Posterior Vaginal Wall Prolapse Research Articles

Preoperative POPQ versus Simulated Apical Support as a Guideline for Anterior or Posterior Repair at the Time of Transvaginal Apical Suspension (PREPARE trial): study protocol for a randomised controlled trial

IntroductionTransvaginal reconstructive surgery is the mainstay of treatment for symptomatic pelvic organ prolapse. Although adequate support for the vaginal apex is considered essential for durable surgical repair, the optimal management...

Outcomes of Surgery with Vaginal Native Tissue for Posterior Vaginal Wall Prolapse Using a Special Technique.

There are several techniques for repairing prolapse in the posterior vaginal compartment, yet there is no general agreement on the best surgical procedure. This study was performed to investigate the outcomes of the common vaginal route technique for posterior vaginal wall prolapse repair in the first Iranian fellowship teaching center for female pelvic floor disorders. This prospective cohort study was performed on women with posterior vaginal wall prolapse with or without prolapse of other vaginal compartments who underwent surgery between 2014 and 2018 in a referral center for female pelvic floor disorders. A follow-up period of 12 months was considered. Patients subjected to the transvaginal technique by attachment of the rectovaginal fascia to the pericervical ring using vaginal native tissue were included. Among the 107 patients, the Pelvic Floor Distress Inventory-20 (PFDI-20) scores were 141.87 ± 34.48 and 100.87 ± 26.48 before and after surgery, respectively, showing the significant improvement of patient’s symptoms after surgery in the 12-month follow-up. Comparing Pelvic Organ Prolapse Quantification (POP-Q) results before and after surgery, a significant improvement in patients’ conditions was seen at the 12-month follow-up. Based on the results of the present study, the surgical procedure of the rectovaginal fascia attachment to the pericervical ring in posterior vaginal wall prolapse repair seems an effective surgical intervention without significant morbidity in the short-term follow-up.

Comparison of cervical length measured by POP-Q C-D and MRI: Why is POP-Q C-D not accurate?

ObjectiveTo investigate the relationship between the cervical length evaluated by Pelvic Organ Prolapse Quantification (POP-Q) point C minus D (C–D; ECL) and the magnetic resonance imaging (MRI)-based cervical length (MCL). Study designThis was a retrospective study of patients with POP II-IV who underwent MRI. The ECL was calculated based on the absolute value of C–D according to POP-Q. The MCL was defined as the distance between the internal and external cervical os on MRI. Intraobserver reliability using the Bland-Altman method. Continuous variables were compared by paired 2-tailed t-tests. Multiple linear regression analysis was used to analyse the factors influencing differences between the ECL and MCL. ResultsAmong 105 eligible patients, 89 patients were eventually included in the study. The Bland-Altman scatter plots show that the intraobserver reliability of MCL was excellent. Furthermore, the mean ECL was significantly longer than the mean MCL (48.15 mm ± 27.46 vs. 28.25 mm ± 10.27, P = 0.000).Body mass index, parity, menopausal status or total vaginal length did not affect the difference between ECL and MCL. However, The larger the point Ba, the larger the difference between the ECL and MCL. The larger the point Bp, the smaller the difference between the ECL and MCL. ConclusionIn general, POP-Q C–D was longer than the cervical length measured by MRI. Deep analysis found that when uterine prolapse is combined with larger anterior vaginal wall prolapse, the difference between ECL and MCL is greater; when uterine prolapse with larger posterior vaginal wall prolapse, the difference between ECL and MCL is smaller.

A five-year analysis of effect on transvaginal high uterosacral ligament suspension with or without native-tissue repair for middle compartment defect

