Mariëlla I. J. Withagen

Risk Factors for Exposure, Pain, and Dyspareunia After Tension-Free Vaginal Mesh Procedure

OBJECTIVE: To identify possible risk factors for exposure, dyspareunia, and pain after insertion of tension-free vaginal mesh in pelvic organ prolapse surgery. METHODS: This was a prospective observational cohort study. Consecutive women who underwent surgery with a trocar-guided tension-free vaginal mesh kit were included and evaluated at 6 weeks and at 6 and 12 months after surgery with respect to anatomy and complications. Logistic regression analysis was performed to identify risk factors for exposure, dyspareunia, and pain. RESULTS: Two hundred ninety-four patients were included. Exposure was found in 34 patients (12%). Smoking and total mesh were risk factors for exposure (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.1–8.7 and OR 3.0, 95% CI 1.2–7.0, respectively). Clinical and surgical experience were inversely related to the risk of exposure (OR 0.5, 95% CI 0.3–0.8 per decade). Pain (OR 3.2, 95% CI 1.2–8.4) and dyspareunia (OR 4.7, 95% CI 1.7–12.8) before surgery were predictive for pain and dyspareunia after surgery, respectively. Pain after surgery was found in 35 out of 275 (13%) patients and dyspareunia was found in 77 out of 171 (45%) patients. CONCLUSION: Smoking, total tension-free vaginal mesh, and experience were predictive factors for mesh exposure. LEVEL OF EVIDENCE: II

Surgical management of mesh-related complications after prior pelvic floor reconstructive surgery with mesh

Introduction and hypothesisThe objective of this study is to evaluate the complications and anatomical and functional outcomes of the surgical treatment of mesh-related complications.MethodsA retrospective cohort study of patients who underwent complete or partial mesh excision to treat complications after prior mesh-augmented pelvic floor reconstructive surgery was conducted.ResultsSeventy-three patients underwent 30 complete and 51 partial mesh excisions. Intraoperative complications occurred in 4 cases, postoperative complications in 13. Symptom relief was achieved in 92% of patients. Recurrence of pelvic organ prolapse (POP) occurred in 29% of complete and 5% of partial excisions of mesh used in POP surgery. De novo stress urinary incontinence (SUI) occurred in 36% of patients who underwent excision of a suburethral sling.ConclusionsMesh excision relieves mesh-related complications effectively, although with a substantial risk of serious complications and recurrence of POP or SUI. More complex excisions should be performed in skilled centers.

The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication

Introduction and hypothesisThe objective of this study is to evaluate cervical amputation with uterosacral ligament plication (modified Manchester) and compare it to vaginal hysterectomy with high uterosacral ligament plication procedure with special regard to the middle compartment.MethodsConsecutive women with pelvic organ prolapse who underwent either vaginal hysterectomy or a modified Manchester procedure were included. Assessments were made preoperatively and at 1-year follow-up, including physical examination with pelvic organ prolapse quantification standardised questionnaires (incontinence impact questionnaire, urogenital distress inventory, and defaecatory distress inventory).ResultsBetween 2002 and 2007, 156 patients were included. Ninety-eight patients returned for a 1-year follow-up. In the modified Manchester group, we found no middle compartment recurrence versus two (4%) in the vaginal hysterectomy group. Anterior and posterior compartment prolapse recurrences (stage ≥2) were similar (approximately 50%). Considering operating time and blood loss, modified Manchester was more favourable. There was no difference in the pre- and postoperative subjective scores. The overall functional outcome was acceptable.ConclusionsWe found an excellent performance of both procedures regarding middle compartment recurrences.

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

The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically‐based consensus Report.

Urinary Incontinence After Surgery for Pelvic Organ Prolapse

This study focused on the changes in urinary incontinence (UI) rates pre‐ and postoperatively and identified risk factors which predict the presence of symptoms of urgency urinary incontinence (UUI) or stress urinary incontinence (SUI) after surgery for pelvic organ prolapse (POP) without concomitant or previous anti‐incontinence surgery.

Predictive factors for overactive bladder symptoms after pelvic organ prolapse surgery.

