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In this cross-sectional study examining 211,708 patients with a diagnosis of uterine prolapse who underwent hysterectomy between 2016 and 2019 identified in the Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample, co-diagnosis of gynecologic malignancy was reported in 2,398 (1.1%) patients, and they were less likely to receive reconstructive surgery at hysterectomy (odds ratio [OR] 0.90, 95% CI 0.84–0.96). This absence of reconstructive surgery was most pronounced among patients with complete uterine prolapse and gynecologic malignancy (OR 0.68, 95% CI 0.57–0.81). The association was also consistent in coexisting gynecologic premalignancy (n=3,357 [1.6%]). In conclusion, this national-level assessment suggests that patients with uterine prolapse and coexisting gynecologic malignancy or premalignancy may be less likely to receive reconstructive surgery for pelvic floor dysfunction at hysterectomy. [ABSTRACT FROM AUTHOR]

Pelvic organ prolapse is a common condition that can be treated safely and effectively with nonoperative options. Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior, posterior, or apical vagina. It is a common condition, with up to 50% of women having prolapse on examination in their lifetimes. This article provides an overview of the evaluation and discussion of nonoperative management of POP for the obstetrician–gynecologist (ob-gyn), with consideration of recommendations from the American College of Obstetricians and Gynecologists, the American Urogynecologic Society, and the International Urogynecological Association. The initial evaluation of POP requires a history documenting whether the patient is experiencing symptoms and what they are, and discovery of which symptoms they believe are attributable to prolapse. Examination determines the vaginal compartment(s) and to what degree prolapse exists. In general, only patients who have symptomatic prolapse or medical indication should be offered treatment. Although surgical options exist, all patients who are symptomatic and desire treatment should be offered nonsurgical treatment first, including pelvic floor physical therapy or a pessary trial. Appropriateness, expectations, complications, and counseling points are reviewed. Educational opportunities between the patient and the ob-gyn include disentangling common beliefs that the bladder is dropping or that concomitant urinary or bowel symptoms are necessarily caused by prolapse. Improving patient education can lead to a better understanding of their condition and better alignment of treatment goals and expectations. [ABSTRACT FROM AUTHOR]

Objective: To compare the safety and effectiveness of transvaginal mesh repair and native tissue repair, in response to a U.S. Food and Drug Administration (FDA) 522 study order to assess co-primary endpoints of superiority and noninferiority.Methods: This was a prospective, nonrandomized, parallel cohort, multi-center trial comparing transvaginal mesh with native tissue repair for the treatment of pelvic organ prolapse. The primary endpoints were composite treatment success at 36 months comprised of anatomical success (defined as pelvic organ prolapse quantification [POP-Q] point Ba≤0 and/or C≤0), subjective success (vaginal bulging per the PFDI-20 [Pelvic Floor Distress Inventory]), and retreatment measures, as well as rates of serious device-related or serious procedure-related adverse events. Secondary endpoints included a composite outcome similar to the primary composite outcome but with anatomical success defined as POP-Q point Ba<0 and/or C<0, quality-of-life measures, mesh exposure and mesh- and procedure-related complications. Propensity score stratification was applied.Results: Primary endpoint composite success at 36 months was 89.3% (201/225) for transvaginal mesh and 80.2% (389/485) for native tissue repair, demonstrating noninferiority at the preset margin of 12% (propensity score-adjusted treatment difference 6.5%, 90% CI -0.2% to 13.2%). Using the primary composite endpoint, transvaginal mesh was not superior to native tissue repair (P=.056). Using the secondary composite endpoint, superiority of transvaginal mesh over native tissue repair was noted (P=.009), with a propensity score-adjusted difference of 10.6% (90% CI 3.3-17.9%) in favor of transvaginal mesh. Subjective success for both the primary and secondary endpoint was 92.4% for transvaginal mesh, 92.8% for native tissue repair, a propensity score-adjusted difference of -4.3% (CI -12.3% to 3.8%). For the primary safety endpoint, 3.1% (7/225) of patients in the transvaginal mesh (TVM) group and 2.7% (13/485) of patients in the native tissue repair (NTR) group developed serious adverse events, demonstrating that transvaginal mesh was noninferior to native tissue repair (-0.4%, 90% CI -2.7% to 1.9%). Overall device-related and/or procedure-related adverse event rates were 35.1% (79/225) in the TVM group and 46.4% (225/485) in the NTR group (-15.7%, 95% CI -24.0% to -7.5%).Conclusion: Transvaginal mesh repair for the treatment of anterior and/or apical vaginal prolapse was not superior to native tissue repair at 36 months. Subjective success, an important consideration from the patient-experience perspective, was high and not statistically different between groups. Transvaginal mesh repair was as safe as native tissue repair with respect to serious device-related and/or serious procedure-related adverse events.Funding Source: This study was sponsored by Boston Scientific and developed in collaboration with FDA personnel from the Office of Surveillance and Biometrics, Division of Epidemiology.Clinical Trial Registration: ClinicalTrials.gov, NCT01917968. [ABSTRACT FROM AUTHOR]