Objective: To assess the five-year effect of the transvaginal high uterosacral ligament suspension (HUS) with or without additional concomitant native-tissue anterior and (or) posterior repair in women suffering from middle compartment defect. Methods: A retrospective review of records identified 79 women who underwent transvaginal HUS with or without additional concomitant native-tissue anterior and (or) posterior repair from January 2007 to January 2018 in Fourth Medical Center, General Hospital of People's Liberation Army. The middle compartment defects were predominant in these patients with point C no less than point Ba or Bp if accompanied with anterior or posterior vaginal wall prolapse. Follow-up visits were performed 2,6 and 12 months after surgery and then annually. Anatomic results of pelvic organ prolapse (POP) was established by pelvic examination using pelvic organ prolapse quantitation system (POP-Q) staging. Funtional results were obtained by patient global impression of improvement (PGI-I) scale in POP, pelvic floor distress inventory-short form 20 (PFDI-20) and pelvic floor impact questionnaire short form (PFIQ-7). Surgical success required the fulfillment of all 3 criteria: (1) anterior or posterior vaginal wall prolapsed leading edge of 0 cm or less and apex of 1/2 total vaginal length or less; (2) the absence of POP symptoms as reported on the PFDI-20 question No.3 ( "Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?" ); and (3) no prolapse reoperations or pessary use during the study period. Results: Of 79 women, 51(65%, 51/79) women completed the five-year follow-up during the study period. The median follow-up time was 5.2 years (2.8-8.3 years). The overall surgery success rate was 86% (44/51) according to above all 3 criteria. Prolapse recurrence rates were isolated anterior 8% (4/51), isolated apical 0, isolated posterior 2% (1/51) and multiple compartments 4% (2/51). Seven women (14%,7/51) developed anterior or posterior prolapse beyond the hymen with the leading edge≤1 cm. No apical prolapsed occurred. None of recurrent women underwent retreatment,including either surgery or pessary usage at last follow-up. The subjective satisfaction rate was 90% (46/51). There was a 1% (1/79) rate of intraoperative ureteral kinking and 3% (2/79) rate of postoperative morbidity. Conclusions: The transvaginal HUS for middle compartment defect offers good long-term anatomical results with excellent vault suspension. With additional concomitant native-tissue anterior and (or) posterior repair, it will be a reconstructive surgery for the majority of moderate-to-severe POP. It is minimal traumatic and worthy of being popularized for clinical application.

Surgical interventions for posterior compartment prolapse and obstructed defecation symptoms: a systematic review with clinical practice recommendations.

Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both conditions among different surgical approaches. A systematic review was performed comparing the impact of surgical interventions in the posterior compartment on prolapse and defecatory symptoms. MEDLINE, Embase, and ClinicalTrials.gov were searched from inception to 4 April 2018. Randomized controlled trials, prospective and retrospective comparative and single-group studies of women undergoing posterior vaginal compartment surgery for vaginal bulge or bowel symptoms were included. Studies had to include both anatomical and symptom outcomes both pre- and post-surgery. Forty-six eligible studies reported on six surgery types. Prolapse and defecatory symptoms improved with native-tissue transvaginal rectocele repair, transanal rectocele repair, and stapled transanal rectocele repair (STARR) surgeries. Although prolapse was improved with sacrocolpoperineopexy, defecatory symptoms worsened. STARR caused high rates of fecal urgency postoperatively, but this symptom typically resolved with time. Site-specific posterior repairs improved prolapse stage and symptoms of obstructed defecation. Compared with the transanal route, native-tissue transvaginal repair resulted in greater improvement in anatomical outcomes, improved obstructed defecation symptoms, and lower chances of rectal injury, but higher rates of dyspareunia. Surgery in the posterior vaginal compartment typically has a high rate of success for anatomical outcomes, obstructed defecation, and bulge symptoms, although these may not persist over time. Based on this evidence, to improve anatomical and symptomatic outcomes, a native-tissue transvaginal rectocele repair should be preferentially performed.

The relationship of defecation symptoms and posterior vaginal wall prolapse in women undergoing pelvic organ prolapse surgery

