Matteo Frigerio

Is Occult Stress Urinary Incontinence a Reliable Predictive Marker

Objective Pelvic reconstructive surgery can be associated to correction, persistence, or onset of stress urinary incontinence. The aim of our study was to evaluate the incidence of stress incontinence (SI) after prolapse repair in 3 groups with different preoperative urodynamic findings and to find out the predictiveness of occult SI. Methods Patients undergoing vaginal hysterectomy, uterus-sacral ligament colposuspension, and traditional anterior repair for pelvic prolapse were retrospectively analyzed. No patient underwent any additional anti-incontinence procedure. Preoperative evaluation included clinical history, physical examination, and urodynamic assessment with a pessary reduction test. According to urodynamic findings, women were divided into SI (A), occult SI (B), and continence (C) groups. Primary outcome was to compare the incidence of postoperative SI among groups. Secondary outcome was to assess postoperative quality of life with International Consultation on Incontinence questionnaire-short form questionnaire. Results One hundred fifty patients were analyzed (A: n = 30; B: n = 43; C: n = 77). Mean follow-up was 18.4 ± 0.9 months without differences among groups. Patients in group B did not have higher postoperative SI rate compared to group C. There were no differences in International Consultation on Incontinence questionnaire-short form scores in symptomatic women among groups. Conclusions In our series, occult stress urinary incontinence is a poor urodynamic marker to predict the development of postoperative SI.

Transvaginal uterosacral ligament suspension for posthysterectomy vaginal vault prolapse repair

Introduction and hypothesisPosthysterectomy vaginal vault prolapse repair represents a challenge for urogynecologists. Surgical management can be successfully achieved with native tissue using a vaginal approach with uterosacral ligament (USL) suspension. However, severe complications have been described, mainly related to ureteral injury.MethodsA 57-year-old woman with symptomatic stage 2 vaginal vault prolapse underwent transvaginal USL suspension according to the described technique.ResultsSurgical procedure was successfully achieved without complications. Final examination revealed excellent apical support and preservation of vaginal length. However, ureteral damage represents the major pitfall of USL suspension. This step-by-step video tutorial may represent an important tool to improve surgical know how and minimize the risk of ureteral injury.ConclusionTransvaginal USL suspension provides an effective technique for apical support without the use of prosthetic materials. Intimate understanding of pelvic anatomy, direct visualization of ureter, and proper suture positioning are the key points to minimize the risk of complications.

Outcomes of Transvaginal High Uterosacral Ligaments Suspension: Over 500-Patient Single-Center Study

Background Uterosacral ligament (USL) suspension is a safe and effective procedure in terms of anatomical, functional, and subjective outcomes for primary surgical treatment of prolapse. Objectives There has been a renewed interest toward native tissue prolapse repair by vaginal route because of low cost and lack of mesh-related complications. Uterosacral ligaments are considered safe, effective, and durable as suspending structures for primary surgical repair of the apical compartment. Our aim was to evaluate complications, anatomical, functional and subjective outcomes of high USL suspension for primary prolapse repair. Methods Data of patients who underwent vaginal hysterectomy followed by high USL suspension for pelvic organ prolapse were retrospectively analyzed. Operative data, as well as complications, were recorded. Anatomical recurrence was defined as descent of any compartment stage II or greater according to the Pelvic Organ Prolapse Quantification system. Functional outcomes focused on urinary, bowel, and sexual dysfunctions. International Consultation on Incontinence Questionnaire–Urinary Incontinence Short Form, Wexner, and Patient Global Impression of Improvement questionnaires were collected. Results Data of 533 women were analyzed. Mean follow-up was 32 (SD, 19) months (dropout rate, 2.6%). Most frequent complication was ureteral kinking (2.6%). Total recurrence rate was 13.7%, with anterior compartment being the most frequent (9.4%), whereas reoperation for symptomatic prolapse recurrence was required in only 1% of patients. Improvement of urinary incontinence, voiding dysfunction, constipation, and dyspareunia was observed. Overall subjective satisfaction was high (Patient Global Impression of Improvement score, 1.3), ranging from “much improved” to “very much improved.” Conclusions Uterosacral ligament suspension is a safe and effective procedure in primary surgical treatment of pelvic organ prolapse. Anatomical, functional, and subjective outcomes were very satisfactory, and reoperation rate for recurrence was only 1%.

Transvaginal sacrospinous ligament fixation for posthysterectomy vaginal vault prolapse repair

Introduction and hypothesisPosthysterectomy vaginal vault prolapse repair is a challenge for urogynecologists. Surgical management can be successful with native tissue by the vaginal approach with sacrospinous ligament fixation. However, severe complications have been described, including nerve injury and life-threatening hemorrhage.MethodsA 68-year-old woman with symptomatic stage III vaginal vault prolapse was admitted for transvaginal sacrospinous ligament fixation according to the described technique.ResultsThe surgical procedure was successful without complications. The final examination revealed excellent apical support and preservation of vaginal length. This step-by-step video tutorial may be an important tool for improving surgical knowledge, thus leading to a reduction in the risk of complications. In particular proper suture positioning requires adequate preparation of the pararectal space and exposure of the sacrospinous ligament, as shown in the video.ConclusionsTransvaginal sacrospinous ligament fixation is a safe and effective technique for apical support without the use of prosthetic materials. Adequate preparation of the pararectal space, direct visualization of the sacrospinous ligament and proper suture positioning are the key points in minimizing the risk of complications.

