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Objective: To compare the effectiveness of a hysteroscopic niche resection versus no treatment in women with postmenstrual spotting and a uterine caesarean scar defect., Design: Multicentre randomised controlled trial., Setting: Eleven hospitals collaborating in a consortium for women's health research in the Netherlands., Population: Women reporting postmenstrual spotting after a caesarean section who had a niche with a residual myometrium of ≥3 mm, measured during sonohysterography., Methods: Women were randomly allocated to hysteroscopic niche resection or expectant management for 6 months., Main Outcome Measures: The primary outcome was the number of days of postmenstrual spotting 6 months after randomisation. Secondary outcomes were spotting at the end of menstruation, intermenstrual spotting, dysuria, sonographic niche measurements, surgical parameters, quality of life, women's satisfaction, sexual function, and additional therapy. Outcomes were measured at 3 months and, except for niche measurements, also at 6 months after randomisation., Results: We randomised 52 women to hysteroscopic niche resection and 51 women to expectant management. The median number of days of postmenstrual spotting at baseline was 8 days in both groups. At 6 months after randomisation, the median number of days of postmenstrual spotting was 4 days (interquartile range, IQR 2-7 days) in the intervention group and 7 days (IQR 3-10 days) in the control group (P = 0.04); on a scale of 0-10, discomfort as a result of spotting had a median score of 2 (IQR 0-7) in the intervention group, compared with 7 (IQR 0-8) in the control group (P = 0.02)., Conclusions: In women with a niche with a residual myometrium of ≥3 mm, hysteroscopic niche resection reduced postmenstrual spotting and spotting-related discomfort., Tweetable Abstract: A hysteroscopic niche resection is an effective treatment to reduce niche-related spotting., (© 2017 The Authors. BJOG An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Background: To reduce the risk of postoperative stress urinary incontinence (POSUI) prolapse repair might be combined with incontinence surgery., Objectives: Compare efficacy and safety of prolapse surgery with and without incontinence surgery., Search Strategy: Including our earlier review a systematic search in PubMed, EMBASE, the Cochrane Library and the Register of Current Controlled Trials was performed from 1995 to 2017., Selection Criteria: Randomised trials comparing prolapse surgery with a midurethral sling (MUS) or Burch colposuspension., Data Collection and Analysis: Two reviewers selected eligible articles and extracted data. Stress urinary outcomes were pooled for preoperative SUI. Urgency incontinence and adverse events were pooled for incontinence procedure., Main Results: Ten trials were included. Women with preoperative SUI symptoms or occult SUI had a lower risk to undergo subsequent incontinence surgery for POSUI after vaginal prolapse surgery with a MUS than after prolapse surgery only: 0 versus 40% [relative risk (RR) 0.0; 95% CI 0.0-0.2] and 1 versus 15% (RR 0.1; 95% CI 0.0-0.6), respectively. These differences were not significant in continent women not tested for occult SUI or without occult SUI. Serious adverse events were more frequent after vaginal prolapse repair with MUS (14 versus 8%; RR 1.7; 95% CI 1.1-2.7), but not after sacrocolpopexy with Burch colposuspension. Combination surgery did not increase the risk of overactive bladder symptoms, urgency incontinence and surgery for voiding dysfunction., Conclusions: Vaginal prolapse repair with MUS reduced the risk of postoperative SUI in women with preoperative SUI symptoms or occult SUI, but serious adverse events were more frequent., Tweetable Abstract: Less stress incontinence after vaginal prolapse repair with sling, but more adverse events., (© 2017 Royal College of Obstetricians and Gynaecologists.)