Cystocele Grade Research Articles

Transvaginal mesh-reconstruction of anterior apical prolapse: a selective implant choosing approach

Introduction. Transvaginal mesh-reconstruction of urogenital prolapse remains a controversial trend in modern urogynecology. We have seen growth in transvaginal mesh surgery since 2004, followed by a sharp decline after 2011 due to FDA restrictions related to imperfections in previously available prostheses and implantation techniques. Improving the efficacy and minimizing complications of transvaginal mesh-surgery is at the forefront of research in the field of modern urogynecology.Purpose of the study. To optimize the indications for transvaginal mesh-reconstruction of anterior apical prolapse.Materials and methods. The study enrolled 375 patients with anterior apical prolapse. The grade of prolapse was assessed using POP-Q. In patients with endopelvic pelvic fascia insufficiency, severe cystocele (Aa ≥ +1) and hysteroptosis grade II – IV, the correction was carried out using the six-arm OPUR® («ABISS», Saint-Étienne, France). lightweight polypropylene monofilament implant (n = 290). When the cystocele was not prominent (Aa ≤ -1) and grade III – IV hysteroptosis, posterior sacrospinal hysteropexy was preferred with the CYRENE® («ABISS», Saint-Étienne, France) tape (n = 85). In 35 patients, the operation was combined with anterior colporrhaphy. In 5 patients, a simultaneous conization/amputation of the cervix was performed. The examination was performed 1 month after surgery and then annually. Prolapse ≥ grade II was as recurrent. The follow-up period of 67 patients was more than 4 years.Results. After OPUR® prosthesis implantation, recurrent hysteroptosis was detected in 6 women with cervical hypertrophy / elongation within a period of 1 mo to 3.5 yr and cystocele in 4 patients. The efficacy was 96%. In 9 patients, an postoperative ischuria was found associated with extensive dissection and hypotension of the bladder wall due to chronic urinary retention in severe cystocele. Urination improved in 88% of cases. In the remaining cases, long-term mediator and hormone replacement therapy were continued., One recurrent hysteroptosis was observed during the implantation of the CYRENE® prosthesis. No damage to the bladder was observed. Acute urinary retention was detected in 1 case, which resolved after intermittent catheterization. Conclusion. The availability of 2 types of transvaginal prostheses for various degrees and configurations of urogenital prolapses allows a differentiated approach to their choice. Both prostheses suggest reliable «reconstruction-imitation» of the sacroiliac ligament by sacrospinal hysteropexy. If necessary, the operation can be supplemented with anterior colporrhaphy. The prevalence of anterior prolapse with endopelvic fascia insufficiency requires more extensive reconstruction, which can be performed relatively safely and effectively by implantation of a 6-arm OPUR® prosthesis.

PD50-01 THE VALUE OF REPAIR OF ASYMPTOMATIC GRADE II PELVIC ORGAN PROLAPSE DURING MID URETHRAL SLING SURGERY FOR STRESS URINARY INCONTINENCE: A PROSPECTIVE RANDOMIZED STUDY OF 72 CASES

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy II1 Apr 2017PD50-01 THE VALUE OF REPAIR OF ASYMPTOMATIC GRADE II PELVIC ORGAN PROLAPSE DURING MID URETHRAL SLING SURGERY FOR STRESS URINARY INCONTINENCE: A PROSPECTIVE RANDOMIZED STUDY OF 72 CASES Samer Morsy, Hussein Hussein, Ahmed Abdel Aziz, Dalia Abdel Azim, Sarah Hassan, Eman Hussein, and Mohamed Abdel Azim Samer MorsySamer Morsy More articles by this author , Hussein HusseinHussein Hussein More articles by this author , Ahmed Abdel AzizAhmed Abdel Aziz More articles by this author , Dalia Abdel AzimDalia Abdel Azim More articles by this author , Sarah HassanSarah Hassan More articles by this author , Eman HusseinEman Hussein More articles by this author , and Mohamed Abdel AzimMohamed Abdel Azim More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2213AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To compare the clinical outcome between midurethtral sling procedure for stress urinary incontinence with and without concomitant repair of asymptomatic grade II pelvic organ prolapse (cystocele) repair. METHODS Seventy two female patients with stress urinary incontinence (SUI) and asymptomatic grade II cystocele were included in a randomized study between June 2014 and June 2015. They were divided equally into two groups. Group (A) treated only with trans-obturator tape (TOT) without treatment of the cystocele while in group (B) TOT was associated with cystocele repair by a tailored proline mesh. Postoperative follow up was performed after 3, 6 and 12 months. The two groups were compared regarding clinical outcome of SUI (cure, improvement or failure) and development of any denovo events. RESULTS For clinical outcomes based on patients' subjective symptoms, the cure rate of group (A) was 77.8%.66.7% and 66.7% meanwhile for group (B) was 85%,90% and 90% at 3,6 and 12 months, respectively (p<0.05). Cystocele was cured in all patients in group (B). Six patients (17%) with asymptomatic cystocele grade II in group (A) became symptomatic or with a higher grade at 6 months duration that required surgical repair. Denovo urgency with or without UUI was 12.5% in group (A) increasing up to 50% at 6 months follow up which was treated with anticholenergic medications, but was 5% in group (B) with highly stastistically significant difference (p<0.05). CONCLUSIONS Concomitant asymptomatic cystocele repair with midurethral sling improve the cure rate of stress urinary insentience, reduce the incidence of denovo urgency incontinence and worsening of existing cystocele. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e979 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Samer Morsy More articles by this author Hussein Hussein More articles by this author Ahmed Abdel Aziz More articles by this author Dalia Abdel Azim More articles by this author Sarah Hassan More articles by this author Eman Hussein More articles by this author Mohamed Abdel Azim More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Urinary tract infection due to Staphylococcus lugdunensis in a 70-year-old woman with cystocele grade 3