Objective: To compare prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension to recurrence after supracervical hysterectomy with mesh sacrocervicopexy for the primary management of uterovaginal prolapse.Methods: We conducted a retrospective cohort study of women undergoing uterovaginal prolapse repair at an academic center from 2009 to 2019. Women who underwent vaginal hysterectomy with uterosacral ligament suspension or laparoscopic supracervical hysterectomy with mesh sacrocervicopexy were included. The primary outcome was composite prolapse recurrence (prolapse beyond the hymen or retreatment with pessary or surgery). Secondary outcomes included mesh complications, time to recurrence, and overall reoperation for either prolapse recurrence or mesh complication. We used propensity scoring with a 2:1 ratio of sacrocervicopexy to uterosacral suspension.Results: The cohort consisted of 654 patients, of whom 228 (34.9%) underwent uterosacral suspension and 426 (65.1%) underwent sacrocervicopexy. The median follow-up was longer for the sacrocervicopexy group (230 vs 126 days, P<.001) and less than 1 year for both groups. The uterosacral group had a greater proportion of composite prolapse recurrence (14.9% [34/228] vs 8.7% [37/426], P=.02) and retreatment for recurrent prolapse (7.5% [17/228] vs 2.8% [12/426], P=.02). The uterosacral group demonstrated a shorter time to prolapse recurrence on multivariable Cox regression (hazard ratio 3.14, 95% CI 1.90-5.16). There were 14 (3.3%) mesh complications in the sacrocervicopexy group. Overall reoperation was similar between groups (4.8% [11/228] vs 3.8% [16/426], P=.51).Conclusion: Total vaginal hysterectomy with uterosacral ligament suspension was associated with higher rate of, and shorter time-to-prolapse recurrence compared with supracervical hysterectomy with mesh sacrocervicopexy. [ABSTRACT FROM AUTHOR]

Objective: To compare surgical outcomes between total laparoscopic hysterectomy and total vaginal hysterectomy with uterine weight greater than 250 g.Methods: We conducted a retrospective cohort study using data from American College of Surgeons' National Quality Improvement Project Hysterectomy Specific Database. Women with uterine weight greater than 250 g undergoing hysterectomy for benign indications by total laparoscopic hysterectomy or total vaginal hysterectomy were matched by propensity scores, which were calculated using preoperative characteristics and uterine weight. Total vaginal hysterectomy was matched to total laparoscopic hysterectomy at a ratio of 1:2. Pairwise analysis was performed using Wilcoxon rank-sum and Fisher exact tests as appropriate. Multivariable logistic regression was performed to identify the independent effect of total vaginal hysterectomy on surgical outcomes.Results: There were 1,870 total vaginal hysterectomies that were matched to 3,740 total laparoscopic hysterectomies. No differences in preoperative demographics and comorbidities were seen for the patients. Uterine weight was similar for both groups: 376 g (interquartile range 293-501) for total vaginal hysterectomy and 384 g (interquartile range 302-515) for total laparoscopic hysterectomy (odds ratio [OR] 0.98, 95% CI 0.92-1.09). The rate of composite major complications was similar between total vaginal hysterectomy and total laparoscopic hysterectomy (4.3% vs 5.3%, OR 0.80, 95% CI 0.61-1.05). Intraoperative cystotomies were higher with total vaginal hysterectomy (0.8% vs 0.3%, OR 2.74, 95% CI 1.17-6.61), and ureteral injuries were more common with total laparoscopic hysterectomy (1.2% vs 0.2%, OR 0.12, 95% CI 0.02-0.38). Total vaginal hysterectomy operating time was significantly shorter compared with total laparoscopic hysterectomy (77 minutes, interquartile range 56-111 vs 122 minutes, interquartile range 91-164; OR 0.69, 95% CI 0.42-0.89). After adjusting for confounders, total vaginal hysterectomy was not found to be independently associated with major morbidity (adjusted odds ratio [aOR] 0.95, 95% CI 0.18-5.11) and was associated with a lower probability of operating times exceeding 2.5 hours (aOR 0.31, 95% CI 0.27-0.43).Conclusion: In patients matched by uterine size and preoperative characteristics, total vaginal hysterectomy is not associated with an increased composite risk of major surgical morbidity or other adverse surgical outcomes. [ABSTRACT FROM AUTHOR]

