Anterior Vaginal Wall Prolapse Research Articles

PRACTICE OF USING IMPLANTS IN GYNECOLOGICAL SURGICAL INTERVENTIONS (SCIENTIFIC LITERATURE REVIEW)

Introduction. The use of implants during surgical interventions in gynecology can contribute to the anatomical restoration of the genital organs. The most commonly used implants in gynecology are polypropylene meshes, which promote tissue ingrowth, thus restoring reproductive organs. One of the reasons for using implants in gynecology is pelvic organ prolapse, including uterine prolapse, anterior or posterior vaginal wall prolapse, and vaginal vault prolapse. Synthetic implants are often utilized to reinforce surgical interventions for gynecological disorders, with better indicators of anatomical success in the long term. The aim of the research is to investigate the biomechanical properties of implants in gynecology as effective means for the surgical restoration of female reproductive organs. Materials and methods. Bibliosemantic, comparative, and systematic analysis methods were employed. The proposed recommendations were developed based on the analysis of contemporary literature, results of randomized trials, and meta-analyses dedicated to studying the impact of implants in surgical interventions in gynecological practice. Results. The analyzed results indicate that the optimal supportive framework of implants for gynecological surgery, particularly in the treatment of prolapse, should aim to facilitate the formation of a new matrix for fascial reinforcement, thereby minimizing the development of scar tissue. Conclusions. The primary objective of using implants in gynecological surgical interventions is to search for optimal designs to complement vaginal surgery. This is essential for prolonging treatment outcomes, increasing patient satisfaction, and reducing complications.

The Application of Shear Wave Elastography to Determine the Elasticity of the Levator Ani Muscle and Vaginal Tissue in Patients With Pelvic Organ Prolapse.

The changes of the extracellular matrix of the connective tissue have significantly contributed to the incidence of pelvic organ prolapse (POP). It seems reasonable that sonoelastography could be a useful tool to evaluate the elasticity of pelvic floor tissue in patients with POP and compare it to those without POP. The main aim of this pilot study was to determine if there are differences in the elasticity of the levator ani muscle (LAM) and vaginal tissue between patients with and without POP. Prospective observation study, including 60 patients (30 with POP and 30 without POP). Sonoelastography was performed to evaluate the elasticity (in kilopascals, kPa) of the following regions of interest: vagina at the level of middle third of the urethra; vagina at the level of the bladder trigone; vagina in the anterior and posterior fornix; vagina at the level of middle third of the anorectal canal; posterior third of the LAM. A total of 60 patients completed the study (30 with POP, 30 without POP). In the POP group, 18/30 (60%) had an anterior vaginal wall prolapse, 3/30 (10%) a uterine prolapse, 15/30 (50%) a rectocele, and 6/30 (20%) a enterocele. Patients with POP had higher elasticity in all anatomical study areas, with statistically significant differences in the anterior fornix (13.6 vs 11.2 kPa; P: .012). A multiple regression (controlling age, menopausal stage, and parity) allowed to detect statistically significant differences in the elasticity of the middle third of the urethra (P: .03) and the middle third of the anorectal canal (P: .019). It is possible to evaluate the elasticity of the LAM and vaginal tissue using sonoelastography, detecting a higher elasticity in patients with POP than in those without POP.

The influence of the combined impairments and apical mesh surgery on the biomechanical behavior of the pelvic floor system.

Objective: The prolapse mechanism of multifactorial impairment of the female pelvic floor system and the mechanics of the pelvic floor after apical suspension surgery are not yet understood, so we developed biomechanical models of the pelvic floor for the normal physiological state (0°) and 90° pathological state. Methods: Under different types and levels of the impairments and uterosacral suspensions, the possible changes in the morphometric characteristics and the mechanical characteristics of suspension and support functions were simulated based on the biomechanical models of the pelvic floor. Results: After the combined impairments, the descending displacement of the pelvic floor cervix and the stress and displacement of the perineal body reached maximum values. After surgical mesh implantation, the stresses of the normal pelvic floor were concentrated on the uterine fundus, cervix, and top of the bladder and the stresses of the 90° pathological state pelvic floor were concentrated on the uterine fundus, uterine body, cervix, middle of the posterior vaginal wall, and bottom of the perineal body. Conclusion: After the combined impairments, the biomechanical support of the bladder and sacrococcyx in the anterior (0°) and 90° pathological state pelvic floor system is diminished, the anterior vaginal wall dislodges from the external vaginal opening, and the posterior vaginal wall forms "kneeling" profiles. The pelvic floor system may evolve with a tendency toward the cervical prolapse with anterior and posterior vaginal wall prolapse and eventually prolapse. After surgical mesh implantation, the cervical position can be better restored; however, the load of combined impairment of the pelvic floor is mainly borne by the surgical mesh suspension, the biomechanical support function of pelvic floor organs and sacrococcyx was not repaired by the physiological structure, and the results of uterosacral suspension alone may be poor.

