Search

Introduction and Hypothesis: Patient-reported outcomes are relevant outcomes in studies on pelvic organ prolapse (POP) surgery, as anatomical recurrence alone does not have a significant correlation with perceived improvement. In the present study, the patient's impression of improvement after 1 year is studied after vaginal hysterectomy (VH) versus sacrospinous hysteropexy (SSH) in large cohorts from daily clinical practice. We hypothesize that there is no difference between the groups., Methods: This is a secondary analysis on prospectively collected data in a multicenter cohort of patients who underwent VH or SSH for symptomatic POP. All patients had a POP-Q stage ≥ 2 in at least one compartment at baseline and were treated with VH or SSH between 2002 and 2019. The primary outcome was the patient-reported score on the patient global impression of improvement index (PGI-I) 1 year after surgery. The secondary outcome was a composite outcome of surgical success, defined as the absence of recurrent POP beyond the hymen with bothersome bulge symptoms and/or repeat surgery., Results: A total of 378 women (196 VH and 182 SSH) were included. The median score on the PGI-I did not differ between VH and SSH. At 1 year post-operatively, 77 women after VH (73%) and 77 women after SSH (75%) considered their condition (very) much improved (p = 0.86). There was no difference in composite outcome of surgical success (126 out of 137 women [92%] after VH, 118 out of 125 women [94%] after SSH; p = 0.44)., Conclusions: Our study shows that there was no difference in the type of surgery, VH or SSH, with regard to the patient's impression of improvement 1 year postoperatively in a large cohort from daily clinical practice., (© 2024. The Author(s).)

Introduction and Hypothesis: The objective was to compare the location and motion of pessaries between women with pelvic organ prolapse (POP) with a successful (fitting) and unsuccessful (non-fitting) pessary treatment on dynamic magnetic resonance imaging (dMRI)., Methods: A cross-sectional exploratory study of 15 women who underwent a mid-sagittal dMRI of the pelvic floor at rest, during contraction and during Valsalva with three different types of pessaries. The coordinates of the pessaries cross section, inferior pubic point (IPP) and sacrococcygeal junction (SCJ) were obtained and the location (position, orientation) and the motion (translation and rotation) were calculated. Differences between the groups and between the pessaries within the groups were compared., Results: Nine women with a fitting pessary and 6 women with a non-fitting pessary were selected. In the non-fitting group, the pessaries were positioned more caudally and rotated more in clockwise direction and descended more, but not significantly, during Valsalva compared with the fitting group. The Falk pessary was positioned more anteriorly in the fitting group and more cranially in the non-fitting group compared with the ring and ring with support pessary., Conclusions: A non-fitting pessary was positioned more caudally at rest; on Valsalva, it rotated more clockwise and moved more caudally, suggesting that the dynamic characteristics of the pessary might play an important role in its effectiveness. Findings of this study serve as a basis for the development of new pessary designs., (© 2023. The Author(s).)

Introduction and Hypothesis: The present study describes an extended follow-up study after 12 years and focusses on subjective outcomes of women who underwent surgery for recurrent pelvic organ prolapse in the randomized index study., Methods: One hundred and ninety-four (194) women had been randomized in the original study and in the present study, 45 (47%) in the vaginal mesh repair versus 43 (43%) women with conventional vaginal native tissue repair completed the long-term questionnaires. The mesh used was a first-generation non-absorbable mesh kit. All types of conventional vaginal native tissue repairs were allowed, and additional vaginal native tissue repairs were allowed in the mesh group. The questionnaires as applied at baseline were used. The Patient Global Impression of Improvement questionnaire (PGI-I) was the primary outcome., Results: At 12 years, 30 (71%) women in the mesh group versus 23 (59%) women in the native tissue repair group reported to be PGI-I (very) much improved (p=0.24). There were no differences found in any of the questionnaire domains. There was, however, a higher number of women who had had additional operations for recurrent pelvic organ prolapse, stress urinary incontinence, and/or exposure in the mesh group: 18 women (40%) in the mesh group versus 8 women (19%) in the native tissue repair group (p=0.03)., Conclusions: There was no difference in subjective outcome between the groups, but there was a statistically significant higher number of women who had needed further operations. This study confirms that vaginal mesh should not be used in all women with recurrent pelvic organ prolapse., (© 2023. The Author(s).)

Introduction and Hypothesis: A treatment choice for female stress urinary incontinence (SUI) is preference sensitive for both patients and physicians. Multiple treatment options are available, with none being superior to any other. The decision-making process can be supported by a patient decision aid (PDA). We aimed to assess physicians' perceptions concerning the use of a PDA., Methods: In a mixed methods study, urologists, gynecologists and general practitioners in the Netherlands were asked to fill out a web-based questionnaire. Questions were based on the Tailored Implementation for Chronic Diseases checklist using the following domains: guideline factors, individual health professional factors, professional interactions, incentives and resources, and capacity for organizational change. Participants were asked to grade statements using a five-point Likert scale and to answer open questions on facilitators of and barriers to implementation of a PDA. Outcomes of statement rating were quantitatively analyzed and thematic analysis was performed on the outcomes regarding facilitators and barriers., Results: The response rate was 11%, with a total of 120 participants completing the questionnaire. Ninety-two of the physicians (77%) would use a PDA in female SUI. Evidence-based and unbiased content, the ability to support shared decision making, and patient empowerment are identified as main facilitators. Barriers are the expected prolonged time investment and the possible difficulty using the PDA in less health-literate patient populations., Conclusions: The majority of physicians would use a PDA for female SUI. We identified facilitators and barriers that can be used when developing and implementing such a PDA., (© 2022. The Author(s).)