Defecation symptoms are common among women with pelvic organ prolapse. However, the relationship between posterior vaginal wall prolapse and defecation symptoms remains debatable. Even though there is a plausible biomechanical rationale for posterior wall prolapse to cause obstructed defecation, previous studies have drawn contradictory conclusions regarding the association. We aimed to examine the association between posterior vaginal wall prolapse and defecation symptoms by assessing the following: (1) does prevalence of defecation symptoms increase along with posterior wall prolapse severity, (2) is postoperative symptom improvement greater in women who underwent posterior compartment procedures in comparison with those who did not, and (3) is symptom improvement related to the symptom's correlation with the degree of prolapse? We used data from a nationwide longitudinal cohort study with 3515 women undergoing pelvic organ prolapse surgery. We measured the prevalence of 9 defecation symptoms at baseline and at 6 and 24 months after surgery using the short form of the Pelvic Floor Distress Inventory. Baseline degree of prolapse was categorized in stages as defined by the Pelvic Organ Prolapse Quantification System. The relationship between the degree of posterior wall prolapse and prevalence of bothersome defecation symptoms was studied with logistic regression and adjusted for patient characteristics and severity of anterior wall and apical prolapse. Generalized estimating equations were used to assess the longitudinal change in symptom prevalence in groups of participants with and without repair for posterior vaginal compartment. Correlations between symptom improvement and symptom dependency on the degree of prolapse was assessed by calculating Pearson's correlation coefficient. The stage of posterior wall prolapse (stage 2 vs stage 0) correlated with splinting, straining, incomplete evacuation, fecal incontinence of liquid stool, pain during defecation, fecal urgency, and anorectal prolapse (adjusted odds ratios, 2.7, 2.1, 2.0, 1.5, 2.1, 1.4, and 2.2, respectively; P ≤ .007 for all). Flatal incontinence and fecal incontinence of solid stool were not associated with the severity of posterior vaginal wall prolapse. Obstructed defecation symptoms (splinting, straining, and incomplete evacuation) improved more in women undergoing posterior compartment surgery compared with women undergoing repair for other compartments. The greatest improvement at follow-up was observed for those symptoms that showed strongest association with the degree of prolapse at baseline. Obstructed defecation symptoms are dependent on the posterior wall anatomy. Women presenting with posterior wall prolapse, and these symptoms can expect to improve after surgery. Other defecation symptoms also improve after pelvic organ prolapse surgery, but they are not as specific to posterior wall anatomy as obstructed defecation symptoms.

Mid-term efficacy of laparoscopic sacral colpopexy of combined transabdominal-transvaginal approach in the treatment of stage Ⅳ pelvic organ prolapse

Objective: To evaluate the clinical effect after laparoscopic sacral colpopexy (LSC) of combined transabdominal-transvaginal approach on stage Ⅳ pelvic organs prolapse (POP). Methods: The clinical data of 65 patients undergoing LSC of combined transabdominal-transvaginal approach from January 1st, 2010 to July 30th, 2017 due to POP stage Ⅳ in First Affiliated Hospital of Guangzhou Medical University were retrospectively analyzed. Objective outcome was assessed by comparing preoperative and postoperative pelvic organ prolapse quantification (POP-Q) systems. Subjective effects were assessed by comparing pelvic floor distress inventory-short form 20 (PFDI-20), pelvic floor impact questionnaire short form (PFIQ-7), pelvic organ prolapse/urinary incontinence sexual questionnaire-12 (PISQ-12) and patient global impression of improvement (PGI-I). Results: All 65 patients were successfully performed without any intraoperative complications. Fifty-three patients were followed in the clinic department and 12 were followed up by telephone. The follow-up duration was 6.1-80.3 months and the median follow-up duration was 24.5 months. The bleeding loss was 20-250 ml. Postoperative urethral catheter residence day was (2.5±1.1) days, length of postoperative stay was (6.2±1.7) days. The postoperative POP-Q scores were compared with preoperative scores which had significantly improved except pb (all P<0.01). The objective cure rates of vaginal anterior wall, apical and posterior wall prolapse stage Ⅳ were 90% (47/52), 100% (23/23) and 95% (20/21).About PGI-I, except for 1 patient who chose "improvement" , the other 64 patients (98%, 64/65) all chose "significant improvement" . Furthermore, preoperative and postoperative PFDI-20, PFIQ-7, and PISQ-12 scores were all statistically significant (all P<0.01). Subjective efficacy was significant. Three cases (5%, 3/65) of postoperative fever occurred. Two cases (4%, 2/53) had mesh exposure. Six patients (11%, 6/53) had recurrence of postoperative prolapse. Five cases had recurrence of vaginal anterior wall prolapse and no reoperation was performed; 1 case was recurrence of posterior vaginal wall prolapse who diagnosed as vaginal posterior wall prolapse stage Ⅲ; no recurrence of apical prolapse. The rate of reoperation (including exposed-mesh removal and pelvic floor reconstruction surgery) was 5% (3/65). Conclusions: The LSC of combined transabdominal-transvaginal approach has a high subjective efficacy rate. The objective cure rate in the case of apical prolapse stage Ⅳ is one hundred percent.The LSC of combined transabdominal-transvaginal approach has low mesh exposure, low postoperative infection and the reoperation rate, which is one of optional pelvic floor reconstruction surgery. However, there is still a risk of recurrence in patients with POP stage Ⅳ with severe bladder bulging.