Ön Vajinal Duvar Prolapsusunu Taklit Eden Subüretral Abse: Olgu Sunumu

Introduction: Anterior vaginal wall prolapse (AVWP), previously known as cystocele, is a herniation of the anterior vaginal wall and the bladder. It is a multifactorial pathology. Patients with AVWP may report a feeling of pelvic pressure and something bulging out of the vagina, urinary incontinence, and dyspareunia which are nonspecific symptoms. Case: A 73-year-old married Turkish G4P4 female who has been menopausal for 20 years, presented to the outpatient clinic with dysuria and urinary incontinence lasting for two weeks, and a palpable mass located in the genital area for 2 years. On her vaginal examination, the vagina and cervix appeared normal, and a grade 3 AVWP along with a semi-mobile mass extending from the distal urethra to the bladder base under the cystocele pouch was observed. She was diagnosed with a grade 3 AVWP with a plan for the surgical excision. A bilobular cystic mass was observed under the urethra, extending to the bladder wall with a size of 4-5 cm. The macroscopic examination showed a membraneous tissue piece of 4.5 x 2.8 x 2 cm, and the microscopic examination revealed a caseified granulomatous inflammation. Upon the suspicion of tuberculosis, we referred her to the infectious diseases (ID) clinic. Her PPD test was 0 mm. She had no complaints of active tuberculosis. She presented to our clinic with urinary incontinence. On her vaginal examination, involuntary leakage of urine with bladder stimulation was observed. We planned the implantation of transvaginal tape (TVT). Discussion: We believe that this case will help establish an idea about the differential diagnosis of AVWP. The differential diagnosis should include the other possible genitourinary pathologies due to the close proximity of the anterior vaginal wall to the bladder and the urethra before ensuring the diagnosis of the AVWP in order not to misdiagnose.

Long-term outcomes of surgical interventions for different types of pelvic organ prolapse

Background. The study aimed to comparatively analyze the nature and frequency of complications and the severity of recurrences among patients with different forms of pelvic organ prolapse (POP). These factors will be examined depending on the surgical technique employed.
 Materials and methods. The study involved a thorough clinical evaluation, surgical intervention, and outpatient monitoring (at 1, 6, 12, 24, and 36 months) of 523 participants, aged 32–80 years, categorized into four main groups and 3–4 subgroups depending on the type of POP and surgical method used. Group 1 comprised 161 women (30.8%) presenting with grade I–III cervical elongation combined with grade I–II anterior vaginal wall prolapse. Group 2 consisted of 207 (39.6%) patients with grade II–III anterior vaginal wall prolapse, whereas group 3 included 107 patients (20.5%) with complete uterine prolapse. Group 4 was made up of 48 women (9.1%) with grade II–III posterior vaginal wall descent.
 Results. Based on the acquired data, synthetic implant extrusion commonly took place 6–12 months after the surgical procedure. Of the 158 patients who received polypropylene endoprostheses, 20 (12.7%) experienced extrusion and required repeated hospitalizations for partial or complete excision, followed by restoration of vaginal wall integrity. POP recurrences typically occurred 12–36 months after surgical treatment and were detected in 69 (13.2%) of 523 patients. The reappearance of symptoms of pelvic organ descent was most commonly identified in patients who underwent surgery using their tissues (26.6%), less frequently with synthetic implants (12.7%), and extremely rarely with titanium endoprostheses (1.6%).
 Conclusions. The results revealed that patients, who underwent surgery using original techniques, employing titanium-made mesh implants and anchors, experienced the fewest complications and postoperative POP incidence. Conversely, the use of synthetic implants increases the likelihood of mesh-associated complications and disease recurrence, necessitating partial or complete excision. The use of autologous tissue for POP surgery is related to a higher likelihood of recurring prolapse symptoms.

Surgical management practice of pelvic organ prolapse among Ethiopian gynecologists, 2021: a descriptive study

IntroductionPelvic Organ Prolapse is the descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus, or the apex of the vagina. Surgical intervention addresses both anatomical defect and associated symptoms. The landscape of prolapse surgery has been evolving constantly over years. Emerging evidences either support or challenge existing surgical treatment options, making urogynecology a dynamic field. In Ethiopia, the surgical management of pelvic organ prolapse has transitioned from abdominal to vaginal hysterectomy, supplemented later by McCall’s culdoplasty. Disparities exist in the national uniformity of surgical approaches, linked to the establishment of Urogynecology centers in certain institutions.ObjectivesThis study was done to assess the surgical management practice of Ethiopian gynecologists on pelvic organ prolapse.MethodsA cross-sectional study encompassing all Gynecologists in Ethiopia took place between January to June 2021. Information was gathered through online Google forms crafted in English. Subsequently, the collected data underwent verification, coding, and entry into Epi info 7 before being exported to SPSS version 22 software for descriptive statistical analysis.ResultsWe reached 280 gynecologists out of the 450 practicing in the Ethiopia making 62% response rate. Anterior colporrhaphy (98.6%), vaginal hysterectomy with McCall’s cul-do-plasty (51.8%), and Posterior colporrhaphy (97.5%) were the most commonly performed surgical procedures for anterior vaginal wall prolapse, apical prolapse (uterine/cervical), and posterior vaginal wall prolapse respectively. Only 3.2% and 0.7% of the gynecologists conducted abdominal and vaginal paravaginal repair for anterior vaginal wall prolapse. Sacrospinous ligament fixation and sacrocolpopexy for apical prolapse were carried out by 32.9% and 9.3% of the gynecologists respectively. Site-specific posterior repair for posterior vaginal wall prolapse was performed only by 23.9% of the gynecologists. The main reasons mentioned not to perform paravaginal repair, sacrocolpopexy, sacrospinous ligament fixation, and site-specific posterior repair were lack of skill and lack of appropriate materials.Conclusion and recommendationMost gynecologists in Ethiopian continue to perform vaginal hysterectomy and colporrhaphy procedures for treatment of pelvic organ prolapse due primarily to lack of skill and appropriate materials to perform the alternative procedures. Implementing short term training on alternative surgical treatment options of pelvic organ prolapse with provision of suitable materials and increasing the number of urogynecologists in the country in the long run holds the potential to enhance the standard of care of women with the condition.