Introduction and Hypothesis: Chronic pelvic pain (CPP) is a common multifactorial condition affecting 6 to 27% of women aged 18-50 years worldwide. This study was conducted to review and meta-analyse the current literature on the reduction of chronic pelvic pain after botulinum toxin A (BTA) injection., Method: In July 2021 we performed a systematic search in PubMed and EMBASE to assess the benefits of BTA injection in pelvic floor muscles in women with chronic pelvic pain. Primary outcome was reduction in visual analogue scale (VAS) after treatment. Secondary outcomes evaluated were: reduction of dyspareunia, pelvic floor resting pressure and quality of life. Identified reports were assessed on quality of reporting and risk of bias. Standardized mean difference (SMD) was used to combine and analyse outcomes of the included studies., Results: Eight studies with 289 participants were considered eligible to be included in this systematic review and meta-analysis. After recalculating SMD into VAS scores (0-100), long-term follow-up (24-26 weeks) showed a significant 15-point improvement in VAS scores (95% CI: 8.8-21.5) for non-menstrual pelvic pain and a 13-point improvement (95% CI: 2.1-24.0) for dyspareunia. BTA injection had a significant effect on pelvic floor resting pressure and quality of life., Conclusion: There is limited scientific evidence on the effectiveness of BTA injections in pelvic floor muscles in women with chronic pelvic pain. The available studies show that BTA injections significantly reduce pain levels and improve quality of life at 6 months follow-up., Prospero Id: CRD42018105204., (© 2022. The Author(s).)

Introduction and Hypothesis: The modified Manchester (MM) and sacrospinous hysteropexy (SSH) are the most common uterus-preserving surgical procedures for uterine descent. Little is known about gynecologists' preferences regarding the two interventions. The study's aim was to identify which factors influence Dutch (uro)gynecologists when choosing one of these techniques., Methods: This qualitative study consists of ten semi-structured interviews with Dutch (uro)gynecologists using predetermined, open explorative questions, based on a structured topic list. An inductive content analysis was performed using Atlas.ti., Results: For SSH, the majority (6/10 gynecologists) reported the more dorsal change of direction of the vaginal axis as a disadvantage and expected more cystocele recurrences (7/10). The most reported disadvantage of MM was the risk of cervical stenosis (7/10). Four gynecologists found MM not to be appropriate for patients with higher stage uterine prolapse. The quality of the uterosacral ligaments was related to the chance of recurrence according to five gynecologists. Patient counseling was biased toward one of the uterus-preserving operations (7/10). Four gynecologists stated they make the final decision while two let patient-preference lead the final decision., Conclusions: Preference for one of the uterus-preserving interventions is mainly based on the gynecologist's own experience and background. The lack of information regarding these two uterus-preserving procedures hampers evidence-based decision making, which explains the practice pattern variation. In conclusion, further research is needed to improve evidence-based counseling and shared decision making regarding the choice of procedure.

Introduction and Hypothesis: The laparoscopic sacrocolpopexy (LSC) is performed to support DeLancey's level I in patients with pelvic organ prolapse (POP). Although several studies have been conducted on the safety, objective and subjective outcomes of LSC, the specific effect of retroperitonealisation of mesh is unknown. This study is aimed at analysing the safety, objective and subjective outcomes of the LSC without peritoneal closure of mesh., Methods: The patients included have undergone an LSC for POP between 2004 and 2014. Retrospectively, a cohort of n = 178 was identified and asked to participate in a follow-up study. Chart research was performed. When informed consent was obtained, questionnaires were sent and the patients underwent a physical examination, including a POP-Q assessment. Each complication was scored by four reviewers for possibly being related to the non-peritonealisation of mesh., Results: The data on the outcome cohorts were complete for safety n = 178, objective n = 124, and subjective n = 61. The Patient Global Impression of Improvement (PGI-I) score is provided in 106 questionnaires. In this study, 77 complications were observed in 49 different patients. The total success rate (no reoperation, no descent beyond the hymen and no bulging symptoms) is 59.0% with a median follow-up (IQR) of 35 months (18-51). Seventy-six patients (71.7%) described their condition as being (much) improved after LSC., Conclusions: Three serious complications observed during the 178 LSCs were, by full consensus, thought to be possibly related to the non-peritonealisation of mesh. More than 70% of the patients found their condition to be (much) improved after the procedure.

