METHODS: A retrospective study conducted between February 2015 and July 2016 at Chang Gung Memorial Hospital. The subjects had had symptomatic anterior or apical prolapse with stage III or IV and undergone pelvic reconstructive surgery using Uphold™ LITE. Patients completed a 3-day voiding diary, urodynamic study, real-time ultrasonography and validated quality-of-life questionnaires at baseline and 12-month follow-up. Primary outcome was the absence of USI. Secondary outcomes included the objective cure rate of POP, ≤ stage 1 at the anterior/apical vaginal wall, and the subjective cure rate, negative feedback to POPDI-6.
RESULTS: Ninety-five women were eligible. Six were excluded because of incomplete data. The postoperative de novo USI and SUI were 22.7 and 19.7%, respectively. There was significant improvement of USI in patients who had MUS insertion (93.8%) and bladder outlet obstruction (96.7%). The objective and subjective cure rate for prolapse was 95.5 and 94.3%, respectively. POP-Q measurements pre- and postoperatively were significantly improved at all points except for Gh and Pb. There was a significant difference in the distance between the bladder neck to the distal end of the mesh during straining both at both the postoperative 3rd month and 1 year.
CONCLUSIONS: Uphold™ mesh has a 20% incidence of de novo USI with acceptable objective and subjective cure rates at 1 year postoperatively. The de novo USI rate was high but not bothersome enough to require surgery.
METHODS: An observational cross-sectional study of 964 archived datasets of women seen for symptoms and signs of lower urinary tract and pelvic organ dysfunction between September 2011 and February 2014 at a tertiary urogynaecology centre in Australia was carried out. An in-house standardised interview, the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) and 4-D translabial ultrasound, followed by analysis of ultrasound volumes for pelvic organ descent and hiatal area on Valsalva, were performed, blinded against other data.
RESULTS: There is a positive association between BMI and posterior compartment prolapse on clinical examination and ultrasound imaging, but not for the anterior and central compartments. There was no association with prolapse symptom bother and a negative association with symptoms of prolapse.
CONCLUSIONS: In this observational study, we found a strong association between all tested measures of posterior compartment descent and BMI, both clinical and on imaging.
MATERIALS AND METHODS: The charts of 796 women who underwent pelvic organ prolapse (POP) surgery from July 2006 to January 2012 in Chang Gung Memorial Hospitals were reviewed. We included women who presented with advanced cuff eversion and treated with TVM surgery. Data were analysed after three years post-surgery. Descriptive statistics were used for demographic and perioperative data. The paired-samples t test was used for comparison of preoperative and postoperative continuous data. The outcomes measured were objective cure (POP-Q stage ≤ 1) and subjective cure (negative response to question 2 and 3 on POPDI-6).
RESULTS: A total of 97 patients was analysed. 61 patients had TVM-A and 36 patients had TVM-AP insertion. Mean follow-up was 52 months. The objective cure rate for TVM-AP was significantly higher than TVM-A, 94.4% versus 80.3%. TVM-AP also showed a higher subjective cure rate (91.7%) though there was no significant difference from TVM-A (p = 0.260). The mesh extrusion rate was low at 3.1% with no major complications seen. In TVM-A the blood loss was lesser and the operation time was shorter.
CONCLUSION: TVM-AP showed better objective cure rate than TVM-A at 52 months. However, TVM-A is less invasive in comparison with an acceptably good cure rates.
MATERIALS AND METHODS: A prospective cohort study, 139 women, underwent transvaginal surgery for anterior and/or apical POP > stage 2, 69 patients had SIM A and 70 patients had SSF. The objective cure was defined as POP ≤ stage 1 anterior, apical according to POP-Q. Subjective cure is patient's negative feedback to question 2 and 3 of pelvic organ prolapse distress inventory 6 (POPDI-6). Patient's satisfaction was reported using validated quality of life questionnaires. Multi-channel urodynamic study was used to report any voiding problems related to the prolapse surgery 6 months after surgery.