Medium-term outcomes of laparoscopic pubocervical fascia reconstruction and sacrospinous ligament fixation with posterior approach for a pelvic organ prolapse: A retrospective study of 124 cases

ObjectivePelvic organ prolapse (POP) is a common gynecological disease in middle-aged and older women that seriously affects patients' physical health and quality of life, increases the financial burden for patients, and becomes a major public health concern. The aim of this study was to investigate the medium-term outcomes of laparoscopic pubocervical fascia reconstruction and sacrospinous ligament fixation with a posterior approach for patients with severe POP. MethodsPatients with severe POP quantitation stage III–IV who underwent laparoscopic pubocervical fascia reconstruction and sacrospinous ligament fixation with a posterior approach at the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine between September 2016 and December 2020 were enrolled in this study. The results and complications were recorded. Data were retrospectively reviewed. ResultsIn total, 124 patients were analyzed. Patients were followed up for 32.27 ± 12.90 months. The objective cure rate for patients who underwent hysterectomy was 91.7% (100/109), with 7 (6.4%) patients had anterior vaginal wall prolapse and 2 (1.8%) patients had posterior vaginal wall prolapse. The objective cure rate for patients who retained uterus was 66.7% (10/15). All 5 patients with recurrence had uterine prolapse, and 3 (20.0%) of them also had anterior vaginal wall prolapse. ConclusionsLaparoscopic pubocervical fascia reconstruction and sacrospinous ligament fixation with the posterior approach is a safe, minimally invasive, and effective method for patients with severe POP. Long-term follow-up is needed to confirm the clinical effects.

A comparison between the vaginal patch plastron associated with the anterior sacrospinous fixation and the Uphold™ LITE vaginal support system for the treatment of advanced anterior vaginal wall prolapse

ObjectiveThe aim of the present study was to compare efficacy and safety of the vaginal patch plastron (VPP) associated to the anterior sacrospinous fixation (SSLF-A) with a TVM procedure (Uphold™ LITE support-system) for the treatment of the advanced anterior vaginal wall prolapse.Study design.Single-center retrospective study. Women with symptomatic anterior prolapse ≥ III stage according to the POP-quantification (POP-Q) system and submitted to the VPP associated with the SSLF-A or to the Uphold™ procedure were included. Primary outcome was to compare objective and subjective cystocele relapse and reoperation rate at 6- and 12-month follow-up. Secondary outcome was to describe peri- and postoperative complications. Pearson chi-square test and exact Fisher test were adopted for categorical variables, while intergroup Mann-Whitney U test and intragroup Wilcoxon Rank Sum Test for continuous variables; the statistical analysis was conducted at 95 % confidence level. ResultsFifty-five women in VPP-group and 118 women in Uphold-group were included. At 6-month follow-up, objective anterior relapse in VPP-group (3/55, 5.4 %) was like Uphold-group (5/118, 4.2 %; p = 0.71), as well as objective apical relapse (0/55, 0 % vs 3/118, 2.5 %; p = 0.55); no significant difference emerged in bulge symptoms (1/55, 1.8 % vs 5/118, 4.2 %; p = 0.67). At 12-month follow-up women were telephonically investigated; no significant difference emerged in bulge symptoms (1/55, 1.8 % vs 6/118, 5.1 %; p = 0.43). Reoperation rate for the composite outcome POP relapse, stress urinary incontinence (SUI) and remotion of the TVM resulted lower in the VPP group (1/55, 1.8 % vs 13/118, 11 %; p = 0.03). Post-operative buttock pain (32/55, 58.2 % vs 24/118, 20.3 %; p < 0.0001) and post-operative urinary retention (16/55, 29.1 % vs 6/118, 5.1 %; p < 0.0001) were higher in VPP-group, with a complete resolution between 2 and 3 weeks after treatment. ConclusionVPP associated with SSLF-A was as effective as Uphold™ LITE support-system for both anterior and central compartment prolapse treatment at 6- and 12-month follow-up. VPP-group presented a lower reoperation rate for the composite outcome prolapse relapse repair, SUI, and removal of the mesh.

