Petr Hubka

Comparison of vaginal mesh repair with sacrospinous vaginal colpopexy in the management of vaginal vault prolapse after hysterectomy in patients with levator ani avulsion: a randomized controlled trial

To compare the efficacy of two standard surgical procedures for post‐hysterectomy vaginal vault prolapse in patients with levator ani avulsion.

Women's quality of life and sexual function after transvaginal anterior repair with mesh insertion.

OBJECTIVE Current evidence about the impact of pelvic floor surgery on sexual function is conflicting. Only a few studies have reported with validated questionnaires on sexual function after transvaginal mesh repair, with a discrepancy in reported outcomes. The aim of this study was to prospectively explore the impact of anterior repair (AR) with mesh insertion on sexual function, quality of life and dyspareunia. STUDY DESIGN 69 women with symptomatic stage II or greater prolapse exclusively of the anterior compartment participated in a prospective study on safety and efficacy of two mesh implantation techniques for anterior vaginal wall prolapse repair between September 2007 and May 2009. They were invited to complete the validated condition-specific short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and quality of life (QoL) questionnaires (Pelvic Organ Prolapse (POP) Distress Inventory (POPDI), Urinary Distress Inventory (UDI), POP Impact Questionnaire (POPIQ), and Urinary Impact Questionnaire (UIQ)) pre-operatively and 6 months post-operatively. All data were processed and analyzed in Statistical Computing Environment R, version 2.9.1. RESULTS A significant decrease of Qol scores and a significant increase of PISQ-12 scores occurred after surgery. All sexually active women resumed sexual activity postoperatively. The majority of non-sexually active women remained sexually inactive. Postoperatively the frequency of pain during intercourse increased in 31% of cases and decreased or stayed unchanged in 69% of cases. The incidence of de novo dyspareunia after mesh repair was 4% while the incidence of dyspareunia slightly increased from 25% to 29% postoperatively. CONCLUSIONS The results of this study suggest no deterioration in sexual function, a significant improvement in quality of life and a low incidence of de novo dyspareunia six months after AR with mesh insertion. Despite these findings, the majority of non-sexually active women remain sexually inactive postoperatively. These conclusions should be confirmed in a longer follow-up.

A serious bleeding complication with injury of the corona mortis with the TVT-Secur procedure: two cases of contact of TVT-S with the corona mortis during cadaver study.

Dear Editor,Recently, Larsson et al. [1] reported a case bleeding fromcorona mortis during tension-free vaginal tape (TVT)-Securprocedure. As is stated in their article, the tape at the leftside was correctly placed at the second attempt. After thesurgery, early laparotomy was performed due to suspicionof haemorrhage—which was confirmed, and the bleedingcorona mortis was ligated.Our team performed several cadaver studies in order todescribe possible complications that might occur duringnew methods for treatment of stress urinary incontinence.One of the methods evaluated is TVT-S in the U position.We have witnessed and well documented two cases of verynear proximity (could be described as almost direct contact)of the TVT-S inserter and the vessels communicatingbetween obturator vessels and external iliac or deepepigastric vessels.The first contact we witnessed in the group forevaluation of TVT-S in the U position that consists of 19formalin-embalmed bodies. Due to the rigidity of theformalin-embalmed bodies, the legs needed to be placedin 30° flexion in the hip joint and in 30° abduction in thehip joint. For that reason, we have also included a group offresh frozen bodies, where the legs were positioned asrecommended in standard procedure. In this group of sixbodies, we have witnessed also one contact with the coronamortis after placing TVT-S in the U position.As can be seen on the attached pictures, the near contactwith the corona mortis is well shown and it would be amatter of fortune if those vessels will start bleeding aftertouching them with a scalpel-shaped inserter.We assume that the injury of the corona mortis describedby Larsson and colleagues [1] happened during the firstattempt to place the TVT-S and it seems to us that the firstattempt was made more upwards similar to the TVT-S inthe U position.For the first time, we thought that the direct contact withthe corona mortis does not have to lead towards injury ofthe aforementioned corona mortis and that the correlationwith the cadaver study to the live surgery might be difficult;still, the description of the injury witnessed by Larsson ismore than clear proof that cadaver study might showpossible complications occurring during a normal urogyne-cological surgery.

Sacrospinous ligaments anterior apical anchoring for needle-guided mesh is a safe option: a cadaveric study.

OBJECTIVE To evaluate the feasibility and safety of using the sacro-spinous ligament (SSL) as a fixation point for anterior-apical pelvic floor compartment mesh implants. The apical support achieved with the sacro-spinous ligament mesh fixation is considered adequate, as it provides a high and stronger anchoring point. Even though, meshes for anterior pelvic floor reconstruction are traditionally anchored to the arcus tendineous fascia pelvis (ATFP). The authors presumed that fixing the anterior mesh to the sacro-spinous ligament instead of the ATFP is both feasible and safe. The present study evaluated the anatomical aspects and relations of a modified tissue passage with sacro-spinous fixation of the anterior apical mesh arms. METHODS In 5 embalmed female cadavers and 1 fresh female cadaver, the apical arms of the anterior needle-guided mesh were placed through the SSLs rather than through the ATFP, using a transgluteal approach. The distances between the mesh arms and the ureters and uterine arteries were measured. RESULTS The minimal final distance between the mesh arms and the ureters or uterine arteries was 1.5 cm in the embalmed cadavers, but only 5 mm in the fresh cadaver. However, when analyzing the procedure carefully, it was noted that during dissection the ureters and arteries were pushed medially by the surgeons finger, thus the operative procedure did not entail any real risk of injury to these structures. The introduced surgical needle caused no trauma to any adjacent cadaveric organs. CONCLUSIONS Anterior pelvic floor meshes may be safely anchored to the SSL, thus potentially improving the apical support.