RESULTS: 119 patients completed a minimum of 3 years follow-up. 89.8% is the overall prolapse correction success rate for SIM A and 73.3% for SSF group (p = 0.020), and 96.6% versus 73.4% at the anterior vaginal compartment respectively (p ≤ 0.001). Statistically significant difference was noticed in apical compartment with 98.3% with SIM A and 85.0% with SSF (p = 0.009). The subjective success rate, 86.4% in the SIM A and 70.0% in the SSF arm (p = 0.030) was significantly noted. Only, Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6) showed significant improvement. Operation time and intra-operative blood loss tend to be more with SIM A.
CONCLUSION: SIM A has better 3 years objective and subjective cure rate than SSF in the anterior and/or apical compartment prolapse.
METHODS: This retrospective observational study involved 1296 women seen in a urogynaecological centre. All had undergone an interview, clinical examination and 4D ultrasound (US) imaging supine and after voiding. Offline analysis of volume data was undertaken blinded against other data. Rectal ampulla position and rectocele depth were measured on Valsalva. A pocket depth of 10 mm was used as a cutoff to define rectocele on imaging.
RESULTS: Most women presented with prolapse (53%, n = 686); 810 (63%) complained of obstructed defecation (OD). Clinically, 53% (n = 690) had posterior-compartment prolapse with a mean Bp of -1 [standard deviation (SD)1.5; -3 to 9 cm]. Mean descent of the rectal ampulla was 10 mm below the symphysis (SD 15.8; -50 to 41). A rectocele on imaging was found in 48% (n = 618). On univariate analysis, OD symptoms were strongly associated with rectal descent, rectocele depth and rectocele on imaging (all P
CASE PRESENTATION: We present a case of a 61-year-old lady with mitral valve prolapse (MVP) who underwent TOE with subsequent presentation of odynophagia with left neck swelling. An upper endoscopy examination was inconclusive; however, a contrasted computed tomography of the neck showed evidence of cervical oesophageal perforation. She was managed conservatively and discharged well.
DISCUSSION: The trauma caused by TOE probe insertion and manipulation accounts for most of the upper gastrointestinal complications. Mortality of patients associated with oesophageal perforation can be up to 20% and doubled if the treatment is delayed for more than 24 h. Mechanism of injury from TOE probe is likely multifactorial. Predisposing factors that increase the risk of tissue disruption include the presence of unknown structural pathology. Imaging studies and an upper endoscopy examination may aid in the diagnosis of oesophageal perforation.
CONCLUSION: A high index of suspicion, coupled with a tailored, multidisciplinary approach, is essential to achieve the best possible outcome. Conservative management may be worthwhile in a stable patient despite delayed presentation. Although TOE is considered a safe procedure, physicians should be made aware of such a dreaded complication.
METHODS: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR).
RESULTS: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse.
CONCLUSION: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.
METHODS: This was a retrospective observational study at a tertiary urogynecological unit. A total of 337 patients were seen for a standardized interview, clinical examination (ICS POP-Q) and 4D translabial ultrasonography. Stored imaging data were analyzed offline to evaluate functional pelvic floor anatomy and investigate associations with symptoms and other findings.
RESULTS: Of the 337 women seen during the study period, 13 were excluded due to missing data, leaving 324. Vaginal laxity was reported by 24% with a mean bother of 5.7. In a univariate analysis, this symptom was associated with younger age, vaginal parity, POP symptoms and bother, clinically and sonographically determined POP and hiatal area on Valsalva maneuver.
CONCLUSIONS: Vaginal laxity or 'looseness' is common in our urogynecology service at a prevalence of 24%. The associated bother is almost as high as the bother associated with conventional prolapse symptoms. It is associated with younger age, vaginal parity, symptoms of prolapse, prolapse bother and objective prolapse on POP-Q examination and imaging, suggesting that vaginal laxity may be considered a symptom of prolapse. The strongest associations were found with gh + pb and hiatal area on Valsalva maneuver, suggesting that vaginal laxity is a manifestation of levator ani hyperdistensibility.
METHODS: This was a retrospective study involving archived data sets of women seen between November 2013 and May 2014. All underwent a clinical interview, POPQ examination, and 4D translabial ultrasound (TLUS). The main outcome measure was organ descent on clinical examination and TLUS. Offline analysis for organ descent was undertaken blinded against all other data.