Objective: To test the hypothesis that preoperative pelvic floor muscle injections and pudendal nerve blocks with bupivacaine and dexamethasone would decrease postoperative pain after vaginal native tissue prolapse repairs, compared with saline and bupivacaine.Methods: We conducted a three-arm, double-blind, randomized trial of bilateral transobturator levator ani muscle injections and transvaginal pudendal nerve blocks before vaginal reconstructive and obliterative prolapse procedures (uterosacral ligament suspension, sacrospinous ligament fixation, levator myorrhaphy, or colpocleisis). Women were randomized to one of three study medication groups: 0.9% saline, 0.25% bupivacaine, or combination 0.25% bupivacaine with 4 mg dexamethasone. Our primary outcome was a numeric rating scale pain score on postoperative day 1. Using an analysis of variance evaluated at the two-sided 0.05 significance level, an assumed variance of the means of 0.67, and SD of 1.75, we calculated 21 women per arm to detect a 2-point change on the numeric rating scale (90% power), which we increased to 25 per arm to account for 20% attrition and the use of nonparametric statistical methods.Results: From June 2017 through April 2019, 281 women were screened and 75 (26.7%) were randomized with no differences in baseline demographics among study arms. There was no significant difference in median pain scores on postoperative day 1 among study groups (median [interquartile range] pain score 4.0 [2.0-7.0] for placebo vs 4.0 [2.0-5.5] for bupivacaine vs 4.0 [1.5-5.0] for bupivacaine with dexamethasone, P=.92).Conclusion: Preoperative pelvic floor muscle injections and pudendal nerve blocks with bupivacaine and dexamethasone did not improve postoperative pain after vaginal native tissue prolapse procedures.Clinical Trial Registration: ClinicalTrials.gov, NCT03040011. [ABSTRACT FROM AUTHOR]

Objective: To estimate the incidence and risk factors for bowel injury in women undergoing hysterectomy for benign indications.Methods: A retrospective cohort study was conducted among women undergoing hysterectomy for benign indications from 2012 to 2016 at institutes participating in the American College of Surgeons National Surgical Quality Improvement Program, including both inpatient and outpatient settings. Bowel injury was identified using Current Procedural Terminology codes as patients who underwent bowel repair at the time of hysterectomy or postoperatively within 30 days. Multivariate logistic regression models were used to control for patient clinical factors and perioperative factors.Results: Bowel injury occurred in 610 of 155,557 (0.39%) included women. After bivariate analysis, factors associated with bowel injury included age, race, body mass index, American Society of Anesthesiologists classification, increased operative time, surgical approach, type of hysterectomy, lysis of adhesions, and operative indication. After adjusting for potential confounders, bowel injury was found associated with older age, surgical indication of endometriosis, and abdominal surgical approach. Compared with the surgical indication of endometriosis (n=63/10,625), the surgical indications of menstrual disorder (odds ratio [OR] 0.33, 95% CI 0.23-0.47; adjusted odds ratio [aOR] 0.33, 95% CI 0.23-0.48; n=67/34,168), uterine leiomyomas (OR 0.80, 95% CI 0.61-1.05; aOR 0.44, 95% CI 0.33-0.59; n=243/51,232), and genital prolapse (OR 0.30, 95% CI 0.20-0.45; aOR 0.41, 95% CI 0.25-0.67; n=36/20,384) were each associated with lower odds of bowel injury. Compared with the vaginal approach to hysterectomy (n=27/27,434), the abdominal approach was found to have significantly increased odds of bowel injury (OR 10.80, 95% CI 7.31-15.95; aOR 10.49 95% CI 6.42-17.12; n=401/38,106); the laparoscopic approach had smaller but significantly increased odds (OR 2.06, 95% CI 1.37-3.08; aOR 2.03 95% CI 1.24-3.34; n=182/90,017) as well.Conclusion: Increased risk of bowel injury is associated with endometriosis and the abdominal surgical approach to hysterectomy. These findings have implications for the surgical care of women with benign uterine disease. [ABSTRACT FROM AUTHOR]