Introduction: Staphylococcus lugdunensis is a coagulase-negative staphylococci that is increasingly being reported as a human pathogen. Case presentation: Here, we describe a clinical case of urinary tract infection (UTI) due to S. lugdunensis in a 70-year-old woman with cystocele grade 3 who was successfully treated with cotrimoxazole. Although S. lugdunensis has rarely been reported to cause urinary tract infections and especially in immunosuppressed patients, we describe a case of UTI caused in an adult without the presence of an indwelling catheter or immunosuppression. Conclusion: S. lugdunensis can be a urinary tract pathogen in adults without the presence of indwelling catheters or other obvious medical problems. Urine cultures that show S. lugdunensis should not be attributed to skin contamination, especially when the clinical findings are compatible with cystitis or pyelonephritis.

Minimally invasive cystocele repair technique using a polypropylene mesh introduced with the transobturator route.

Evaluation of the safety and efficacy of the use of polypropylene mesh for cystocele repair using minimally invasive technique. We retrospectively evaluated the perioperative events, short-term postoperative side-effects, and follow up for 152 patients who underwent repair for cystocele grade 2 or more using a polypropylene mesh. The repair was performed through a small anterior vaginal wall incision, with the arms of the mesh passed through a transobturator route using a corkscrew needle. Stress urinary incontinence (SUI) tests and the International Continence Society Pelvic Organ Prolapse Quantification (POP-Q) staging systems were documented before and after surgery. The average time and blood loss for the procedure were 18 min and 100 cc, respectively. Bladder injury and excess bleeding (>500 cc) occurred in one and two cases during the procedure, respectively. The early postoperative complications included pain (10.5 %), mesh erosion (1.3 %), fever (1.3 %), and urinary tract infection (7.9 %). Among the 122 patients who were followed up (median follow-up time, 18.2 months), the subjective and objective cure rates for the prolapse were 98 and 95 %, respectively. Complications during the follow up included mesh erosion (four cases) and persistent dyspareunia (four cases). Cystocele repair with mesh placement through transobturator route can be considered a minimally invasive, promising method for the correction of cystocele and SUI based on the low rate of complications, the high rate of success, and the low incidence of recurrence.

377 Follow up for urinary continence after pelvic organ prolapse repair

CONCLUSIONS It’s well-know that the risk for woman of being the operated for 80 years about the pelvic organ prolapse (POP) or stress urinary incontinence (SUI) is about 11% [1]. It should be noted that approximately 22-30% of patients who were continent before surgery noted SUI postoperatively [2], [3], which has a strong impact on the quality of life of patients. Objective of our study was to evaluate the incidence of SUI and anti-incontinence surgery for 6 months in patients after surgical correction of pelvic organ prolapse (POP) by the vaginal approach. This study included 82 women suffering from POP (cystocele grade 2-4 by POP-Q) who underwent transvaginal surgical repair. The study was approved by the local ethics committee, and all patients. All patients were submitted to standard protocol of preoperative examination including a history taking and gynecological examination with cough tests with or without prolapse repositioning by speculum, pessary or manually. All patients were operated by vaginal approach. The results of surgical treatment of POP were evaluated for the presence SUI within 1, 3 and 6 months after the operation during office visits and using the UDI-6 questionnaire.