RESULTS: A total of 224 women were assessed. Mean age was 57 (23-84) years. Median parity was 3 (0-7). Ninety-three percent (n=208) were vaginally parous. Fifty-eight percent (n=129) complained of symptoms of prolapse: 49% (n=110) of a vaginal lump, 27% (n=61) of a dragging sensation. Clinically, mean point B anterior (Ba) was -0.86 (-3 to +7.5) cm, mean cervical station (C) was -4.1 (-9 to +8) cm, mean point B posterior (Bp) was -1.1 (-3 to +5) cm. On imaging, mean bladder, uterine, and rectal descent were -8.3 (-68.0 to 34) mm, +18.6 (-56.4 to 46.3) mm, and -5.3 (-39.8 to 36) mm respectively. On univariate analysis, both symptoms were strongly associated with objective prolapse clinically and on TLUS, with "vaginal lump" consistently the stronger predictor.
CONCLUSIONS: The symptom of a "vaginal lump or bulge" was consistently a stronger predictor of objective POP than "dragging sensation." This finding was insensitive to adjustments for potential confounders. However, a "dragging sensation" is clearly a symptom of prolapse.
METHODS: A total of 271 patients were analysed in a retrospective study utilising archived ultrasound volume datasets. Symptoms of obstructed defecation (straining at stool, incomplete bowel emptying, perineal, vaginal and anal digitation) were ascertained on interview. Postprocessing of stored 3D/4D translabial ultrasound datasets obtained on maximal Valsalva was used to diagnose descent of the rectal ampulla, rectocoele, enterocoele and rectal intussusception at a later date, blinded to all clinical data.
RESULTS: Digitation was reported by 39 % of our population. The position of the rectal ampulla on Valsalva was associated with perineal (p = 0.02) and vaginal (p = 0.02) digitation. The presence of a true rectocoele was significantly associated with perineal (p = 0.04) and anal (p = 0.03) digitation. Rectocoele depth was associated with all three forms of digitation (P = 0.005-0.02). The bother of symptoms of obstructed defecation was strongly associated with digitation (all P
AIMS: This study aimed to assess the pelvic floor ultrasound characteristics of Ugandan women suffering with obstetric fistula, unrepaired fourth degree obstetric tears and pelvic organ prolapse, and determine whether obstructed labour resulting in obstetric fistula causes more levator muscle defects compared to parous women without a history of obstructed labour.
MATERIALS AND METHODS: This was a prospective study in western Uganda assessing 82 women with obstetric fistula, unrepaired fourth degree obstetric tears and pelvic organ prolapse with a pelvic floor ultrasound scan.
RESULTS: Demographic characteristics were significantly different, with women suffering pelvic organ prolapse being older and more parous. Hiatal area on Valsalva was significantly smaller in the obstetric fistula group (mean 21.45 cm2 ) compared to non-obstetric fistula group (unrepaired fourth degree obstetric tears and pelvic organ prolapse; mean 30.44 cm2 ); a mean difference of 9.0 cm2 (95% CI: 5.4-12.6 cm2 , P
MATERIAL AND METHODS: In this retrospective observational study the records of patients attending a tertiary urogynecological unit between January 2012 and December 2014 were analyzed. POP assessment included a standardized interview, clinical examination using Pelvic Organ Prolapse Quantification and four-dimensional translabial ultrasound. Puborectalis muscle trauma was assessed with tomographic ultrasound imaging using two continuous scoring systems and a previously established discrete system. Receiver operating characteristics and adjusted odds ratios were used for comparison of scoring systems in predicting symptoms and signs of POP.
RESULTS: Of 1258 women analyzed, 52.6% complained of prolapse symptoms. On ultrasound imaging, 65.7% of women had sonographically significant POP. Complete avulsion was diagnosed in 25.3% of women, being unilateral in 13.9% and bilateral in 11.4%. A maximum score in the 6-point and the 12-point tomographic ultrasound imaging scale increased the odds for a diagnosis of any significant POP on ultrasound by 4.4 and 4.8 times, respectively, compared with 4.6 times for the discrete diagnosis of bilateral avulsion. For all avulsion scoring systems the relation was strongest for cystocele and uterine prolapse.