Effect of age in women undergoing laparoscopic sacrocolpopexy: A retrospective study.

To determine whether elderly women (≥65 years) have an increased risk of complications and lower success when undergoing laparoscopic sacrocolpopexy (LSC) compared with younger women (<65 years). This was a retrospective study of all LSC procedures performed from August 2014 to February 2021 by a single urogynecologic surgeon in an academic affiliated hospital system. Charts were identified through procedure codes. Patient demographics, clinical, surgical, and postoperative data were collected. The primary outcome of this study was to compare complications associated with LSC, including intraoperative and postoperative complications. Secondary outcomes included subjective, objective, and composite success. In total, 312 participants met the criteria. The mean age of the group who were younger than 65 years was 55.7 years (±6.5) and of the group aged 65 years or older was 69.3 years (±3.5). Racial demographics revealed no differences between the two groups. Patients aged 65 years or older had a statistically significant lower body mass index (calculated as weight in kilograms divided by the square of height in meters), a higher rate of hypertension, smaller genital hiatus, and a larger anterior vaginal wall prolapse compared with the younger cohort. They also less often underwent a posterior repair. No statistically significant differences were found with regards to intraoperative and postoperative complications, including 30-day re-admission, between the two age groups. Both groups had high anatomic success rates, with no significant difference (<65 = 96.3%; ≥65 = 98.4%; P = 0.326). Those aged younger than 65 years compared with those aged 65 years or older had lower subjective success that was not significantly different (<65 = 62.8%; ≥65 = 71.0; P = 0.134). Composite success was noted to reach the threshold of a statistically significant difference in the group aged younger than 65 years compared with those aged 65 years or older (60.1% vs 71.0%; P = 0.0499). In this study, elderly patients did not have increased intraoperative and postoperative complications after undergoing LSC. Similar rates of anatomic and subjective success were also found with younger patients having a lower composite success. Proper candidates for LSC should not be excluded based upon age.

Association Between Enlarged Genital Hiatus and Composite Surgical Failure After Vaginal Hysterectomy With Uterosacral Ligament Suspension

ABSTRACT Commonly performed at the time of total vaginal hysterectomy to combat uterovaginal prolapse, uterosacral ligament suspension and sacrospinous ligament fixation are native tissue apical suspensions. Because recurrent pelvic organ prolapse increases over time after apical suspensions, nonmodifiable and modifiable risk factors have been explored. It is suggested by numerous studies that 1 risk factor for recurrent prolapse is an enlarged preoperative and postoperative genital hiatus (GH). An enlarged GH may be indicative of a caudal shift in pelvic viscera, increasing stress on vaginal supports. However, short-term follow-up, retrospective design, and lack of patient perspectives on prolapse outcomes limited the overall impact of those findings. The SUPeR trial (Study of Uterine Prolapse Procedures-Randomized) compared vaginal mesh hysteropexy with vaginal hysterectomy with uterosacral ligament suspension in a randomized trial design with long-term follow-up postoperatively. Postoperative assessments included the patient’s assessment of prolapse symptoms. The primary objective of this manuscript was to evaluate the efficacy of the vaginal hysterectomy with uterosacral ligament suspension amidst groups defined by surgical changes in GH size. The hypothesis predicted higher prolapse recurrence proportions for those with persistently enlarged GH size at 4–6 weeks postoperatively, compared with those with smaller preoperative and postoperative GH sizes. SUPeR participants included in this ancillary analysis underwent vaginal hysterectomy with uterosacral ligament suspension and then completed a 2-year follow-up. Based on preoperative to postoperative GH measurement changes, participants were divided into 3 groups. These groups were (1) persistently enlarged GH (“persistently enlarged”), (2) improved GH (“improved”), and (3) stable or normal GH preoperatively and postoperatively (“stably normal”). Prolapse was defined as any compartment with prolapse 1 cm or more beyond the hymen. The primary aim was comparison of composite surgical failure across the GH groups at 24 months, defined by any of the following conditions: anatomic failure, retreatment for prolapse, or symptoms of bothersome vaginal bulge. Secondary outcomes included the composite surgical failure components, postoperative complications, POP-Q measurements, and pain during intercourse. A total of 81 women were included in this secondary analysis. Predominant characteristics included a median age of 65.6 years, with 50 patients in the “improved group,” 14 patients in the “persistently enlarged” group, and 17 patients in the “stably normal” group. Notably, the prevalence of advanced anterior prolapse at baseline was greatest in the persistently enlarged group compared with that of both the improved and stably normal groups. Also, the prevalence of posterior colporrhaphy during the index procedure varied across groups and was more common in the improved group than the stably normal group. The surgery performed for almost all patients was a vaginal hysterectomy with uterosacral ligament suspension. The study found that following vaginal hysterectomy, after adjustment for the prevalence of advanced anterior prolapse, a woman with persistently enlarged GH at 4–6 weeks would not be at higher of composite surgical failure 2 years postsurgery when compared with other groups. The adjusted odds ratio for composite surgical failure in the persistently enlarged group compared with the stably normal group was 6.0 (95% confidence interval, 1.0–37.5; P = 0.06). Ultimately, baseline GH size is not a modifiable risk factor; however, there does appear to be an association between postvaginal hysterectomy and anterior vaginal wall prolapse when performing a presurgical and postsurgical comparison of normal GH measurements. Nonetheless, this study was not able to confirm a significant relationship between risk of recurrent prolapse and patients grouped by GH size in this manner.