Introduction and Hypothesis: The objective was to compare medium-term efficacy and safety of a partially absorbable mesh kit and native tissue repair in pelvic organ prolapse (POP)., Materials and Methods: Women with primary POP stage ≥ II were randomized to transvaginal trocar-guided partially absorbable mesh (81 women) or native tissue repair (82 women). Primary outcome was overall anatomical success (POP < stage II) at 24 months. Secondary outcomes were composite success, global improvement, and adverse events., Results: Sixty-nine (85%) of the women allocated to partially absorbable mesh underwent mesh surgery; 8 (10%) crossed over to native tissue repair and 4 women (5%) withdrew from the study. Eighty (98%) of the women allocated to native tissue repair underwent the assigned treatment and 2 (2%) withdrew. Twenty-four months later, 140 surgically treated women (89%) demonstrated an overall anatomical success of 39%; 45% (32 out of 71 women) for mesh, and 32% (22 out of 69) for native tissue repair (RR 1.4, 95% CI 0.92 to 2.2). Composite success was 88 and 73% respectively (RR: 1.1, 95% CI 0.93 to 1.4). There was global improvement in 86% (48 out of 56 women) in the mesh group and in 77% (47 out of 60 women) in the native tissue group (RR: 1.1, 95% CI 0.92 to 1.3). Four women were diagnosed with mesh exposure at 2 years (6%)., Conclusion: At 24 months, no significant anatomical or composite benefit of partially absorbable mesh over native tissue repair could be demonstrated in women who had been surgically treated for primary POP.

Introduction and Hypothesis: Condition-specific sexual questionnaires are important patient-reported outcome measures. The aim of this study was to translate and validate the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-International Urogynecology Association Revised (PISQ-IR) into Dutch., Methods: The translated PISQ-IR was linguistically validated, followed by psychometrical validation among women presenting with symptoms of pelvic floor dysfunction in urogynecology clinics. For analysis of the criterion validity, the Pelvic Floor Dysfunction Inventory-20 (PFDI-20) and Female Sexual Function Index (FSFI) were used. Descriptive statistics, floor and ceiling effects, internal consistency using Cronbach's alpha coefficient and Pearson's and Spearman's correlations were calculated for all PISQ-IR subscales., Results: The PISQ-IR was completed by 220 women, of whom 61 (27.7%) considered themselves not sexually active (NSA) and 159 (72.3%) sexually active (SA). The mean age of participating women was 57 years; 49.5% reported symptoms of pelvic organ prolapse (POP), 66.8% urinary incontinence and 2.3% anal incontinence. The PISQ-IR subscales were analyzed separately for SA and NSA women with Cronbach's alpha coefficient ranging from 0.61 to 0.87. Moderate to high correlations were observed between PISQ-IR subscales and corresponding FSFI subscales and a moderate correlation between urinary distress and the condition impact (CI) subscale among NSA subjects., Conclusions: The Dutch PISQ-IR demonstrated a good internal consistency and criterion validity compared with the FSFI, but criterion validity compared with the PFDI-20 was poor except for urinary distress in NSA women and needs further attention.

Introduction and Hypothesis: We aimed to estimate the level of de-implementation of preoperative routine urodynamics (UDS) before stress urinary incontinence (SUI) surgery in The Netherlands and to analyze facilitators and barriers. Routine UDS was performed by 37% of the medical specialists in 2010. We hypothesized that the recommendations from the recent Value of Urodynamics prior to Stress Incontinence Surgery (VUSIS) and Value of Urodynamic Evaluation (ValUE) studies would have been followed by a reduction of routine UDS., Methods: A national survey was performed among all Dutch gynecologists and urologists dealing with SUI in daily practice. The questionnaire contained two parts: (1) respondents' characteristics and their actual care concerning preoperative UDS, and (2) facilitators and barriers., Results: The response rate was 41% (127/308). Of the respondents, 93% (n = 118) did not perform routine UDS in the preoperative workup for women in this group. Professional characteristics associated with not following the recommendations were profession urologist, academic hospital, and a lower number of midurethral sling (MUS) placed yearly. Facilitators to follow the recommendation not to perform routine UDS were adequate design of the VUSIS-II study and outcome and recommendations from the studies. Barriers not to follow the recommendation were believe in the additional value of UDS, especially the pressure transmission ratio, and the presence of detrusor overactivity., Conclusion: According to respondents to this questionnaire, VUSIS-II and ValUE study results are well implemented in The Netherlands. The vast majority of respondents replied as not performing routine preoperative UDS in women with primary, uncomplicated (predominant) SUI. Therefore, there is no need for a further de-implementation strategy.