Histologic and metabolic assessment in a cohort of patients with genital prolapse: preoperative stage and recurrence investigations

BACKGROUND Biological basis of prolapse development and recurrence are still unclear. Aim of this observational and prospective study is to correlate clinical stage of anterior vaginal wall prolapse and anatomical recurrence to histological and metabolic characteristics of vaginal tissue. METHODS Patients undergoing surgery were divided into two groups according to anterior stage ≤II (group A) and ≥III (group B). Full-thickness excisional biopsies of the anterior vaginal wall were obtained after hysterectomy. Hystological characteristics and metalloproteinases activity (MMP-2) were analyzed. RESULTS Sixty-nine patients (35 group A; 34 group B) completed evaluation. Mean follow-up was 35 months. Collagen amount and organization were significantly higher in group B both in lamina propria and fascia specimens, but MMP-2 activity was significantly lower in this group. Recurrence rate of anterior compartment was 10.1%. Collagen cellularity of fascia was higher in recurrence groups. On the contrary MMP-2 activity showed a close to significant correlation to surgical success (P=0.07). CONCLUSIONS Patients with advanced stages of prolapse have increased collagen amount associated to decreased MMP-2 activity. This suggests that connective tissue is more abundant but less metabolically active in patients with severe prolapse. A similar trend can be found in recurrences.

Transvaginal iliococcygeus fixation for posthysterectomy vaginal vault prolapse repair

Introduction and hypothesisPosthysterectomy vaginal vault prolapse repair is a surgical challenge. Successful surgical management using native tissue can be achieved via the vaginal approach by iliococcygeus fascia fixation. However, although iliococcygeus fascia fixation is technically simple and has a low morbidity, it is not commonly performed. The aim of the video is to provide anatomic views and the surgical steps necessary to achieve successful transvaginal iliococcygeus fascia fixation for vaginal vault prolapse repair.MethodsA 60-year-old woman with symptomatic stage III vaginal vault prolapse was admitted for transvaginal iliococcygeus fascia fixation according to the described technique.ResultsSurgery was successful without complications. The final examination showed good apical support and preservation of vaginal length. This step-by-step video tutorial may be an important tool to improve practical surgical knowledge. In particular, proper suture positioning requires adequate pararectal space preparation and levator ani exposure, as shown in the video.ConclusionsTransvaginal iliococcygeus fascia fixation is an alternative technique for apical support without the use of synthetic prosthetic materials. This technique may be indicated when an abdominal approach or a synthetic device is not recommended.

Risk factors for stress urinary incontinence recurrence after single-incision sling

The aim of the study was to identify in a pure stress urinary incontinence (SUI) population risk factors for recurrence after single‐incision slings (SIS).

Transvaginal levator myorrhaphy for posthysterectomy vaginal vault prolapse repair

Introduction and hypothesisPosthysterectomy vaginal vault prolapse repair represents a surgical challenge. Surgical management can be successfully achieved with native-tissue repair through levator myorrhaphy. Despite low morbidity, levator myorrhaphy is not a common procedure. The aim of the video is to provide anatomic views and surgical steps necessary to achieve a successful transvaginal levator myorrhaphy for vaginal vault prolapse repair.MethodsA 72-year-old woman with symptomatic stage IV vaginal vault prolapse was admitted for transvaginal levator myorrhaphy according to the described technique.ResultsSurgical repair was successfully achieved without complications. The final examination revealed good apical support and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know how.ConclusionsTransvaginal levator myorrhaphy provides an alternative technique for apical support without using prosthetic materials. This technique can be indicated when abdominal approach or synthetic device are not recommended or when peritoneum opening may be challenging. However, due to its possible constricting effect, it should be reserved to sexually inactive patients.

Transvaginal native-tissue repair of enterocele

Introduction and hypothesisEnterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).MethodsA 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.ResultsSurgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.ConclusionsTransvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.

Management of unrecognized bladder perforation following suburethral tape procedure

Several complications associated with tension-free vaginal tape procedure have been described, including bladder perforation[1]. This complication is considered a minor injury if noted and corrected at the time of the procedure. However, trocar perforation may be unrecognized because of inadequate or lack of cystoscopy. In this case, such perforation can lead to disabling consequences, including hematuria, irritative bladder symptoms, recurrent urinary tract infections, bladder stones, and pelvic pain[1]. This article is protected by copyright. All rights reserved.