MP7-07 MRI IN PATIENTS SUFFERING FROM PELVIC ORGAN PROLAPSE AND STRESS URINARY INCONTINENCE

INTRODUCTION AND OBJECTIVES: The aim of our study was to identify differences in anatomical parameters using MRI in patients suffering from pelvic organ prolapse (POP) according to their continence function. METHODS: This study included 44 women suffering from POP (cystocele grade 2-4 by POP-Q) who underwent transvaginal surgical repair. The study was approved by the local ethics committee, and all patients provided signed informed consent. For evaluation of continence, the UDI-6 questionnaire was used. We found that 14 patients (group 1) had concomitant SUI and prolapse. The remaining patients without complaint of SUI were divided into 2 groups: group 2 (n1⁄416) had a negative cough test after prolapse repositioning, and group 3 (n1⁄414) had occult SUI. Dynamic MRI was performed for every patient on MR tomograph General Electric Signa HDxt 3,0 Tesla (Figure 1). The following parameters were recorded: hypermobility of the urethra, dilatation of the bladder neck, retrovesical angle (more than 140 ), urethral length, urethral kinking, bladder neck and base descent, uterus descent, cervical elongation, urethral rhabdosphincter thickness, levator gap width and pelvic fascia defect. RESULTS: Comparing groups 1 and 2, statistically significant differences were obtained for the dilatation of the bladder neck during Valsalva and for the increase of the retrovesical angle at the Valsalva of more than 140 and at rest was noted (Table 1), which indicates the importance of these factors for continence in patients with pelvic organ prolapse. Statistical analysis did not reveal differences in these parameters between groups 2 and 3. CONCLUSIONS: Patients with POP and SUI have certain anatomical features that should be considered when planning surgical treatment. Further studies on the prognostic significance of these parameters with a large sample are necessary to develop an algorithm of treatment for this category of patients.

Vaginal sacrocolporectopexy for the surgical treatment of uterine and vaginal vault prolapses: confirmation of the surgical method and perioperative results of 101 cases

In this study, we sought to confirm the surgical method of vaginal sacrocolporectopexy and previously reported positive perioperative results of this procedure in a large patient group. We describe the approach which offers a vaginal, safe alternative to sacrospinous repair, laparoscopic or open vaginosacropexy and the use of synthetic meshes to treat pelvic organ prolapse. We conducted a monocentric, prospective, nonrandomized study for treatment of patients with uterine and vaginal vault relapse (grade 2-4). All patients underwent a preoperative urogynecological urodynamic examination. We focus on method, operative time, complications, blood transfusions, hospital stay and clinical data. Between March 2006 and March 2011, 101 consecutive patients of mean age 64 (40-89) years, with sub or total uterine prolapse (n=69, grade 2-4) and vaginal vault prolapse (n=32, grade 2-4) were treated with vaginal sacrocolporectopexy. Cystocele (grade 2-4) was found in 88 (87.1%) and rectocele (grade 2-4) in 43 (42.5%) patients. Mean duration of surgery with sacrocolporectopexy was 70 min (28-165) without hysterectomy, and 76 min (40-219) with hysterectomy. Regression analysis of all patients (n=101) showed a significant decrease of operative time in the group without hysterectomy after 40 cases. Three bladder lesions, two in patients with a history of hysterectomy, occurred during surgery and were corrected intraoperatively without further complications. No patient required a blood transfusion. Hemoglobin levels decreased slightly from a preoperative mean of 13.6 mg/dl (10.3-15.7) to a postoperative mean of 11.7 mg/dl (8.6-14.7). Vaginal sacrocolporectopexy is a safe vaginal method for the treatment of sub-/total uterine/vaginal vault prolapse.

Double promontofixation laparoscopique versus laparoscopique robot-assistée : morbidité, résultats anatomiques et fonctionnels à court terme

The purpose of our study was to compare the morbidity and the short-term anatomical and functional outcome of the double promontofixation according to the surgical access laparoscopic versus laparoscopic robot-assisted. Forty-six patients were operated for anterior and posterior promontofixation with two mesh between March 2008 and February 2010, 19 were robot-assisted (PR) and 27 laparoscopic (PL). All the patients were contacted again by telephone to answer a questionnaire estimating the functional results. Both groups (PR vs PL) were comparable in terms of age, score ASA and of surgical histories. There was no difference in terms of hospital stay nor per- and postoperative complications. The mean operating time was significantly more important in the group PR (P=0.049). With a mean follow-up of 10,7±7,8 months (PL) versus 8,8±5,9 months (PR), the anatomical result was good without recurrence in 93,5% of the cases. The rate of recurrence was similar in both groups with three patients who had a cystocele grade 2, two in the group PR and one in the group PL (P=0.411). The urinary and sexual functional results were comparable between both groups with an improvement of the rate of dyspareunia and dysuria. However we observed more postoperative constipation in the group PR (10/19 vs 6/27, P=0.033). The robot-assisted laparoscopic promontofixation is a reproducible technique with a morbidity and anatomical and functional results comparable to the laparoscopic way.