Introduction and Hypothesis: Our aim was to evaluate clinically relevant long-term outcomes of transvaginal mesh or native tissue repair in women with recurrent pelvic organ prolapse (POP)., Methods: We performed a 7-year follow-up of a randomized controlled trial on trocar-guided mesh placement or native tissue repair in women with recurrent POP. Primary outcome was composite success, defined as absence of POP beyond the hymen, absence of bulge symptoms, and absence of retreatment for POP. Secondary outcomes were adverse events, pain, and dyspareunia. Multiple imputation was used for missing data of composite success and pain; estimates are presented with 95% confidence intervals (CI)., Results: Between August 2006 and July 2008, 194 women were randomized; 190 underwent surgery. At 7 years, 142 (75%) were available for analysis, of whom, the primary outcome could be calculated in 127. Composite success was 53% (95% CI 41, 66) for mesh and 54% (95% CI 42, 65) for native tissue. Repeat surgery for POP was 25% for mesh and 16% for native tissue (difference 9%; 95% CI -5, 23) and occurred in untreated compartments in the mesh group and treated compartments in the native tissue group. Mesh exposure rate was 42%; pain with mesh 39% and native tissue 50% (difference - 11%, 95% CI -27, 6); dyspareunia with mesh 20% and native tissue 17% (difference 3%, 95% CI -9, 17)., Conclusions: Seven-year composite success rates appeared similar for mesh and native tissue. Mesh did not reduce long-term repeat surgery rates due to de novo POP in nonmesh-treated vaginal compartments. Mesh exposure rates were high, though significant differences in pain and dyspareunia were not detected., Clinical Trial Registration: ClinicalTrials.gov , NCT00372190.

Introduction and Hypothesis: National and international guidelines do not provide clear recommendations on the mode of delivery in a subsequent pregnancy after obstetric anal sphincter injury (OASI). The aim of this study was to investigate the opinion of gynecologists in The Netherlands on this choice and the extent to which this choice is affected by the gynecologist's characteristics., Methods: Of 973 gynecologists sent a questionnaire seeking their opinion on the mode of delivery in 16 different case descriptions, 234 (24%) responded. Factors influencing the opinion of the respondents on the mode of delivery, the presence of anal symptoms, the degree of OASI and the characteristics of the respondents were analyzed by univariate and multivariate logistic regression analysis., Results: Recommendations on the mode of delivery in a subsequent pregnancy after OASI showed considerable variation. The recommendations depended on (previous) symptoms and the degree of OASI. For gynecologists who based their recommendations on endoanal ultrasonography outcomes (7-20% depending on the case), the degree of OASI and severity of (previous) symptoms were less important. Gynecologists basing their recommendations on endoanal ultrasonography recommended a primary cesarean section less often. Gynecologist's characteristics (including years of experience, type of hospital and subspecialty) had a small effect on their recommendations on the mode of delivery., Conclusions: Due to lack of evidence, recommendations of gynecologists in The Netherlands on the mode of delivery in a subsequent pregnancy after OASI vary widely and depend on (previous) symptoms and the degree of OASI. Gynecologists who based their recommendations on endoanal ultrasonography outcomes recommended cesarean section less often.

Introduction and Hypothesis: Pelvic organ prolapse (POP) recurrence after surgery is a major problem. POP that is more advanced preoperatively is associated with a higher risk of recurrence postoperatively. We hypothesized that women with a stage 2 cystocele differ from those with a stage 3 or 4 cystocele. The aim of this study was to compare the baseline characteristics of women with mild and those with more advanced cystocele., Methods: Patients had participated in one of two multicenter prospective cohort studies on women undergoing conventional anterior colporrhaphy without previous POP surgery. This was a secondary analysis of these data. Women with a preoperative cystocele stage 2 were compared with women with a stage 3 or 4 cystocele. Logistic regression models were employed to calculate odds ratios (OR) and 95% confidence intervals (CI)., Results: Two hundred and sixty-nine women were assessed, of whom 132 (49.1%) had an advanced cystocele. Only older age was significantly associated with advanced cystocele preoperatively, with an OR of 1.07 (95% CI 1.04-1.10). There were no significant differences between women with advanced or stage 2 cystocele in body mass index, vaginal deliveries, assisted delivery, positive family history of POP, concurrent rectocele, concurrent uterine of vaginal vault prolapse, major levator ani muscle defects, or levator hiatal area., Conclusions: Women with advanced cystocele were significantly older than women with stage 2 cystocele. This raises the question whether it would be favorable to perform POP surgery in an earlier stage, i.e., at a younger age, in order to prevent POP recurrence.

Introduction and Hypothesis: Obstetric anal sphincter injuries (OASIS) contribute significantly to the development of anal incontinence (AI) in women. The aim of this study was to establish the incidence of AI after OASIS and to study the influence on the quality of life (QoL) in patients with OASIS., Methods: This cohort study, with prospective case-control follow-up, involves women who were treated for OASIS between 2005 and 2012 in two academic medical centers in The Netherlands. Three hundred and thirteen patients and 780 controls were invited to complete a validated questionnaire (Defecation Distress Inventory, Wexner Incontinence Score, and Fecal Instrument Quality of Life) regarding symptoms and bother of AI subsequent and QoL after delivery. The main outcome measures were the presence of AI and the impact on QoL., Results: The questionnaire was completed by 141 patients and 194 controls. Mean follow-up was 4 years (range 1-9 years) in both groups. In the patient group, 55 women (39 %) reported AI symptoms compared with 38 women (20 %) in the control group (odds ratio 2.7, 95 % confidence interval 1.66-4.47, p < 0.01). In women who experienced symptoms of AI as very bothersome, QoL was affected in 14 (82.0 %) patients and three (33.5 %) controls (p = 0.012)., Conclusions: In this study, women with OASIS had a more than doubled risk of longer-term bothersome symptoms of AI compared with controls. Symptoms were experienced as bothersome and as having an influence on QoL.