Objective: To report rates and identify risk factors for urinary tract infection (UTI) after hysterectomy for benign conditions or combined with pelvic reconstructive surgery.Methods: This is a cohort study that included women who underwent hysterectomy either for benign gynecologic conditions or hysterectomy combined with pelvic reconstructive surgery from January 1, 2012, through June 30, 2014, at a single institution. The primary outcome was UTI within 8 weeks of surgery. Logistic regression modeling was used to develop a model for predicting UTI after surgery.Results: Of 1,156 women included in the study, 136 (11.8%, 95% CI 10.0-13.8) developed UTI within 8 weeks. Women who underwent hysterectomy for a benign gynecologic condition that was not combined with pelvic reconstructive surgery had an overall UTI rate of 7.3% (95% CI 5.6-9.3) vs 21.7% (95% CI 17.6-26.4) after hysterectomy combined with pelvic reconstructive surgery. After adjusting for hormone therapy use, the following were independent variables associated with postoperative UTI: premenopausal status with an adjusted odds ratio (OR) of 1.80 (95% CI 1.11-2.99), anterior vaginal wall prolapse with an adjusted OR of 4.39 (95% CI 2.77-6.97), and postvoid residual greater than 150 mL with an adjusted OR of 2.38 (95% CI 1.12-4.36). Using this model, postoperative UTI rates ranged from 4.3% to 59.4% with high postvoid residual and presence of anterior prolapse having the strongest association.Conclusion: There are wide variations in the rate of UTI after hysterectomy for begin disease including pelvic reconstructive surgery. These variations can be explained with a model based on available preoperative data. [ABSTRACT FROM AUTHOR]

Objective: To retrospectively compare surgical success and complications between vaginal vault prolapse compared with uterovaginal prolapse in women who underwent apical prolapse repair for stage II-IV prolapse.Methods: Women in one of three Pelvic Floor Disorders Network prolapse surgical trials were included. Absence of bothersome bulge symptoms, no prolapse beyond the hymen, and no subsequent prolapse treatment defined success and was our primary outcome. Secondary outcomes included comparison of quality-of-life measures, anatomic changes, and adverse events. Pelvic organ prolapse quantification (POP-Q) and quality-of-life measures were administered at baseline and 1-2 years postoperatively. Comparisons were controlled for study site, age, body mass index, baseline POP-Q, apical and anterior or posterior repair performed, and prior prolapse repair. Outcomes measured at multiple time points were analyzed using longitudinal models to assess whether differences existed across study follow-up.Results: Four hundred twenty-one women underwent vault prolapse, and 601 underwent uterovaginal prolapse apical repair. The vault prolapse group was older, more likely to be white, and to have prior urinary incontinence or prolapse repair, stage IV prolapse, and more prolapse bother on a validated scale (all P≤.034). The vault prolapse group was more likely to undergo sacrocolpopexy (228/421 [54%] vs 93/601 [15%]); the uterovaginal prolapse group was more likely to undergo vaginal repair (508/601 [85%] vs 193/421 [46%] P<.001). There were no differences in success (odds ratio [OR] 0.76 for vault prolapse vs uterovaginal prolapse, 95% CI 0.51-1.15, P=.20), changes in Pelvic Organ Prolapse Distress Inventory scores (-79.4 vs -79.8, P=.89), postoperative POP-Q point C measurements (-7.0 vs -7.1 cm, P=.41), or serious adverse events (86/421 [20%] vs 90/601 [15%], P=.86) between groups. Among women who underwent a vaginal approach for repair of vault prolapse (n=193) or uterovaginal prolapse (n=508), there were no differences in success rates (OR 0.67, 95% CI 0.43-1.04, P=.09) at 1-2 years postoperatively.Conclusion: Surgical success of stage II-IV vault prolapse and uterovaginal prolapse apical repair was similar whether performed vaginally or abdominally at 1-2 years postoperatively. [ABSTRACT FROM AUTHOR]