Repair of recurrent rectocele with posterior colporrhaphy or non-absorbable polypropylene mesh\u2014patient-reported outcomes at 1-year follow-up

Introduction and hypothesisThe aim of this study was to compare the results of repair of isolated, recurrent, posterior vaginal wall prolapse using standard posterior colporrhaphy versus non-absorbable polypropylene mesh in a routine health care setting.MethodsThis cohort study was based on prospectively collected data from the Swedish National Register for Gynaecological Surgery. All patients operated for recurrent, posterior vaginal wall prolapse in Sweden between 1 January 2006 and 30 October 2016 were included. A total of 433 women underwent posterior colporrhaphy, and 193 were operated using non-absorbable mesh. Data up to 1 year were collected.ResultsThe 1-year patient-reported cure rate was higher for the mesh group compared with the colporrhaphy group, with an odds ratio (OR) of 2.06 [95% confidence interval (CI) 1.03–4.35], corresponding to a number needed to treat of 9.7. Patient satisfaction (OR = 2.38; CI 1.2–4.97) and improvement (OR = 2.13; CI 1.02–3.82) were higher in the mesh group. However, minor surgeon-reported complications were more frequent with mesh (OR = 2.74; CI 1.51–5.01). Patient-reported complications and re-operations within 12 months were comparable in the two groups.ConclusionsFor patients with isolated rectocele relapse, mesh reinforcement enhances the likelihood of success compared with colporrhaphy at 1-year follow-up. Also, in our study, mesh repair was associated with greater patient satisfaction and improvement of symptoms, but an increase in minor complications. Our study indicates that the benefits of mesh reinforcement may outweigh the risks of this procedure for women with isolated recurrent posterior prolapse.

The main clinical symptoms in patients with posterior vaginal wall prolapse and modern non-drug technologies for its relief

Background. Rectocele is one of the leading causes of abnormal position and dysfunction of the pelvic floor and rectum.&#x0D; Objective: to develop and scientifically substantiate the use of a rehabilitation complex, including general magnetotherapy, electromyostimulation with biofeedback in combination with fractional microablative CO2 laser therapy in patients of different age groups with rectocele after surgery.&#x0D; Methods. The article presents the results of treatment of 100 women with rectocele, who were divided into main and control groups, within each group, depending on their age, they were divided into 2 subgroups: women of childbearing age were included in subgroup A, and women of peri- and menopausal age were included in subgroup B. Patients of the main group in the early postoperative period after plastic surgery for rectocele (from 1 day) were given a course of General magnetotherapy and in the late postoperative period (one month after the operation) a set of measures was performed, consisting of a course of electromyostimulation with biological connection of the pelvic floor muscles 2 intravaginal procedures of fractional microablative CO2 laser therapy at intervals of 45 weeks. Patients of the control group after surgical treatment of rectocele in the late postoperative period received symptomatic therapy, including painkillers and spasmolytics and a set of Kegel exercises.&#x0D; Results. Significant improvements in postoperative treatment were observed in patients of the main group: pelvic pain and periodic pain in the lower abdomen and lower back disappeared in 100% of cases; the main complaints related to violation of rectal emptying and urination were preserved in no more than 57% of cases, sexual complaints in 5%; in 95% of cases, general, vegetative and pre-climacteric complaints disappeared.&#x0D; Conclusion. As a result of the conducted research, it is shown that under the influence of the developed rehabilitation complex, regardless of age, there was a highly reliable dynamics of all complaints due to the influence of physical factors included in it on various pathogenetic links in the development of the disease.

Prolapse reduction deteriorates the urethral closure mechanism.

Pelvic organ prolapse (POP) reduction is often performed in the preoperative assessment of women before POP surgery. Using urethral pressure reflectometry (UPR), we sought to investigate how POP reduction affects the urethral closure mechanism. Women with anterior or posterior vaginal wall prolapse stage ≥II with and without POP reduction were examined with a speculum. We performed prolapse staging according to the Pelvic Organ Prolapse Quantification system, UPR measurements at rest and during squeezing, and standardized stress tests with 300ml saline. All examinations were repeated after insertion of a speculum. We included 38 women: 22 with anterior and 16 with posterior vaginal wall prolapse POP-Q stage ≥II. During POP reduction, resting and squeezing urethral pressures decreased by 2.5 cmH2O (p = 0.007) and 5.1 cmH2O (p < 0.0001), respectively, in all women. During POP reduction, the number of positive stress tests increased from four (18%) to eight (36%) in women with anterior vaginal wall prolapse and from one (6%) to nine (56%) in women with posterior vaginal wall prolapse. POP reduction decreases urethral pressure, especially during squeezing, and consequently increases the number of positive stress tests. The test itself artificially deteriorates the urethral closure mechanism.