CONCLUSIONS: A continuous avulsion scoring system based on tomographic findings does not provide superior performance for the prediction of subjective symptoms and objective findings of prolapse compared with a discrete diagnostic system of unilateral or bilateral avulsion.
AIMS: Our objective was to investigate long-term association between delivery mode, LAM avulsion and obstetric anal sphincter injuries (OASIS) in women at least 20 years after their first birth.
METHODS: All women recruited at 'index birth' of the Dunedin (New Zealand) arm of ProLong (PROlapse and incontinence LONG-term research) Study, were invited to have translabial and transperineal ultrasound assessment of LAM and anal sphincters. Post-processing analysis of imaging data was performed blinded against delivery data. Statistical analysis was performed using the χ2 test and results are expressed as odds ratios (OR).
RESULTS: Of the initial 1250 participants, 196 women returned for examination. Mean age was 50.8 years with a mean body mass index of 27.6 and median parity was three. They were seen on average 23 years after their first delivery. Four data sets were unavailable and one declined ultrasound assessment, leaving 191 for analysis. LAM avulsion was diagnosed in 29 (15.2%), and 24 women (12.6%) had significant anal sphincter defect. LAM avulsion was associated with forceps delivery (OR 2.45, 95% CI 1.04-5.80, P = 0.041). Forceps conveyed a greater risk of OASIS (21%) compared to a spontaneous vaginal delivery (11%) but did not reach statistical significance.
CONCLUSIONS: Forceps delivery is associated with long-term injurious effect on pelvic floor structures. Discussions of the long-term negative impact of pelvic floor structures and their functions are necessary to achieve an informed consent toward an operative vaginal delivery.
METHODS: Incidence of thigh pain was lower in 2008 compared to 2006 and 2007 (p < 0.0001). The percentage of patients requiring blood transfusions (p = 0.09), duration of IDC ≥ 7 days (p = 0.27), wound dehiscence and re-operation rate were lower in 2008 in contrast to 2006 and 2007 (p = 0.43). Only 209 patients (82.3%) were available for review at 1 year. There were two (1.0%) cases of recurrent vault prolapse.
RESULTS: The subjective and objective cure rates at 1 year after this mesh implant surgery in 2006, 2007 and 2008 were 92.1% and 92.1%; 97.0% and 92.4% and 100% and 97%, respectively. The mesh erosion rate was remarkably lower in 2008 as compared to 2007 and 2006 (p < 0.001).
CONCLUSIONS: This synthetic mesh-augmented implant surgery is effective and safe, and surgical outcome appears related to the learning curve of the surgeon.
DESIGN: Retrospective observational study.
POPULATION: A total of 1258 consecutive women attending a tertiary urogynaecological unit for the investigation of lower urinary tract or pelvic floor disorders between January 2012 and December 2014.
METHODS: Obstetric history and clinical examination data were obtained from the unit database. Prolapse quantification on imaging was performed using stored four-dimensional translabial ultrasound volume data sets. Women were grouped into four groups according to the most traumatic delivery reported. The presence of symptoms and signs of POP were compared between delivery groups while controlling for potential confounders.
MAIN OUTCOME MEASURES: Prolapse symptoms, visual analogue score for prolapse bother, International Continence Society Prolapse Quantification System findings and ultrasound findings of anterior, central and posterior compartment descent.
RESULTS: Nulliparae showed the lowest prevalence of most measures of POP, followed by women exclusively delivered by caesarean section. Highest prevalences were consistently found in women delivered at least once by forceps, although the differences between this group and women delivered by normal vaginal delivery and/or vacuum extraction were significant in three out of eight measures only. Compared with women in the caesarean section group, the adjusted odds ratios for reporting symptoms of prolapse were 2.4 (95% CI 1.30-4.59) and 3.2 (95% CI 1.65-6.12) in the normal vaginal delivery/vacuum extraction group and forceps group, respectively.
CONCLUSIONS: There is a clear link between vaginal delivery and symptoms and signs of pelvic organ prolapse in urogynaecological patients.
TWEETABLE ABSTRACT: Compared with caesarean section a history of vaginal delivery more than doubles the risk for POP.