Background: Bladder exstrophy is a rare congenital anomaly affecting the lower abdominal wall, pelvis, and genitourinary structures. Pregnant women with bladder exstrophy present a unique challenge to the obstetrician.Case: The patient is a 35-year old pregnant woman with bladder exstrophy, an extensive surgical history, and uterine prolapse with an abnormal, rubbery consistency to her cervix. Prenatally, she was counseled on the potential use of Dührssen incisions to facilitate vaginal delivery. Labor was induced at 36 4/7 weeks of gestation after her pregnancy was complicated by recurrent pyelonephritis. Vaginal delivery was achieved 8 minutes after the creation of Dührssen incisions.Conclusion: The care of pregnant women with bladder exstrophy requires multidisciplinary management and careful delivery planning. Successful vaginal delivery can be attained in these patients. [ABSTRACT FROM AUTHOR]

Graph: John O. L. DeLancey, MD The debate about vaginal mesh for the treatment of pelvic organ prolapse has raged for decades and is ongoing. As Richard TeLinde pointed out at the end of his long and illustrious career, "Every honest surgeon of extensive and long experience will have to admit that he is not entirely and absolutely satisfied with the long-term results of all his operations for prolapse."[2] This remains true today, even though it was hoped that the introduction of vaginal mesh placement for the treatment of pelvic organ prolapse would achieve better long-term outcomes. [Extracted from the article]

Objective: To update clinical practice guidelines on graft and mesh use in transvaginal pelvic organ prolapse repair based on systematic review.Data Sources: Eligible studies, published through April 2015, were retrieved through ClinicalTrials.gov, MEDLINE, and Cochrane databases and bibliography searches.Methods Of Study Selection: We included studies of transvaginal prolapse repair that compared graft or mesh use with either native tissue repair or use of a different graft or mesh with anatomic and symptomatic outcomes with a minimum of 12 months of follow-up.Tabulation, Integration, and Results: Study data were extracted by one reviewer and confirmed by a second reviewer. Studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic absorbable, synthetic nonabsorbable), and outcome (anatomic, symptomatic, sexual function, mesh complications, and return to the operating room). We found 66 comparative studies reported in 70 articles, including 38 randomized trials; quality of the literature has improved over time, but some outcomes still show heterogeneity and limited power. In the anterior vaginal compartment, synthetic nonabsorbable mesh consistently showed improved anatomic and bulge symptom outcomes compared with native tissue repairs based on meta-analyses. Other subjective outcomes, including urinary incontinence or dyspareunia, generally did not differ. Biologic graft or synthetic absorbable mesh use did not provide an advantage in any compartment. Synthetic mesh use in the posterior or apical compartments did not improve success. Mesh erosion rates ranged from 1.4-19% at the anterior vaginal wall, but 3-36% when mesh was placed in multiple compartments. Operative mesh revision rates ranged from 3-8%.Conclusion: Synthetic mesh augmentation of anterior wall prolapse repair improves anatomic outcomes and bulge symptoms compared with native tissue repair. Biologic grafts do not improve prolapse repair outcomes in any compartment. Mesh erosion occurred in up to 36% of patients, but reoperation rates were low. [ABSTRACT FROM AUTHOR]