Surgery for women with posterior compartment prolapse.

Surgery for women with posterior compartment prolapse.

Improvement of overactive bladder symptoms: Is correction of the paravaginal defect in anterior vaginal wall prolapse necessary?

BackgroundTo explore the relationship between overactive bladder (OAB) symptoms and paravaginal defects (PVDs), and to identify the necessity of PVD repair by transvaginal mesh (TVM) for the treatment of OAB symptoms. MethodsA retrospective clinical study of 30 women with advanced cystocele with limited apical and posterior vaginal wall prolapse was conducted to identify any changes in OAB symptoms following a single Perigee procedure. Prolapse was assessed using the pelvic organ prolapse quantification (POP-Q) system, and paravaginal defects were identified by sonography. Complete urodynamic examination was performed prior to and one year after operation. All patients completed the overactive bladder questionnaire pre- and postoperatively for a quantitative assessment of OAB symptoms. ResultsAll patients showed a significant improvement at points Aa and Ba in the POP-Q system. The results of the administered questionnaire revealed statistically significant improvement postoperatively. The difference of OAB symptoms between the group with PVDs and that with central defects was not statistically significant (p = 0.67). Moreover, no statistically significant improvement of OAB symptoms in the group with repaired PVDs was observed postoperatively (p = 0.42). ConclusionStatistical improvements of symptoms exist after Aa and Ba points recovery as evaluated by POP-Q system regardless of PVD existence identified by sonography. Repairing PVD did not show significantly improve the severity of OAB symptoms in objective urodynamic data or subjective questionnaire data. The superiority of TVM in PVD repair to manage OAB symptoms seems not manifest.

Adaptation of Pelvic Organ Prolapse Guideline in Iranian Adult Women

Pelvic organ prolapse (POP) is a common disease which present as symptomatic descent of the anterior or posterior vaginal wall prolapse, uterus or apical prolapse subsequent to hysterectomy, and entrocele. Since, social and cultural factors have impact on interval between symptoms incidence and seek for medical care, diagnosis method and treatment process, it was important to prepare a guideline for management of the Iranian women with POP.

Correlation between the posterior vaginal wall and apex in pelvic organ prolapse.

ObjectiveThe aim of our study is to reveal the correlation between the posterior vaginal wall and apex in pelvic organ prolapse.MethodsWe retrospectively reviewed the records of all new patient visits to a urogynecology clinic between January 2013 and December 2015.ResultsFour hundred five cases were enrolled in our study. When all POP stages were included, the Bp (pelvic organ prolapse quantification point) had a moderate correlation with the C (Pearson's r=0.419; P<0.001). Cases where Bp was stage 3 and above presented strong positive correlations with C (Spearman's ρ=0.783; P<0.001). Cases where C was stage 3 and above presented also strong positive correlations with Bp (Spearman's ρ=0.718; P<0.001).ConclusionPosterior vaginal wall prolapse and apical prolapse were correlated with each other, and this correlation was more prominent as stage increased. Therefore, when admitting a patient suspected of posterior vaginal wall prolapse or apical prolapse, it is necessary to evaluate both conditions. Especially in cases more severe or equal to stage 3, it is a must to suspect both conditions as the 2 are strongly correlated.

