUR after abdominal surgery.

To evaluate the safety and efficacy of transvaginal mesh surgery using a polytetrafluoroethylene mesh to treat pelvic organ prolapse. This prospective observational study included women undergoing transvaginal mesh surgery for pelvic organ prolapse that used new polytetrafluoroethylene mesh cut into a shape similar to that of Elevate. We evaluated the subjective and objective outcomes at 3 and 12months, as well as postoperative complication rates. This study included 55 patients. The pelvic organ prolapse quantification scores improved significantly at 3 and 12months after surgery compared with scores before surgery. In four patients (7.3%), a pelvic examination showed stage2 objective recurrence without subjective symptoms. Clavien-Dindo grades2 and 3 perioperative complications were observed in 9.1% and 1.8% of the patients, respectively. Vaginal mesh exposure occurred in one patient (1.8%) at the time of the 3-month follow-up evaluation. The mesh was exposed at the proximal midline of the anterior vaginal wall. These findings show the safe and effective use of the polytetrafluoroethylene mesh for transvaginal mesh surgery.

Objective: This study aims to evaluate the risk factors for subjective recurrence and complications of patients who underwent transvaginal synthetic mesh surgery. Design: This retrospective cohort study included patients who received transvaginal mesh (TVM) surgery between January 2005 and June 2019. Methods: The information of patients was collected, including basic characteristics, subjective recurrence, and mesh-related complications. The clinical characteristics of patients with and without subjective recurrence were compared. The sexual activities of patients before and after the operation were recorded. SPSS 20.0 was used for the statistical analysis. Results: A total of 257 patients were included. Among them, 62 (24.1%) patients were lost to follow-up. The median follow-up time was 80 months (12 months, 170 months). Finally, 195 patients were followed up, 11 (5.6%) patients had a subjective recurrence of pelvic organ prolapse, and 26 (13.3%) patients had mesh-related complications (11 patients with de novo pain and 15 patients with mesh exposure). We found significant differences in age (68.9 ± 5.1 vs. 63.4 ± 5.8 years old), years of postmenopause (17.5 ± 6.3 vs. 13.3 ± 6.9 years), previous hysterectomy (27.3% vs. 6.0%), and concomitant hysterectomy (45.5% vs. 81.0%) between patients with and without subjective recurrence (p < 0.05). The mesh exposure proportion of patients with total vaginal mesh (47.6%) was significantly higher than that with anterior vaginal mesh (2.9%) (p < 0.05). Furthermore, 6.7% of sexually active patients reported de novo dyspareunia. Limitation: The investigators could only record the subjective recurrence of patients, and thus there is a lack of objective recurrence data. Conclusion: Age, years of postmenopause, and previous hysterectomy are risk factors for subjective recurrence of TVM surgery; however, concomitant hysterectomy is a protective factor. Mesh exposure is the most common complication, especially for total vaginal mesh repair surgery.

Mesh surgeries, such as sacrocolpopexy and transvaginal mesh surgery, are commonly used to treat pelvic organ prolapse. Although mesh surgeries have a high success rate, they are unsuitable for some patients. For a patient with pelvic organ prolapse and highly calcified multiple fibroids, we performed hybrid sacrocolpopexy combined with transvaginal mesh surgery with a method modified for the patient's condition. Three months after surgery, the results were highly satisfactory. This approach is simple, secure, and versatile for patients who are not good candidates for conventional mesh surgeries. This novel hybrid mesh surgery is an option for treating various types of pelvic organ prolapse.

To develop a locally tailored ERAS program for 60-80-year-old patients with pelvic organ prolapse (POP) undergoing transvaginal mesh (TVM) surgery in low- and middle-resource countries. In this multicenter randomized controlled trial conducted at seven tertiary hospitals, 262 women aged 60-80 scheduled for elective TVM surgery were randomly allocated (1:1) to receive either a comprehensive ERAS perioperative intervention or conventional perioperative management (131 participants per group). The primary outcomes were postoperative length of stay, pain scores, time to first flatus, removal of urinary catheter, first assisted walking, postoperative complications, readmission, emergency visit, in-hospital costs, PGI-I, QoR-15, PONV, and residual urine volume. ERAS group had significantly shorter postoperative length of stay (median 3.92days vs. 4.99days, HR = 1.42, 95% CI 1.11-1.82, P = 0.005), lower pain scores within 24h, faster time to first flatus, removal of urinary catheter, and first assisted walking. There were no significant differences between the ERAS and conventional groups regarding postoperative complications, readmission, emergency visit, in-hospital costs, PGI-I, QoR-15, PONV, and residual urine volume. There was no 30-day postoperative readmission in both groups. ERAS program can reduce length of stay and improve postoperative outcomes in patients undergoing vaginal reconstructive surgery. Recommend implementing ERAS for 60-80-year-olds in East Asia where TVM surgeries are still an option for POP. ChiCTR2200057422 (March 12, 2022).