Objective: To measure the proportion of women with transvaginal prolapse mesh complications and their association with surgeon volume.Methods: We conducted a retrospective, population-based cohort study of all women who underwent a mesh-based prolapse procedure using administrative data (hospital procedure and physician billing records) between 2002 and 2013 in Ontario, Canada. The primary outcome was surgical revision of the mesh. Primary exposure was surgeon volume: high (greater than the 75th percentile, requiring a median of five [interquartile range 5-6] procedures per year) and very high (greater than the 90th percentile, requiring a median of 13 [interquartile range 11-14] procedures per year) volume mesh implanters were identified each year. Primary analysis was an adjusted Cox proportional hazards model.Results: A total of 5,488 women underwent mesh implantation by 1 of 368 unique surgeons. Median follow-up time was 5.4 (interquartile range 3.0-8.0) years. We found that 218 women (4.0%) underwent mesh reoperation a median of 1.17 (interquartile range 0.58-2.90) years after implantation. The hazard of reoperation for complications was only lower for patients of very high-volume surgeons (3.0% [145/3,001] compared with 4.8% [73/2,447], adjusted hazards ratio 0.59, 95% confidence interval 0.40-0.86). In multivariable modeling, younger age, concomitant hysterectomy, blood transfusion, and increased medical comorbidity were all associated with vaginal mesh reoperation.Conclusion: Approximately 5% of women who underwent mesh-based prolapse surgery required reoperation for a mesh complication within 10 years. The risk of reoperation was lowest for surgeons performing 14 or more procedures per year. [ABSTRACT FROM AUTHOR]