Introduction and Hypothesis: Pelvic organ prolapse (POP) is a common condition with multifactorial etiology. The purpose of this systematic review was to provide an overview of literature on risk factors for POP and POP recurrence., Methods: PubMed and Embase were searched with "pelvic organ prolapse" combined with "recurrence" and combined with "risk factors," with Medical Subject Headings and Thesaurus terms and text words variations until 4 August 2014, without language or publication date restrictions. Only cohort or cross-sectional studies carried out in western developed countries containing multivariate analyses and with a definition of POP based on anatomical references were included. POP recurrence had to be defined as anatomical recurrence after native tissue repair without mesh. Follow-up after surgery should have been at least 1 year. Articles were excluded if POP was not a separate entity or if it was unclear whether the outcome was primary POP or recurrence., Results: PubMed and Embase revealed 2,988 and 4,449 articles respectively. After preselection, 534 articles were independently evaluated by two researchers, of which 15 met the selection criteria. In 10 articles on primary POP, 30 risk factors were investigated. Parity, vaginal delivery, age, and body mass index (BMI) were significantly associated in at least two articles. In 5 articles on POP recurrence, 29 risk factors were investigated. Only preoperative stage was significantly associated in at least two articles., Conclusion: Parity, vaginal delivery, age, and BMI are risk factors for POP and preoperative stage is a risk factor for POP recurrence.

Introduction and Hypothesis: Defecatory complaints have a severe impact on quality of life. The additional value of pelvic floor MRI in patients with defecatory complaints is unclear. Our aim was to correlate the presence of defects and atrophy of the anal sphincter complex using pelvic floor MRI in women with mixed pelvic floor symptoms and to establish patient characteristics and self reported complaints predictive of pathology., Methods: This is a retrospective study among women with mixed pelvic floor symptoms who underwent external phased-array MRI and completed a questionnaire on bothersome defecatory complaints. Data on patient characteristics, including obstetrical history and questionnaire scores were correlated with the assessment of anal sphincter defects and atrophy on pelvic floor MRI., Results: One hundred and fifty-eight women were included. A defect of the external anal sphincter (EAS) and internal anal sphincter (IAS) was found in 18 (11%) and 5 (3%) patients respectively. Atrophy of the EAS was present in 72 patients (46%), with more cases of mild (n = 52, 33%) than severe atrophy (n = 20, 13%). The variable "previous third or fourth degree tear" had a significant positive association with an IAS defect on MRI, with an OR of 9.533 (1.425-63.776). Patients with EAS atrophy had higher scores for fecal incontinence (indicating more bother) than patients without EAS atrophy. Higher age and BMI were true predictors of the presence of more severe EAS atrophy., Conclusion: Atrophy of the EAS was highly prevalent in this population and was associated with bothersome symptoms of fecal incontinence.

Introduction and Hypothesis: Our aim was to estimate agreement between transperineal and endovaginal ultrasound in assessing levator ani biometry and avulsion in nullipara and primipara women and determine agreement between levator avulsion palpation and ultrasound., Methods: This longitudinal cohort study assessed 269 nullipara women at 36 weeks gestation and 191 primipara women 13 weeks postpartum. Women underwent levator palpation, and avulsion was diagnosed if no attachment to the pubic bone was felt. Subsequently, 3/4D transperineal and 3D endovaginal ultrasound were performed. A standardized protocol was used to perform measurements at rest. Levator avulsion was diagnosed on endovaginal ultrasound at rest if >50 % was avulsed and on transperineal tomographic ultrasound imaging at maximum contraction if the central three slices were avulsed. Levator avulsion was analyzed by two independent, blinded investigators. A third investigator resolved discrepancies. Intraclass correlation coefficient and limits of agreement were calculated for each time point., Results: Intraclass correlation coefficient for levator urethra gap was 0.44-0.54, hiatus area 0.76-0.79, transverse diameter 0.51-0.59, anteroposterior diameter 0.70-0.72. Levator thickness correlated poorly. Endovaginal ultrasound measurements were generally smaller; however limits of agreement were acceptable for hiatus measurements. Overall agreement between both ultrasound techniques in diagnosing levator avulsion was 95 %; correlation 0.72 [95 % confidence interval (CI) 0.67-0.76]. Agreement between palpation and transperineal ultrasound was 92 % (kappa = 0.34), and between palpation and endovaginal ultrasound was 92 % (kappa = 0.37)., Conclusions: Transperineal and endovaginal ultrasound can both be used to analyze hiatus area and anteroposterior diameter with the patient at rest and to diagnose levator avulsion. Palpation correlates only fairly with both methods.