Single-cell transcriptomic data reveal the increase in extracellular matrix organization and antigen presentation abilities of fibroblasts and smooth muscle cells in patients with pelvic organ prolapse.

We aimed to explore the cellular properties of fibroblasts and smooth muscle cells (SMCs), the two major cell types of the vagina wall, in pelvic organ prolapse (POP) to improve the knowledge of the underlying molecular mechanisms of POP. The single-cell RNA sequencing (scRNA-seq) profile GSE151202 was downloaded from NCBI Gene Expression Omnibus, in which vaginal wall tissues were harvested from patients with anterior vaginal wall prolapse and control subjects respectively. The scRNA-seq data of samples (5 POP and 5 controls) were adopted for analysis. Cluster analysis was performed to identify the cell subclusters. Trajectory analysis was applied to construct the differentiation trajectories of fibroblasts and SMCs. Cellular communication analysis was carried out to explore the ligand-receptor interactions between fibroblasts/SMCs and immune cells. Ten subclusters were determined in both groups, among which fibroblasts and SMCs were the most abundant cell types. Compared with controls, fibroblasts increased whereas SMCs declined in POP. During the transition of fibroblasts and SMCs from a normal into a disease state, extracellular matrix organization and antigen presentation were heightened. The intercellular communications were altered in POP. Interactions between fibroblasts/SMCs and macrophages/natural killer/T cells were strengthened as more ligand-receptor pairs involved in antigen presentation pathways were gained in POP. Extracellular matrix organization and antigen presentation abilities of fibroblasts and SMCs were enhanced in POP.

Effect of gestational weight gain on postpartum pelvic floor function in twin primiparas: a single-center retrospective study in China

BackgroundThe effect of gestational weight gain (GWG) as a controllable factor during pregnancy pelvic floor function has rarely been investigated, and studies on twin primiparas are even less frequent. The objective of the present study was to explore the effect of GWG on postpartum pelvic floor function in twin primiparas.MethodsWe retrospectively analyzed the clinical data of 184 twin primiparas in the pelvic floor rehabilitation system of the First Affiliated Hospital of Chongqing Medical University from January 2020 to October 2021. Based on the GWG criteria recommended by the Institute of Medicine, the study subjects were classified into two groups: adequate GWG and excessive GWG. Univariate and multivariate logistic regression models were applied to explore the relationship between GWG and pelvic floor function.ResultsAmong the 184 twin primiparas, 20 (10.87%) had excessive GWG. The rates of abnormal vaginal dynamic pressure (95% vs. 74.39%), injured type I muscle fibers (80% vs. 45.73%), anterior vaginal wall prolapse (90% vs. 68.90%), and stress urinary incontinence (50% vs. 20.12%) of twin primiparas with excessive GWG were significantly higher than those with adequate GWG. There was no significant difference between the total score of the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20) or the scores of the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6), the Colorectal-Anal Distress Inventory 8 (CRADI-8), and the Urinary Distress Inventory 6 (UDI-6) in the two groups (P > 0.05). After adjusting for potential confounding factors, the results showed that excessive GWG was positively associated with abnormal vaginal dynamic pressure (OR = 8.038, 95% CI: 1.001–64.514), injured type I muscle fibers (OR = 8.654, 95% CI: 2.462–30.416), anterior vaginal wall prolapse (OR = 4.705, 95% CI: 1.004–22.054), and stress urinary incontinence (OR = 4.424, 95% CI: 1.578–12.403).ConclusionExcessive GWG in twin primiparas was positively correlated with the prevalence of pelvic floor dysfunction but did not exacerbate pelvic floor symptoms in twin primiparas. Controlling GWG within a reasonable range is recommended for reducing the risk of PFDs in pregnant women with twins.

Long-term efficacy of the pelvic floor muscle rehabilitation for women with stress urinary incontinence.