Non-Oral Poster 42

OBJECTIVES: To determine whether known risk factors for pelvic organ prolapse such as age and body mass index (BMI) affect cystocele severity MATERIALS AND METHODS: All patients presenting to a single outpatient urogynecologic center from 2007 to 2009 were reviewed. Patients with symptomatic cystoceles diagnosed by physical exam were included in the study. The Baden-Walker system was used to grade cystoceles and patients were separated into two groups based on the severity of their prolapse. Patients with grade I-II cystoceles were placed into the “low severity” group and those with Grade III-IV cystoceles were placed into the “high severity” group. Age and BMI were evaluated for their effect on cystocele severity using the student's t-test. Multivariate ordinal regression analysis was performed to determine if age and BMI are independent risk factors for cystocele severity and to quantify the magnitude of their effect. RESULTS: 67 patients met criteria for inclusion in the study. Of these, 63% were classified as low severity (24% Grade I, 39% Grade II) and 37% were classified as high severity (28% Grade III, 9% Grade IV). Age was noted to be significantly different between the two groups, with increasing age being a risk factor for greater cystocele severity (52 ± 14.4 vs. 61 ± 8.3, P < 0.05). BMI had no significant effect on cystocele grade (29.2 ± 5.22 vs. 31.4 ± 7.49, P = 0.25). In the multivariate ordinal regression analysis, age was shown to be independently correlated with cystocele severity (OR 6.46, CI 2.02–20.61, P = 0.01). BMI was not correlated with cystocele severity (OR 1.17, CI 0.21–6.53, P = 0.43). CONCLUSION: Patient age and BMI are documented risk factors for pelvic organ prolapse according to the current literature. However, there are no reports of the effects of these risk factors on the severity of cystocele alone. In our study increasing age was significantly correlated with cystocele severity in both univariate and multivariate analyses. There was no positive or negative correlation identified between BMI and cystocele grade.

Comparison of gynecologic and perineal ultrasound examination of women with stress incontinence

A COMPARISON AIM: To determine how well results of gynecological and perineal sonographic examinations of the urethrovesical junction correlate. 186 women with urodynamically verified stress incontinence underwent a perineal ultrasound and then a gynecologic examination. Standardised procedures were used for both. The findings of the gynecological examination were compared with measurement values and morphological findings from perineal ultrasound. There was agreement on the cystocele grade in 69% of the cases. The position of the bladder neck as assessed by the ultrasound image revealed typical measurement values for this disorder. The expected bladder neck funneling was detected in 49% of these women. In stress-incontinent women there is good correlation between the findings of the gynecological and perineal sonographic examinations. Bladder neck funneling-a morphological sign of stress incontinence-can be detected with perineal ultrasound in nearly one-half of the cases.

Cystocele—vaginal approach to repairing paravaginal fascial defects

The objective of this study is to determine the efficacy and safety of vaginal approach to repair paravaginal defects in patients with symptomatic cystocele. This was a retrospective study of 66 women with a diagnosis of symptomatic cystocele grade 2 to 4, referred to our unit between January 2002 and March 2005. A clinical evaluation was carried out using the Baden-Walker classification before and after the surgery. The same surgical team performed every surgery. The repair of paravaginal fascial defects was carried out through a vaginal approach, exposing the arcus tendineus. The paravaginal fascial defects were corrected through suspension of vesicovaginal fascia to the arcus tendineus with nonreabsorbable Ethibond 0 sutures. Women were seen for follow-up at 3, 6, and 12 months. The presence of well-demarcated vaginal lateral sulci at grade 0, firmly apposed to the lateral pelvic sidewalls and no anterior relaxation with Valsalva maneuver, were used as criteria for cure. Grade 2 cystocele was diagnosed preoperatively in most women. The mean duration of complaints due to prolapse was 64.6 months. There were no major intraoperative complications. Mean time of inpatient stay was of 4.9 days. The cure rate at 12 months was 91.6%. There were five cases of recurrence of cystocele 6 months after surgery. Surgical repair of symptomatic cystocele through a paravaginal approach is a safe and efficacious technique. Vaginal approach to repair paravaginal fascia defects had a low postoperative morbidity and high cure rate at 12 months (91.6%).