Effect of Pelvic Floor Muscle Rehabilitation in Preventing Recurrent Vulvovaginal Candidiasis and Recurrent Bacterial Vaginosis

Objective To investigate the effect of pelvic floor muscle rehabilitation on recurrent vulvovaginal candidiasis (RVVC) and recurrent bacterial vaginosis (RBV). Methods Between January 2014 and July 2015, 121 cases of RVVC and RBV were selected, and the patients were randomly divided into control group and experimental group. For the control group of RVVC: miconazole suppository and vaginal delivery were utilized in every patient, 1 piece per night, the period of treatment was 7 to 14 days; oral intake of fluconazole was used again after 72 hours. Clotrimazole suppository or fluconazole was still chosen for the maintenance treatment: (1) 1 piece per week and lasted 6 months for every case; (2) 400 mg of itraconazole was used, 1 time every month or 100 mg was used once a week, the period of treatment lasted for 6 months. RBV: oralintake of metronidazole or clindamycin was chosen. One piece of metronidazole suppository by vaginal utilization was still needed per night, or 2% clindamycin ointment was used by inunction for 7 days. Experimental group: pelvic floor muscle rehabilitation. Results Before rehabilitation treatment, there were 4 cases with level 4 or 5 of type I muscle strength and 8 cases level 4 or 5 of type II muscle strength. After the treatment, there were 59 cases with level 4 or 5 of type I muscle, and 60 cases with level 4 or 5 of type II muscle (P＜0.001). There were no statistical differences on the treatment of anterior vaginal wall prolapse. Before the treatment, the number of anterior vaginal wall prolapse was 53 cases, the number was 49 cases after treatment (P=0.328). Before treatment, the number of posterior vaginal wall prolapse was 25 cases, the number was11 cases after treatment (P=0.005). The number of Uterine prolapse was 14 cases, the number was 2 cases after treatment (P=0.002). Compared with the group with drug treatment, the rate of relapse in vaginitis was decreased significantly after pelvic floor rehabilitation within 1 year, 61 patients with vaginitis, there were only 2 cases of recurrences were observed after treatment (P＜0.05). Conclusion Pelvic floor rehabilitation treatment could improve the pelvic floor function significantly, and also get significant recovery of sagging and prolapse in vagina which was injured by pregnancy and childbirth. Compared with the drug treatment group, the rate of relapse in RVVC and RBV was decreased significantly after pelvic floor muscle rehabilitation.

Prolapse of the apical compartment. Surgical techniques that preserve the uterus. The benefits of the Saba Nahedd technique

The prolapse of the apical compartment is defined as the herniation of the vaginal apex below the plane of the hymen and it is most often associated with an anterior and/or posterior vaginal wall prolapse. The vaginal apex is formed by the uterus or cervix and/or the vaginal cuff in women who received a subtotal or total hysterectomy respectively. The etiology of the apical prolapse is connected to the integrity of the connective tissue which is contained in the uterosacral, cardinal ligaments and the endopelvic fascia. The changes in the life style and beliefs, the current tendency towards a less invasive surgery which involves reduced surgical risk and lower costs have determined more women with genital prolapse to opt for surgical methods that preserve the uterus. These methods include abdominal, vaginal or laparoscopic routes, the chose depending on the local situation and the experience of the surgeon. One of the vaginal techniques which have showed very good results in terms of postoperative morbidity, rate of recurrence and life quality is the “Saba Nahedd” procedure which uses a special kit consisting of an isthmic and a suburethral strip and special clamps for the suspension of the uterus. The aim of this paper is to present the current data on the surgical options that preserve the uterus in women with uterine prolapse, especially, grade II and III with focus on the transvaginal approach using the S.N. method compared with other transvaginal techniques that preserve the uterus.

Re: Clinical Effectiveness and Cost-Effectiveness of Surgical Options for the Management of Anterior and/or Posterior Vaginal Wall Prolapse: Two Randomised Controlled Trials within a Comprehensive Cohort Study-Results from the PROSPECT Study.

Re: Clinical Effectiveness and Cost-Effectiveness of Surgical Options for the Management of Anterior and/or Posterior Vaginal Wall Prolapse: Two Randomised Controlled Trials within a Comprehensive Cohort Study-Results from the PROSPECT Study.