Introduction and Hypothesis: To evaluate the interobserver reliability of diagnosing levator avulsions between observers from different centers using tomographic ultrasound imaging (TUI) in women after their first delivery., Methods: Transperineal ultrasound volume datasets of 40 women 6 months after their first delivery were analyzed by five observers from four different centers. Levator avulsions were diagnosed using TUI and datasets were assessed as optimal or suboptimal image quality and optimal or suboptimal pelvic floor contraction. Cohen's kappa was used to evaluate the interobserver reliability of diagnosing levator avulsions for the total group, the group with optimal and suboptimal image quality, and the group with optimal and suboptimal pelvic floor contraction. Consensus on the presence or absence of avulsions was scored according to the number of observers who diagnosed an avulsion (0 = consensus on the absence of avulsion, 1-4 = avulsion diagnosed by 1 to 4 observers, 5 = consensus on the presence of avulsion)., Results: For the total group, the interobserver reliability varied widely, with kappa values ranging from -0.07 to 0.72. Analyzes in the subgroups showed comparable results. Of the women who potentially have an avulsion (avulsion diagnosed by at least one observer), consensus on the presence of an avulsion was reached in 0.0 to 20.0 %. Of the women who potentially have no avulsion (no avulsion diagnosed by at least one observer), consensus on the absence of an avulsion was reached in 46.7 to 85.7 %., Conclusions: Diagnosing levator avulsions using TUI in women 6 months after their first delivery is strongly observer-dependent and therefore not generalizable.

Introduction and Hypothesis: The rs1800255, COL3A1 2209 G>A polymorphism in the alpha 1 chain of collagen type III has been associated with an increased risk of pelvic organ prolapse (POP). In one of our previous studies however, polymerase chain reaction-based restriction fragment length polymorphism (PCR-RFLP) misdiagnosed rs1800255, COL3A1 2209 G>A in 6 % of cases. The high-resolution melting (HRM) analysis on the contrary obtained a 100 % accordance for this specific polymorphism and was used in the present study to validate this risk factor for POP., Methods: In this case-control study, women with and without symptoms of POP were included and compared. DNA was extracted from blood samples. HRM analysis was used to assess for the presence of the homozygous rs1800255. Groups were compared using the Pearson chi-square, Mann-Whitney, and t tests. The discrepancy between HRM and PCR-RFLP results was investigated using PCR-RFLP results available from our previous study., Results: The study included 354 women: 272 patients with POP and 82 controls; 18 (7 %) cases versus 3 (4 %) controls had a homozygous rs1800255, COL3A1 2209 G>A polymorphism (odds ratio 1.9, 95 % confidence interval 0.5-6.9, compared to the wild type), and thus no association between POP and the homozygous polymorphism could be demonstrated. A discrepancy between HRM and PCR-RFLP results was found in 8 % of the samples., Conclusions: The previously found statistically significant association between the rs1800255, COL3A1 2209 G>A polymorphism as measured with PCR-RFLP and POP could no longer be demonstrated. This raises concerns regarding the results of other association studies using PCR-RFLP.

Introduction and Hypothesis: The aim of this study was to compare failure and complication rates in patients who underwent a trocar-guided vaginal mesh repair with either a non-absorbable or a partially absorbable mesh., Methods: Retrospective analysis of prospectively collected data from consecutive women undergoing either non-absorbable or partially absorbable mesh for symptomatic stage 2 prolapse or higher were evaluated at 12 months. Outcome measures included objective and subjective failure rates, patient's satisfaction, complications and perioperative outcomes., Results: Five hundred and sixty-nine women (347 with non-absorbable mesh, 222 with partially absorbable mesh) were included. Failure rates were similar in the two groups; the re-operation rate in the untreated compartments was higher in the non-absorbable mesh group compared with the partially absorbable mesh group (5% vs 1%). Mesh exposure rate in the non-absorbable mesh group was 12% and in the partially absorbable mesh group it was 5%. Other complication and patient satisfaction rates were similar., Conclusions: Non-absorbable and partially absorbable mesh demonstrated similar outcome rates at 12 months. The risk of reoperation was lower for partially absorbable mesh. The mesh exposure rate was significantly lower for the partially absorbable mesh group compared with the non-absorbable mesh group.

Introduction and Hypothesis: The objective of this work was to collect and summarize a detailed historical review of the surgical treatment of pelvic organ prolapse (POP) in which we specifically focused on the anterior compartment., Methods: A literature search in English, Dutch, and German was carried out using the keywords pelvic organ prolapse, anterior colporrhaphy, cystocele, and interposition operations in several databases (e.g., PubMed and HathiTrust Digital Library). Other relevant journal and textbook articles were found by retrieving references cited in previous articles and textbooks., Results: Probably the first explanation of the treatment of POP dates from 1500 B.C. The Egyptians gave a description to "falling of the womb" in the Kahun Papyrus. More than a millennium later, Euryphon, a contemporary of Hippocrates (400 B.C.) described some interesting therapeutic options, from succussion (turning a women upside down for several minutes) to irrigating the displaced uterus with wine. A wide range of techniques has been attempted to repair the prolapsing anterior vaginal wall. By 1866, Sim had already performed a series of operations very similar to a modern anterior repair. The first reviews about the abdominal approach to correcting a cystocele were in 1890. The first description of using mesh to cystoceles was the use of tantalum mesh in 1955. In 1970, the first report of collagen mesh in urogynecology was described. Nowadays, robot-assisted surgery and cell-based tissue engineering are the latest interventions., Conclusion: Many surgeons have tried to find the ideal surgical therapy for anterior compartment prolapse, but to date, this has not been achieved.