This study aimed to evaluate sexual activity and quality of life (QOL) after transvaginal mesh (TVM) surgery in Japanese patients with pelvic organ prolapse (POP). The objective cure rate and associated complications were also investigated. The cases of patients who underwent TVM surgery were retrospectively analyzed. QOL was assessed using the Prolapse Quality of Life Questionnaire (P-QOL), and sexual function was evaluated using the Female Sexual Function Index (FSFI) before surgery and 12 months after surgery. A total of 237 patients completed the planned follow-up examinations. All P-QOL domains were significantly improved after surgery. In total, 6 (2.5%), 5 (2.1%), 13 (5.5%), 4 (1.7%) and 1 (0.4%) patients developed recurrent POP, mesh extrusion, de novo stress urinary incontinence, inguinal pain and de novo dyspareunia, respectively. Before surgery, 124 of the 237 patients (52.3%) refused to complete the FSFI because they had not engaged in any sexual activity. Among the 113 patients who completed the FSFI, 13 (11.5%) were sexually active. After surgery, 79 patients completed the FSFI, and 14 (17.7%) were sexually active. The overall scores for sexual function and arousal were significantly improved after surgery. Patients who underwent TVM surgery at our institution exhibited quite low sexual activity levels both before and after the operation. But TVM surgery achieved good QOL outcomes, a high success rate and a low complications rate at 12 months in Japanese POP patients. TVM implantation for POP is safe and effective in sexually inactive patients.

Comparison of the Changes in Sexual Function of Premenopausal and Postmenopausal Women Following Transvaginal Mesh Surgery

BackgroundThe purpose of this study was to investigate the relevant factors of pain after transvaginal mesh (TVM) surgery for the treatment of pelvic organ prolapse and to analyse the management and relief of the pain.MethodsA multicentre retrospective study of a clinical database of patients who underwent TVM surgery was conducted, and pain related aspects were analysed.ResultsA total of 1855 patients were included in the study. We divided the patients into two groups: pain-free (1805 patients) and pain (50 patients) group. The incidence of pain after TVM surgery was 2.70%, with a median occurrence time of 7.5 months. Pain mainly involved the vagina, perineum, buttocks, groin, inner thighs, and lower abdomen. Excessive intraoperative blood loss (OR = 1.284, 95% CI 0.868–2.401) and postoperative anatomic failure (OR = 1.577, 95% CI 0.952–3.104) were analysed as risk factors with statistical significance. Mesh exposure rate in the pain group was 38%, showing a significant difference between the groups (P < 0.01). Forty patients underwent non-surgical treatment, with a relief rate of 40.0%, 33 patients received surgical treatment, 15 underwent partial mesh removal, and 18 underwent complete mesh removal, with a relief rate of 84.8%. The total relief rate was 88% within all 50 patients suffering from pain.ConclusionsExcessive intraoperative bleeding and unsatisfactory postoperative anatomic outcomes can increase the risk of postoperative pain; mesh exposure is also associated with the pain. Most patients can get pain relief with proper management, more than half of whom may need mesh removal with differing approach.

Kidney transplantation is cost-effective therapy for end-stage renal disease relative to dialysis (1). The most significant contributors to the overall expense are the costs associated with the transplant procedure itself and the length of the initial hospitalization (2, 3). We hypothesized that early removal of the urethral (Foley) catheter would lead to faster recovery and earlier discharge from the hospital. At our center, Foley catheter removal is dictated by individual surgeon preference and occurs on postoperative days 2, 3, or 5. We performed a retrospective analysis of 141 consecutive renal transplants at the University of Pittsburgh Medical Center from 1 July, 2005 to 1 January, 2006. Kidney transplant recipients were divided into two groups: group A, in whom Foley catheter removal occurred on postoperative day 2; and group B, in whom removal occurred on postoperative days >2. Exclusions included patients who expired within the perioperative period prior to discharge (one in each group). The following endpoints were analyzed: length of stay, acute urinary retention requiring reinsertion of Foley catheter, urine leak, and readmission within 30 days of transplantation. All patients had double J ureteral stents (6 F×12 cm) placed at the time of transplantation. Stents were removed approximately 6 weeks posttransplant. The immunosuppressive regimen included 30 mg alemtuzumab (Campath-1H; Berlex, Seattle, WA) followed by steroid-free posttransplant low-dose tacrolimus monotherapy. There were 66 patients in group A and 75 patients in group B. The 66 patients who underwent urethral catheter removal at day 2 (group A) were similar to the 75 patients who underwent urethral catheter removal >day 2 (group B) in terms of recipient age, race, and sex, and cold ischemia time (Table 1). Group A comprised proportionately more deceased donor kidney transplantations (100% vs. 49%) and exhibited more delayed graft function (33% vs. 16% P=0.0164). The median length of stay was 3.2 days in group A compared to 5.0 days in group B (P=0.0014). Urinary retention requiring reinsertion of the urethral catheter occurred once in group A (1.5%) and twice in group B (2.6%). There were no urine leaks. Readmission within 30 days of transplantation was significantly associated with delayed graft function (P=0.0164) and longer posttransplant length of stay (P=0.0014), but not day of urethral catheter removal (P=0.1430).TABLE 1: Donor and recipient demographic and transplant characteristicsThis analysis of adult kidney transplant recipients demonstrated that Foley catheter removal on posttransplant day 2 is safe and optimizes length of stay, compared to Foley removal on posttransplant days 3–5. Length of stay is a large factor contributing to the cost of kidney transplantation; successful efforts to decrease length of stay, including establishment of an intensive outpatient unit (1) and implementation of clinical pathways (2) have optimized costs of kidney transplantation (1–3). The practice in many institutions is to remove the Foley catheter between 3–6 days after transplantation (4, 5). We have demonstrated that earlier removal is a simple and inexpensive means of reducing length of stay without compromising safety and quality of care. T. Cole Department of Surgery Conemaugh Memorial Medical Center Johnstown, PA Jonathan Hakim Ron Shapiro Liise K. Kayler Thomas E. Starzl Transplant Institute University of Pittsburgh Medical Center Pittsburgh, PA