Stress urinary incontinence is a common disease with many therapeutic ways, but it lacks long-term follow-up. This study aims to conduct a retrospective study on the long-term efficacy of women with mild and moderate stress urinary incontinence after pelvic floor rehabilitation treatment for 3-years so as to provide a more effective treatment plan for this disease. Data were collected from 279 female patients, who were diagnosed with stress urinary incontinence at the Pelvic Floor Rehabilitation Center of the Third Xiangya Hospital of Central South University from January 2017 to January 2019. All patients received health education and were instructed to perform Kegel exercises for 20 min daily at home. According to the treatment pattern, patients were divided into 3 groups as A, B, and C. Group A (n=94) received pelvic floor biofeedback, electrical stimulation and electroacupuncture; Group B (n=99) received pelvic floor biofeedback and electrical stimulation; Group C (n=86) only got pelvic floor function examinations and did not receive any pelvic floor treatment. The pelvic floor functional examinations included a pelvic floor electrophysiological test, pelvic organ prolapse quantitive examination (POP-Q), and stress urinary incontinence severity assessment. All patients were followed up with questionnaire consisting of the International Committee on Urinary Incontinence Questionnaire-Short Form (ICI-Q-SF) and the Quality of Life questionnaire of Urinary Incontinence (I-QOL) before and after the treatment, as well as at 1-, 2-, and 3-years after the treatment (5 times in total). Among the patients who received the treatment, 43 returned to the hospital, including 21 in group A (Group Areturn) and 22 in group B (Group Breturn). Pelvic floor electrophysiological test and POP-Q were performed on the 2 groups. For the leakage rate at the end of the treatment and the following 1-, 2-, and 3-years: Group A<Group B<Group C, and the recurrence rate of their leakage remained stable after 2 to 3 years of the treatment (P<0.05). Meanwhile, there was no significant difference in the I-QOL scores between Group A and Group B at the end of the treatment (P>0.05), but the I-QOL scores of Group A and Group B were much higher than that in Group C (both P<0.05). On the other hand, the I-QOL scores at 1-, 2-, and 3-years after the treatment were Group A>Group B>Group C (all P<0.05). In addition, the ICI-Q-SF scores at the end of the treatment and 1-, 2-, and 3-years after the treatment were Group A<Group B<Group C (P<0.05). There was also a significant effect of delivery on I-QOL and ICI-Q-SF scores after the treatment (P<0.05). Besides, the production method also had an impact on the ICI-Q-SF scores after the treatment (P<0.05). The results of the re-evaluation showed that there was no significant difference in the anterior vaginal wall prolapse score (point Aa) between Group A return and Group Breturn at the end of the treatment, but 3 years later, the score of anterior vaginal wall prolapse in Group Areturn was less than that in Group Breturn (P<0.05). Besides, no significant difference was found in the pelvic floor muscle strength between Group A return and Group Breturn at the end of the treatment (P>0.05). While the pelvic floor muscle strength in Group Areturn was much higher than that in Group Breturn (P<0.05) after 3 years of the treatment. What's more, the pelvic floor muscle potential in Group Areturn was much higher than that in Group Breturn (both P<0.05) at the end of the treatment and after 3 years of the treatment. Compared with pelvic floor biofeedback and electrical stimulation for stress urinary incontinence, electroacupuncture combined with pelvic floor electrical stimulation and biofeedback reveal more remarkable short-term efficacy and more stable long-term efficacy, which can significantly improve the quality of life in female patients.

Variations in structural support site failure patterns by prolapse size on stress 3D MRI.

Our objective was to develop a standardized measurement system to evaluate structural support site failures among women with anterior vaginal wall-predominant prolapse according to increasing prolapse size using stress three-dimensional (3D) magnetic resonance imaging (MRI). Ninety-one women with anterior vaginal wall-predominant prolapse and uterus in situ who had undergone research stress 3D MRI were included for analysis. The vaginal wall length and width, apex and paravaginal locations, urogenital hiatus diameter, and prolapse size were measured at maximal Valsalva on MRI. Subject measurements were compared to established measurements in 30 normal controls without prolapse using a standardized z-score measurement system. A z-score greater than 1.28, or the 90th percentile in controls, was considered abnormal. The frequency and severity of structural support site failure was analyzed based on tertiles of prolapse size. Substantial variability in support site failure pattern and severity was identified, even between women with the same stage and similar size prolapse. Overall, the most common failed support sites were straining hiatal diameter (91%) and paravaginal location (92%), followed by apical location (82%). Impairment severity z-score was highest for hiatal diameter (3.56) and lowest for vaginal width (1.40). An increase in impairment severity z-score was observed with increasing prolapse size among all support sites across all three prolapse size tertiles (p < 0.01 for all). We identified substantial variation in support site failure patterns among women with different degrees of anterior vaginal wall prolapse using a novel standardized framework that quantifies the number, severity, and location of structural support site failures.

Long-term outcomes of cable-suspended suture technique versus conventional suture for anterior vaginal wall prolapse: a retrospective cohort study