Introduction and Hypothesis: Levator defects are risk factors for pelvic organ prolapse (POP) and its recurrence. The most widely used scoring systems for severity of defects shown on magnetic resonance imaging (MRI) and perineal ultrasound (US) are not identical. The aim of this study was to investigate the differences between these classification systems with regard to levator defects on US and their clinical relevance for recurrence after prolapse surgery., Methods: Women with previous cystocele repair underwent transperineal 3D US. Levator defects were graded according to the scoring system described with regard to MRI (DeLancey et al.) and perineal US (Dietz et al.). The results were compared using the weighted kappa and receiver operating characteristic (ROC) curves (SPSS version 20.0)., Results: We assessed 152 women. On US classification, more defects were categorized as highest grade compared with MRI classification [n = 64 (42 %) vs. n = 41 (28 %), p < 0.01]. The grades of levator defects on both scoring systems showed very good agreement, with a weighted kappa of 0.82 [95 % confidence interval (CI) 0.75-0.88). The predictive value of scoring systems for cystocele recurrence after prolapse surgery showed an area under the receiver operating curve (AUC) of 0.63 and 0.64, respectively., Conclusions: Comparison of the two scoring systems showed good agreement but was lowest for the highest-grade defects. There was no difference in predictive value between scoring systems for cystocele recurrence after prolapse surgery.

Introduction and Hypothesis: To evaluate current practice in the surgical treatment of uterine descent among members of the Dutch Urogynecological Society and to analyze possible trends in the surgical treatment of pelvic organ prolapse in the Netherlands during the last decade., Methods: A questionnaire, including case scenarios, was sent to the members of the Dutch Urogynecological Society. Using a nationwide registry from the Netherlands, we assessed the number and type of surgical procedures performed for pelvic organ prolapse between 1997 and 2009., Results: The response rate was 73%, with 161 questionnaires completed. Vaginal hysterectomy, sacrospinous hysteropexy, and the Manchester Fothergill procedure were the most frequently performed surgical interventions for uterine descent. In the case of lower stage uterine descent, uterus preservation was preferred, but in the case of higher stage there was wide variation. Two thirds of the respondents stated that in recent years they tended to save the uterus more often. The registered number of hospital admissions for uterine descent increased by 30% between 1997 and 2009 and the number of surgical procedures almost doubled. The number of vaginal hysterectomies performed because of uterine descent increased by only 15% in this period., Conclusions: In the Netherlands, surgical policy in the case of uterine descent is very variable, with no clear preference for either hysterectomy or uterus preservation. There was a high increase in hospital admissions and pelvic organ prolapse procedures in the last decade. The number of vaginal hysterectomies performed because of uterine descent did not follow this change, which reflects a trend toward preserving the uterus.

The aims of this systematic literature review were to assess whether the detection of pubovisceral avulsions using magnetic resonance (MR) imaging or perineal ultrasonography was clinically relevant in women with pelvic floor dysfunction and to evaluate the relation with anatomy, symptoms, and recurrence after surgery. We performed a systematic literature review using three bibliographical databases (PubMed, Embase, and CINAHL) as data sources. Clinical studies were included in which pubovisceral avulsions were studied in relation to pelvic organ prolapse (POP) stage, pelvic floor symptoms, and/or recurrence of POP after surgery. Ultimately, 21 studies met the inclusion criteria. POP stage and recurrence of POP after surgery were strongly associated with pubovisceral avulsions. Contradictory results were found regarding the relation between pubovisceral avulsions and urinary symptoms and symptoms of anorectal dysfunction. Pubovisceral avulsions, as diagnosed by MR imaging or perineal ultrasonography, are associated with higher stages of POP and recurrence of POP after surgery.

Introduction and Hypothesis: There is growing evidence that pelvic organ prolapse (POP) is at least partly caused by underlying hereditary risk factors. The aim of our study was to provide a systematic literature review and meta-analysis of clinical studies on family history of POP as a risk factor for POP in individual women., Methods: The databases PubMed and Embase were searched. Clinical studies reporting on family history of POP in relation to POP in individual women were included., Results: Sixteen studies were included, of which eight enabled us to calculate a pooled odds ratio (OR). The pooled OR of POP in case of a positive family history of POP was 2.58 (95 % confidence interval 2.12-3.15)., Conclusions: Women with POP are substantially more likely to have family members with the same condition compared to women without POP. This strengthens the hypothesis that genetic predisposition plays an important role in the development of POP.