Urogynecology

BackgroundPrevious prediction models for postoperative stress urinary incontinence (SUI) cannot be applied to patients receiving transvaginal mesh (TVM) surgery and colpocleisis or those with preoperative subject urinary incontinence. This study aimed to develop and validate a new machine learning model and compare it to previous models.MethodsFemale patients who underwent prolapse surgeries for stage 2–4 anterior or apical prolapse between January 1, 2015, and December 31, 2019, at Peking Union Medical College Hospital were enrolled. Prolapse surgeries included native tissue repair, LeFort/colpocleisis, sacrocolpopexy, and TVM surgery. The existing models to predict postoperative SUI were externally validated. Subsequently, the dataset was randomly divided into 2 sets in a 4:1 ratio. The larger group was used to construct and internally validate models of logistic regression, random forest, and extreme gradient boosting (XGBoost), which were then externally validated. The discrimination of the prediction models was evaluated using the area under the curve, while the calibration of the models was measured using the Spiegelhalter z test, mean absolute error (MSE), and calibration curves.ResultsOverall, 555 patients were enrolled, and 116 experienced SUI 1 year postoperatively. Previous logistic models had poor performance, with areas under the curve of 0.544 and 0.586. In the model construction, the areas under the curve were 0.595, 0.842, and 0.714 for the logistic, random forest, and XGBoost models, respectively. However, only the XGBoost model exhibited good discrimination and calibration for both internal and external validations. Body mass index (BMI), C point of pelvic organ prolapse (POP) quantification stage, age, Aa point of POP quantification stage, and TVM surgery were the 5 most important predictors of postoperative SUI in the XGBoost model.ConclusionsPrevious models had poor discrimination and calibration among a Chinese population. Hence, we developed and validated an XGBoost model, which performed well irrespective of the preoperative subjective urinary incontinence (preUI) and surgical methods. Further validation is still required.

Objective To investigate the influence of urethral catheter (UC) removal on urinary retention rate in patients following laparoscopic colon surgery with epidural analgesia (EA). Methods Clinical data of 46 patients undergoing laparoscopic colon surgery were selected from January 2014 to December 2015 in our hospital, including 23 cases in test group (UC removed within EA) and 23 cases in control group (UC removed following cessation of EA). The rates of urinary retention, urinary tract infection, lung infection, surgical site infection, and satisfaction of the two groups were observed and analyzed. Results There were no statistically significant differences in the rates of urinary retention (8.7% vs.4.3%), lung infection (4.3% vs.8.7%), and surgical site infection (4.3% vs.13.0%) between the test group and the control group (P>0.05). No urinary tract infection was found in both groups. The satisfaction rate of the test group was higher than that of the control group (78.3% vs.47.8%, P<0.05). Conclusion Patients following laparoscopic colon surgery with epidural analgesia may remove their UC early, which can reduce the incontinence caused by indwelling catheter. Key words: Colon cancer; Urethral catheter; Urinary retention; Time of UC removal

Predictors of an improvement in the severity of concomitant urodynamic stress incontinence after transvaginal mesh surgery for pelvic organ prolapse

Pelvic organ prolapse (POP) often coexists with stress urinary incontinence (SUI), posing challenges in surgical management. De novo SUI post-surgery remains unpredictable, prompting this study to explore ultrasound’s role in assessing de novo SUI after transvaginal mesh (TVM) surgery. A retrospective analysis of 92 women undergoing TVM surgery revealed a 36.9% incidence of de novo SUI. Specific ultrasound parameters, such as proximal urethral rotational angle and levator urethral gap during straining, were found associated with de novo SUI after TVM surgery. Despite certain limitations in this study, ultrasound emerges as a valuable tool for assessing pelvic floor integrity and guiding clinical decisions in urogynecology.