BackgroundAnterior colporrhaphy (AC) is a conventional surgical repair technique for cystocele but with high recurrence rate. We present a novel technique: Cable-suspended structure (CSS) by non-absorbable suture combined with "bridge" formation in surgical treatment of cystocele. This study aimed to evaluate and compare the long-term outcome of CSS technique for anterior vaginal wall repair with AC.MethodsA retrospective review was performed on patients who underwent anterior vaginal wall repair between January 2012 and March 2017 at our center. All the patients were under a follow-up survey. The primary outcomes were objective cure (anterior prolapse POP-Q ≤ stage 1) and subjective cure (no symptoms of bulge or retreatment for prolapse). Secondary outcomes included quality of life (QOL) and patients’ satisfaction, outcomes of site-specific POP-Q points Aa, Ba and C, as well as postoperative complications.ResultsOf 91 included participants, 43 underwent AC and 48 underwent CSS. The proportion of sarcrospinous ligament fixation in the CSS group was higher than in the AC group (81.4% vs. 77.1%, P < 0.05). At a median follow-up of 69 months, the CSS group showed significantly higher objective cure rate compared with the AC group (72.9% vs. 51.2%, odds ratio 2.57, 95%CI 1.07–6.16). After adjusting for sarcrospinous ligament fixation, the CSS group still significantly showed higher objective cure rate (adjusted odds ratio 2.88, 95%CI 1.16–7.21). The proportion of the patients with POP-Q 0 stage in the CSS group was particularly higher than the AC group (25% vs. 7.0%, P = 0.025). There was no difference between the groups with respect to subjective cure, patients’ satisfaction and postoperative complication.ConclusionsThe CSS technique showed better objective outcome than AC, however, subjective cure rate did not significantly differ between the two. Future prospective trial with large-scale should confirm the effectiveness and safety of CSS in sexually active women.

Effect of anterior vaginal wall prolapse repair by modified transvaginal mesh surgery: a retrospective cohort study.

To explore clinical outcomes and complications of modified Transvaginal mesh (M-TVM) for advanced anterior vaginal wall prolapse in 1year follow-up. 574 patients underwent TVM surgeries from 2019 to 2020 were collected and divided into TVM group and M-TVM group, all preoperative and postoperative data was obtained and compared between the two groups. 285 women were involved eventually, including 181 in TVM group and 104 in M-TVM group. No significant difference of general conditions was found between these two groups. After long-term follow-up, patients in TVM group were more likely to suffer from pelvic pain than M-TVM group (P = 0.046). Meshes seemed much wider in M-TVM group (4.5 ± 0.69cm) than in TVM group (3.0 ± 0.91cm). No matter TVM or M-TVM, surgeries can significantly change point Aa and Ba when compared to preoperative data. Compared to TVM group, point C and D were significant changed in patients in M-TVM group after surgery (P < 0.001) CONCLUSION: M-TVM is a commendable procedure that can significant correct anterior prolapse with mesh extended wider, and also supply stable apical support at the same time.

Fecal Incontinence and the Risk of Urinary Tract Infection in Patients Presenting for Urogynecological Consultation.

Urinary tract infection (UTI) is common in urogynecology patients. Patients with fecal incontinence (FI) often attribute their UTIs to FI, but this association has not been evaluated. The objectives of this study were to compare the prevalence of UTI in urogynecology patients with and without FI and to characterize factors associated with UTI and recurrent UTI. This retrospective cohort study included all new adult patients who presented to an academic female pelvic medicine and reconstructive surgery practice with FI from January 2014 through December 2017. Patients were age-matched to new adult patients with stage <2 pelvic organ prolapse without FI. All urine culture results from 1 year before and 1 year after the first visit were identified. Logistic regression identified factors associated with UTI. Among 399 patients, 106 (27%) had a culture-confirmed UTI in the year before or after their first urogynecology visit; the prevalence of UTI was 23% (45/198) in patients with FI and 30% (61/201) in those without FI (P = 0.09). The rate of recurrent UTI was 11.5% overall and did not differ among those with and without FI. In multivariate models, variables that were statistically significantly associated with UTI included age, diabetes mellitus, anterior vaginal wall prolapse, and sexual activity. Fecal incontinence was not associated with any or recurrent UTI. The prevalence of UTI and recurrent UTI was similar in urogynecology patients with and without FI. Variables that were associated with UTI risk included older age, sexual activity, diabetes mellitus, and anterior vaginal wall prolapse.

Comparative Outcomes of Surgical Treatments for Primary Stress Urinary Incontinence in Women: A Retrospective Cohort Study

Introduction: The study evaluates the outcomes of different surgical techniques, including Tension-free Vaginal Tape (TVT), Trans-Obturator Tape (TOT), Burch Colpopexy (BC), and Anterior Vaginal Wall Prolapse Repair (APR), in treating primary stress urinary incontinence (SUI) in women. Materials and Methods: A retrospective cohort study was conducted in a tertiary care center, comprising 62 women diagnosed with primary SUI who underwent one of the aforementioned surgical procedures. Demographic and clinical variables were analyzed, including age, BMI, menopausal status, reproductive history, incontinence types, anticholinergic use, and preoperative assessments. Results: No differences were found in age (p=0.227), weight (p=0.943), height (p=0.333), and BMI (p=0.642) among the four treatment groups. The distribution of menopausal patients and reproductive history variables did not differ among the groups. Postoperative anticholinergic prescription rates (p=0.769) and duration of use (p=0.531) were not different across the groups. The majority of patients in the TVT, TOT, and BC groups had a grade 2 cystocele (p=0.065). The BC group had 100% grade 1 rectocele, which was not significant compared to other groups (p=0.126). Conclusion: Our results showed no potential difference in comparable outcomes among TVT, TOT, BC, and APR for the surgical treatment of primary SUI.