Introduction and Hypothesis: The aim of this study is to assess variations in practice in the use of preoperative urodynamics in women with stress urinary incontinence (SUI)., Methods: We performed an E-survey among all Dutch gynecologists and urologists who have SUI as focus in daily practice. The questions concerned the common policy and preferred policy. Descriptive statistics were used., Results: Of the 260 targeted specialists, 163 (63%) responded. We found that 37% of the respondents performed standard preoperative urodynamics; in the preferred practice, this would reduce to only 18%. Eighty percent indicated they would operate a patient with a positive stress test without urodynamic SUI, whereas 21% would do this also in case the clinical stress test was negative. Only 9% of the respondents indicated they adapted the choice of the type of sling based on urethral pressure profilometry parameters., Conclusions: Urodynamics are not routinely performed, and outcomes hardly influence the choice of treatment.

Introduction and Hypothesis: Pelvic organ prolapse (POP) and other disorders, such as varicose veins and joint hypermobility, have been associated with changes in collagen strength and metabolism. We hypothesized that these various disorders were more prevalent in both POP patients and their family members., Methods: In this study, the prevalence of various collagen-associated disorders, including POP, was compared between POP patients (n = 110) and control patients (n = 100) and their first and second degree family members., Results: POP patients reported a higher prevalence of varicose veins, joint hypermobility and rectal prolapse and were more likely to have family members with POP as compared to the control group (p < 0.01). In contrast, the family members of the POP group did not report a higher prevalence of collagen-associated disorders compared to the family members of the control group (p = 0.82)., Conclusions: POP and other collagen-associated disorders may have a common aetiology, originating at the molecular level of the collagens.

Introduction and Hypothesis: The 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., Methods: All 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., Results: Ninety-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., Conclusions: A 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.

The incidence of pelvic organ prolapse is 18% in women with bladder exstrophy. A vaginal technique to correct the prolapse may be preferable in these women with multiple abdominal operations in their histories. We have performed a modified Prolift procedure for the repair of severe uterine prolapse in two young women. A review of the literature is presented.

Introduction and Hypothesis: The factors influencing a patient's subjective improvement 1 year after pelvic organ prolapse (POP) surgery were studied., Methods: Women after POP surgery were divided into improved and non-improved group based on their score on the questionnaire Patient Global Impression of Improvement (PGI-I) 1 year after surgery. Anatomical and functional outcomes were assessed as influencing factors for improvement using multivariate logistic regression., Results: Three hundred eighty-six (386) women were included in the study, of whom 40 (10%) had not subjectively improved. First POP operation, symptoms and bother of genital prolapse and overactive bladder, and anterior compartment anatomy were independent factors related to subjective improvement. A threshold needed to be reached in these parameters., Conclusions: The first operation was more often associated with subjective improvement, and both anatomical and functional outcomes were of importance. The mere finding of a statistical significant improvement was no guarantee for subjective improvement after POP surgery.

Introduction and Hypothesis: To evaluate the variation in techniques of anterior colporrhaphy among members of the Dutch Urogynecologic Society., Methods: A questionnaire evaluating the technique of anterior colporrhaphy, preoperative and postoperative care, and use of the POP-Q score was sent out by e-mail., Results: One hundred thirty-three completed questionnaires were received. The response rate was 65%. There are large variations in incisions, use of hydrodissection, method of plication, and excision of redundant vaginal epithelium. The urinary catheter was generally removed on day 2 after surgery and the vaginal pack on day 1. Less than half of the respondents used the POP-Q score routinely., Conclusions: Dutch gynecologists use a variety of surgical techniques to operate on a cystocele. This suggests that there is no widely accepted opinion on the best surgical approach. The lack of differentiation between central and lateral defects is striking and in contrast with the, mostly, American literature.

A needle fragment was lost during a sacrospinous ligament fixation. This was recognized during the procedure, but could not be found at that moment. The patient complained of severe buttock pain postoperatively. The needle fragment was localized on CT scan of the pelvis. A fetal scalp electrode helped as a search device to localize the needle on X-ray during the secondary surgery. The patient was operated successfully and was free of pain after 6 weeks.

Introduction and Hypothesis: This study focussed on the factors which predict the presence of symptoms of overactive bladder (OAB) after surgery for pelvic organ prolapse (POP)., Methods: Consecutive 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)., Results: Five 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., Conclusion: The absence of bothersome OAB symptoms preoperatively was the best predictor for the absence of postoperative symptoms.

Introduction and Hypothesis: The aim of this dynamic magnetic resonance (MR) imaging study was to assess the relation between the position and mobility of the perineum and patients' symptoms of pelvic floor dysfunction., Methods: Patients' symptoms were measured with the use of validated questionnaires. Univariate logistic regression analyses were used to study the relationship between the questionnaires domain scores and the perineal position on dynamic MR imaging, as well as baseline characteristics (age, body mass index, and parity)., Results: Sixty-nine women were included in the analysis. Only the domain score genital prolapse was associated with the perineal position on dynamic MR imaging. This association was strongest at rest., Conclusions: Pelvic organ prolapse symptoms were associated with the degree of descent of the perineum on dynamic MR imaging. Perineal descent was not related to anorectal and/or urinary incontinence symptoms.