Introduction and hypothesisThis study focussed on the factors which predict the presence of symptoms of overactive bladder (OAB) after surgery for pelvic organ prolapse (POP).MethodsConsecutive women who underwent POP surgery with or without the use of vaginal mesh materials in the years 2004–2007 were included. Assessments were made preoperatively and at follow-up, including physical examination (POP-Q) and standardised questionnaires (IIQ, UDI and DDI).ResultsFive hundred and five patients were included with a median follow-up of 12.7 (6–35) months. Bothersome OAB symptoms decreased after POP surgery. De novo bothersome OAB symptoms appeared in 5–6% of the women. Frequency and urgency were more likely to improve as compared with urge incontinence and nocturia. The best predictor for the absence of postoperative symptoms was the absence of preoperative bothersome OAB symptoms.ConclusionThe absence of bothersome OAB symptoms preoperatively was the best predictor for the absence of postoperative symptoms.

Measuring echogenicity and area of the puborectalis muscle: method and reliability.

To develop a semi‐automated method to assess puborectalis muscle echogenicity on three‐dimensional/four‐dimensional (3D/4D) volume transperineal ultrasound images using 4D View and Matlab® software and evaluate its intra‐ and interobserver reliability.

Between hope and fear: patient's expectations prior to pelvic organ prolapse surgery.

Introduction and hypothesisThe aim of our study was to analyse the patient’s expectations (fears and goals (hopes)) in women who are scheduled for pelvic organ prolapse (POP) surgery.MethodsAll consecutive women awaiting surgery for POP in a tertiary urogynaecological centre were included. A short questionnaire with two open questions on goals and fears with regard to the operation was used.ResultsNinety-six out of 111 distributed questionnaires (86%) were analysed. Goals and fears were categorized into five groups. De novo symptoms (63%), POP recurrence (34%) and surgical complications (29%) were the most important fears. Symptom release (96%), improved lifestyle (physical capabilities; 30%) and improved sexual life (18%) were important goals.ConclusionsA wide variety of expectations both positive and negative can be found in women before POP surgery and should be an integral part of preoperative counselling. Achieving the individual goals as based on expectations, positive (goals) and negative (fears), should be part of the POP surgery evaluation.

Does the method of dissecting in anterior colporraphy lead to a difference in thickness of removed vaginal tissue

OBJECTIVE To evaluate the difference in thickness of the anterior vaginal wall removed after different surgical dissecting techniques of anterior colporrhaphy. STUDY DESIGN In patients undergoing primary anterior colporrhaphy, trimmed vaginal tissue was taken following different surgical techniques of vaginal wall dissection. Tissues were preserved in formalin and stained with hematoxylin-eosin and elastica-van Giesen stains. The examiner was an experienced pathologist blinded to the surgical technique. The specimens were examined for the epithelial thickness (ET), lamina propria thickness (LPT), muscular layer thickness (MT) and total thickness (TT). RESULTS Tissue was analysed in 93 women who underwent anterior compartment pelvic organ prolapse surgery. There was no difference between the different surgical techniques in thickness measured in the three histological layers and for the total thickness. The use of hydrodissection was the only independent factor leading to thicker removed vaginal tissue. CONCLUSIONS Dissecting the vaginal wall as thin as possible does not result in a thinner vaginal layer than dissecting in the most optimal surgical plane. The use of hydrodissection provides a thicker trimmed tissue.

The use of synthetic mesh in vaginal prolapse surgery: a survey of Dutch urogynaecologists.

OBJECTIVE To evaluate the use of mesh in vaginal prolapse surgery amongst members of the Dutch Urogynaecologic Society. STUDY DESIGN A questionnaire evaluating the use of mesh vs. native tissue repair in vaginal prolapse surgery was sent out by email to all members. Some specific questions on standard measures of infection prevention were included. RESULTS One hundred and thirty-three completed questionnaires were received. The response rate was 65%. Seventy-one percent of respondents stated that they apply use synthetic meshes in their patients. The mean percentage of mesh use in overall vaginal pelvic organ prolapse surgery was 14%. Most responders use mesh in recurrent surgery only. Prolift is the most commonly used brand. All women received prophylactic antibiotics. Although only half of the respondents changed gloves. CONCLUSIONS Meshes are commonly used in the Netherlands. The major indication is repair of a recurrent prolapse.