Prevalence and surgical outcomes of stage 3 and 4 pelvic organs prolapse in Jimma university medical center, south west Ethiopia

BackgroundPelvic organ prolapse (POP) affects about half of the women and affects their quality of life. The current study is, therefore, aimed at determining the prevalence and surgical outcomes of severe stage POP at Jimma University medical center from November 2016 to May 2018.MethodA Hospital-based cross-sectional study was conducted on all patients with stage 3 and 4 POP, who were admitted, and had surgery. Data were collected from the patient’s chart, and logbooks, which were filled up from entry till her discharge. A Simplified POPQ(S-POPQ) was used to stage the prolapse at admission, at discharge, and three months follow-ups.ResultsAmong 92 patients who were analyzed, POP accounts for 10.6% of all gynecologic admissions, and 43.8% of all gynecologic surgeries. The mean age of patients is 46 (± 12) years, and nearly 34% of the patients had stage 3 and 66% had stage 4 POP. Based on the type of prolapse, 93.5% of patients had stage 3 and more anterior vaginal wall prolapse (AVWP) and apical prolapse, while 57.6% had stage 3 or more posterior vaginal wall prolapse.Out of 72 patients who had anterior colporrhaphy, 58.7% had anterior colporrhaphy with colposuspension. Out of 83 patients who had apical suspension, 48.2%, 39.8%, and 12% had uterosacral, sacrospinous, and Richardson respectively.Ninety-seven patients had stage 0 or 1 POP at discharge while 90% of 20 patients who returned for follow-up at three months had stage 0 or 1 POP. Eight patients had surgery-related complications; bladder injury, urinary retention, Hemorrhage during SSLF, and rectal injury.ConclusionThe prevalence of pelvic organ prolapse is high and the majority of patients presented with advanced-stage pelvic organ prolapse, with a long duration of symptoms and associated problems. The surgical techniques used have resulted in a high immediate success rate of 97% and 90% at discharge and three months follow up respectively. Therefore, awareness creation activities are important to facilitate an early presentation for treatment to improve the quality of life and the current surgical technique; native tissue vaginal repair (NTVR), being practiced in the setup has had better success.

Diagnostic test accuracy of magnetic resonance imaging and pelvic floor ultrasound for diagnosis of levator ani muscle avulsion.

To estimate the diagnostic test accuracy of magnetic resonance imaging (MRI) and pelvic floor ultrasound for levator ani muscle (LAM) avulsion in a general parous population, with view to establishing if ultrasound could substitute for MRI to diagnose LAM avulsion. This was a cross-sectional study of 135 women 4 years after their first delivery. Signs and symptoms of pelvic floor dysfunction were assessed using validated methods. All women underwent four-dimensional transperineal ultrasound (TPUS), three-dimensional endovaginal ultrasound (EVUS) and MRI. Images were acquired at rest, on pelvic floor muscle contraction (PFMC) and on maximum Valsalva maneuver, and analyzed by two blinded observers. Predefined cut-off values were used to diagnose LAM avulsion. In the absence of a reference standard, latent class analysis (LCA) was used to establish diagnostic test characteristics for LAM avulsion as the primary outcome measure. Secondary outcomes were kappa (κ) agreement between imaging techniques, intraclass correlation coefficients (ICC) for hiatal measurements at rest, on PFMC and on maximum Valsalva maneuver, and the association of LAM avulsion with signs and symptoms of pelvic floor dysfunction. The prevalence of LAM avulsion was 23.0% for MRI, 11.1% for TPUS and 17.8% for EVUS. The prevalence of LAM avulsion using LCA was 15.7%. The sensitivity for LAM avulsion of TPUS (71% (95% CI, 50-90%)) and EVUS (91% (95% CI, 74-100%)) was lower than that of MRI (100% (95% CI, 84-100%)). The specificity of TPUS (100% (95% CI, 97-100%)) and EVUS (95% (95% CI, 91-99%)) was higher than that of MRI (91% (95% CI, 85-97%)). MRI and EVUS had high predictive values for the assessment of major LAM avulsion (positive predictive value (PPV), 95% and negative predictive value (NPV), 100%; PPV, 100% and NPV, 98%, respectively), while TPUS had high predictive values for minor LAM avulsion (PPV, 100% and NPV, 95%). Major LAM avulsion on MRI and EVUS was associated with anterior vaginal wall prolapse, which was not found for TPUS. The agreement in the diagnosis of LAM avulsion (κ, 0.69) and hiatal measurements (ICC, 0.60-0.81) was highest between MRI and EVUS. Pelvic floor ultrasound can be implemented as a triage test to assess parous women for LAM avulsion because of its high specificity. Ultrasound cannot substitute for MRI because of its lower sensitivity. The predictive ability of ultrasound is moderate for the presence, and very good for the absence, of LAM avulsion. A positive test should be confirmed by a different observer or imaging technique. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.