Cystocele repair by a synthetic vaginal mesh secured anteriorly through the obturator foramen

Objective: Our aim was to assess the feasibility and short-term results of cystocele repair by the placement of a synthetic subvesical mesh secured anteriorly through the obturator foramen. Study design: Between 1 November 2001 and 31 July 2002, 30 consecutive patients with a grade 2 ( n=18, 60%) or 3 ( n=12, 40%) cystocele were prospectively included in the study. Results: The obturator route was feasible in all cases. No intraoperative complications arose. After a mean follow-up of 6.7 months (range: 2–12), 90% ( n=27) of the patients were cystocele grade 0, 7% ( n=2) grade 1 and failure was observed in a young patient (3%) treated without hysterectomy. Two vaginal erosions (7%) were observed at six and nine months. For the 14 patients (47%) who had sexual relations after surgery, 2 (14%) complained of anterior dyspareunia. Conclusion: The obturator approach is a simple and sure technique for placing a polypropylene synthetic subvesical mesh. The long term stability and tolerance of the results must be confirmed.

Is transabdominal repair of mild to moderate cystocele necessary for correction of prolapse during a modified Burch procedure?

A nonconcurrent cohort study by chart review of cases was carried out at the Urogynecology Unit of Mount Sinai Hospital in Toronto, Canada, in 380 patients with stress urinary incontinence (SUI) undergoing Burch retropubic urethropexy (RPU) with or without transabdominal internal anterior repair (TIAR). There were 191 subjects (group A) who had both RPU and TIAR, and 189 (group B) who had RPU alone. The main outcome measures were postoperative recurrence of cystocele and SUI. Statistical analysis was performed using multiple regression analysis; P<0.05 was considered statistically significant. Of patients with preoperative cystocele grade 1 and 2 (mild to moderate) followed-up at 1 year, recurrence in groups A and B, respectively, was found in 13/114 (11.4%) vs. 4/99 (4.0%) (P<0.05). Regression analysis showed this trend of greater recurrence with TIAR to persist at 5 years, although a significant number of patients were lost to follow-up. There was no statistically significant difference in the cure of SUI between the groups. There was a 2.1% incidence of inadvertent cystotomy during TIAR (with no bladder injuries in group B), although this complication was always recognized and repaired without sequelae. In patients with both SUI and mild to moderate cystocele, TIAR may not be a necessary addition to RPU for treatment of the cystocele, although a randomized clinical trial is needed to determine the optimal transabdominal treatment in such cases. There is no detrimental effect of TIAR on the Burch procedure's success in curing SUI.

The Bologna bladder neck suspension procedure for treatment of stress urinary incontinence associated with cystocele.

The object was to study retrospectively the perioperative complications and results of the Bologna procedure for the treatment of stress urinary incontinence associated with cystocele grade 2 or more. In the study, 80 patients underwent a repair of all defects of pelvic support plus the Bologna procedure. Mean duration of follow-up was 40.2 months (range 3-127). The incidence of operative complications was 2.5% for inadvertent cystostomy and for hemorrhage. Mean hospital stay was 7.2 days (range 2-17). At 2-year follow-up 85% of the patients were completely free of incontinence symptoms (95% CI: 75-92) and 76% at 3-year follow-up (95% CI: 66-86). None of the parameters tested in a univariate analysis was independently linked with surgical failure. Further studies are needed to establish the place of this technique in the surgical management of urinary incontinence associated with genital prolapse.

Evaluation of Long-Term Results of Surgical Correction of Stress Urinary Incontinence

A total of 109 patients submitted to surgery for the correction of urinary stress incontinence (USI) by two different techniques, i.e. anterior colporrhaphy (group I, n = 57) when cystocele grade II/III was present, and Burch procedure (group II, n = 52) when cystocele grade I was present, were reevaluated an average of 5 years after surgery (range: 54-66 months). The curve constructed with the reevaluation data showed a sharp superiority of the Burch technique in terms of correction of USI and associated genital prolapses. There was a progressive recurrence rate that stabilized at 5 years, with values of 78.9% in group I and 40% in group II. Anterior colporrhaphy was ineffective for the correction of any of these parameters in group I. The data clearly show the need to improve the presurgical diagnostic methods for the selection of patients that will benefit from treatment: detailed history of the current disease and auxiliary tests such as Q-tip test, transvaginal ultrasound, and urodynamic study. Other factors were associated with ineffective treatment in both groups, such as hypoestrogenism (20/109), excessive weight gain (19/109) and chronic intestinal constipation and/or coughing present in 36 patients, with recurrence in 28 of them.