Avoidance of the vaginal incision site for mesh placement in vaginal wall prolapse surgery: A prospective study

ObjectiveTo evaluate efficacy of a minimal surface area, vaginally-installed polypropylene tape (VPT), avoiding insertion on the incision line to treat an anterior, posterior or anteroposterior vaginal wall prolapse. Study designPatients with an anterior, posterior or anteroposterior vaginal wall prolapse waiting for surgical treatment were included in the study. Primary outcome was the incidence of prolapse recurrence reported with combined outcome measures and was reported with Kaplan-Meier cumulative incidence. Secondary outcomes were operative complications, adverse events, urinary, colorectal and sexual functions as well as quality of life. Participation in the study involved up to 8 visits over 5 years. At each visit, patients used a self-reported questionnaire to report symptoms related to pain, urinary, colorectal, sexual functions, and quality of life. A physical examination was also performed. Paired t-tests were used to investigate change in POP-Q and quality of life measurements since baseline. Results71 patients underwent the procedure and were followed-up for an average (standard deviation) of 32.5 (18.7) months. Only 2 (2.8%) women experienced a recurrence of their pelvic organ prolapse. Only one case of erosion and no case of persistent pain have been recorded up to 5 years post-surgery. Quality of life was improved and then sustained throughout the follow-up period (p<0.01). ConclusionThis VPT surgical procedure is safe and has a high level of efficacy to treat anterior, posterior or anteroposterior vaginal wall prolapse. It is also associated with improvements in quality of life of patients which are sustained for many years.

Vaginal Changes Due to Varying Degrees of Rectocele Prolapse: A Computational Study.

Pelvic organ prolapse (POP), downward descent of the pelvic organs resulting in a protrusion of the vagina, is a highly prevalent condition, responsible for 300,000 surgeries in the U.S. annually. Rectocele, a posterior vaginal wall (PVW) prolapse of the rectum, is the second most common type of POP after cystocele. A rectocele usually manifests itself along with other types of prolapse with multicompartment pelvic floor defects. To date, the specific mechanics of rectocele formation are poorly understood, which does not allow its early stage detection and progression prediction over time. Recently, with the advancement of imaging and computational modeling techniques, a plethora of finite element (FE) models have been developed to study vaginal prolapse from different perspectives and allow a better understanding of dynamic interactions of pelvic organs and their supporting structures. So far, most studies have focused on anterior vaginal prolapse (AVP) (or cystocele) and limited data exist on the role of pelvic muscles and ligaments on the development and progression of rectocele. In this work, a full-scale magnetic resonance imaging (MRI) based three-dimensional (3D) computational model of the female pelvic anatomy, comprising the vaginal canal, uterus, and rectum, was developed to study the effect of varying degrees (or sizes) of rectocele prolapse on the vaginal canal for the first time. Vaginal wall displacements and stresses generated due to the varying rectocele size and average abdominal pressures were estimated. Considering the direction pointing from anterior to posterior side of the pelvic system as the positive Y-direction, it was found that rectocele leads to negative Y-direction displacements, causing the vaginal cross section to shrink significantly at the lower half of the vaginal canal. Besides the negative Y displacements, the rectocele bulging was observed to push the PVW downward toward the vaginal hiatus, exhibiting the well-known "kneeling effect." Also, the stress field on the PVW was found to localize at the upper half of the vaginal canal and shift eventually to the lower half with increase in rectocele size. Additionally, clinical relevance and implications of the results were discussed.

Posterior colporrhaphy does not affect the urethral closure mechanism.

Studies have suggested that a posterior vaginal wall prolapse might compress the urethra and mask stress urinary incontinence (SUI), much like an anterior vaginal wall prolapse. A recent study with urethral pressure reflectometry (UPR) has shown that the urethral closure mechanism deteriorates after anterior colporrhaphy; this could explain the occurrence of postoperative de novo SUI. We hypothesized that urethral pressure would also decrease after posterior colporrhaphy. This was a prospective, observational study where women with posterior vaginal wall prolapse ≥stage II were examined before and after posterior colporrhaphy. We performed prolapse staging according to the Pelvic Organ Prolapse Quantification system, UPR measurements at rest, during squeezing and straining, and standardized stress tests with 300ml saline. The women filled out International Consultation on Incontinence-Urinary incontinence (ICIQ-UI) short forms. The sample size was 18, with a power of 99.9% and a level of significance of 5%. Parameters were compared using paired t tests or Fisher's exact test, where appropriate; p values <0.05 were considered statistically significant. Eighteen women with posterior vaginal wall prolapse ≥stage II were recruited. One woman did not undergo surgery. There were no changes in urethral pressure at rest (p=0.4), during squeezing (p=0.2) or straining (p=0.2), before and after surgery. The results of the stress tests and ICIQ-UI short forms were the same after surgery. The urethral closure mechanism is not affected by posterior colporrhaphy. Our study does not support the theory that the posterior vaginal wall prolapse compresses the urethra and masks SUI.