Objective: To analyze the association between patient characteristics and the probability of undergoing any uterine-sparing procedure (endometrial ablation, myomectomy, and uterine artery embolization) compared with hysterectomy as the first uterine leiomyoma (index) procedure and the probability of undergoing a specific uterine-sparing procedure.Methods: We conducted a retrospective analysis using a commercial insurance claims database containing more than 13 million enrollees annually. Based on the index procedure performed 2004-2009, women were classified into one of the four procedure cohorts. Eligible women were aged 25-54 years on the index date, continuously insured through 1-year baseline and 1-year follow-up, and had a baseline uterine leiomyoma diagnosis. Logistic regression was used to assess the association between patient characteristics and leiomyoma procedure.Results: The study sample comprised 96,852 patients (endometrial ablation=12,169; myomectomy=7,039; uterine artery embolization=3,835; and hysterectomy=73,809). Patient characteristics associated with undergoing any uterine-sparing procedure compared with hysterectomy included health maintenance organization health plan enrollment, Northeast region residence, the highest income and education quintiles based on zip code, an age-race interaction, and baseline diagnoses including menstrual disorders, pelvic pain, anemia, endometriosis, genital prolapse, and infertility. Among those who had a uterine-sparing procedure, characteristics associated with undergoing uterine artery embolization or endometrial ablation compared with myomectomy included increasing age, being from the Midwest relative to the Northeast, and certain baseline conditions including menstrual disorder, pelvic pain, endometriosis, and infertility.Conclusion: Both clinical and nonclinical factors were associated with the receipt of alternatives to hysterectomy for uterine leiomyomas in commercially insured women. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To compare anatomical and patient- reported outcomes at 12 months postoperatively for women who had anterior compartment pelvic organ prolapse (POP) surgery using a repair augmented with porcine small intestine submucosa mesh (Mesh Group) compared with those who had a native tissue repair (No Mesh Group). METHODS: This was a randomized controlled trial with 12 months follow-up. The surgical procedure was identical in both groups except for the placement of intervening mesh. The primary outcome was anatomical "cure" (Ba of -1 or less on Pelvic Organ Prolapse Quantification [POP-Q]). Secondary outcomes included POP-Q stage, patient-reported outcomes, and patient satisfaction. The study was powered to detect a 40% difference at 80% power (α=0.05). RESULTS: Fifty-seven women were randomized (28 to Mesh Group, 29 to No Mesh Group). Forty-five (79%) underwent concomitant surgery. At the 12-month follow-up, 56% (15/27) in the Mesh Group and 61% (17/28) in the No Mesh Group were considered cured (relative risk 0.90, 95% confidence interval 0.52-1.54). There were no significant differences between groups in recurrent or persistent prolapse (7% in each group) nor in patient-reported outcomes at 12 months. Pelvic girdle pain occurred in 4 of 27 in the Mesh Group and 3 of 28 in the No Mesh Group. CONCLUSION: No significant differences were observed in anatomical or patient-reported outcomes outcome parameters at 12 months after correction of symptomatic anterior POP by mesh or no mesh repair. In our study, porcine small intestine submucosa mesh did not confer additional benefit over a native tissue repair. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To construct and validate a prediction model for estimating the risk of de novo stress urinary incontinence (SUI) after vaginal pelvic organ prolapse (POP) surgery and compare it with predictions using preoperative urinary stress testing and expert surgeons' predictions. MATERIALS AND METHODS: Using the data set (n=457) from the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial, a model using 12 clinical pre-operative predictors of de novo SUI was constructed. De novo SUI was determined by Pelvic Floor Distress Inventory responses through 12 months postoperatively. After fitting the multivariable logistic regression model using the best predictors, the model was internally validated with 1,000 bootstrap samples to obtain bias-corrected accuracy using a concordance index. The model's predictions were also externally validated by comparing findings against actual outcomes using Colpopexy and Urinary Reduction Efforts trial patients (n=316). The final model's performance was compared with experts using a test data set of 32 randomly chosen Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial patients through comparison of the model's area under the curve against: 1) 22 experts' predictions; and 2) pre-operative prolapse reduction stress testing. RESULTS: A model containing seven predictors discriminated between de novo SUI status (concordance index 0.73, 95% confidence interval [Cl] 0.65-0.80) in Outcomes Following Vaginal Prolapse Repair and Mid- urethral Sling participants and outperformed expert clinicians (area under the curve 0.72 compared with 0.62, P<.001) and preoperative urinary stress testing (area under the curve 0.72 compared with 0.54, P<.001). The concordance index for Colpopexy and Urinary Reduction Efforts trial participants was 0.62 (95% Cl 0.56-0.69). CONCLUSION: This individualized prediction model for de novo SUI after vaginal POP surgery is valid and outperforms preoperative stress testing, prediction by experts, and preoperative reduction cough stress testing. An online calculator is provided for clinical use. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To compare surgeons' intraoperative surgeon acceptability or assessment of the operative field regarding bowel contents and patients' satisfaction with or without a mechanical bowel preparation before reconstructive vaginal prolapse surgery. METHODS: In this single-blind, randomized trial, women scheduled to undergo vaginal prolapse surgery with a planned apical suspension and posterior colporrhaphy were allocated using block randomization to an intervention or control group. Surgeons were blinded to patient allocation. One day before surgery, mechanical bowel preparation instructions consisted of a clear liquid diet and two self-administered saline enemas; the participants in the control group sustained a regular diet and nothing by mouth after midnight. The primary outcome was surgeons' intraoperative assessment of the surgical field regarding bowel content as measured on a 4-point Likert scale (1, excellent; 4, poor). Secondary outcomes included participant satisfaction and bowel symptoms. The primary outcome was determined by intention-to-treat analysis and other analyses were per protocol. RESULTS: Of the 150 women randomized (75 women to intervention and control group), 145 completed the study. No differences existed in the demographic, clinical, and intraoperative characteristics between groups (P>.05). Surgeons' intraoperative assessment rating was 85% "excellent or good" with bowel preparation compared with 90% for participants in the control group (odds ratio [OR] 0.59, 95% confidence interval [Cl] 0.21-1.61; P=.30). The bowel preparation group was less likely to report "complete" satisfaction compared with the participants in the control group (OR 0.11, 95% Cl 0.04-0.35; P<.001). Abdominal fullness and cramping, fatigue, anal irritation, and hunger pains were greater in the bowel preparation group (all P<.01). CONCLUSION: Before reconstructive vaginal surgery, mechanical bowel preparation conferred no benefit regarding surgeons' intraoperative assessment of the operative field, reflected decreased patient satisfaction, and had increased abdominal symptoms. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Complications from transvaginal mesh placed for prolapse often require operative management. The aim of this study is to describe the outcomes of vaginal mesh removal. METHODS: A retrospective review of all patients having surgery by the urogynecology group in the department of obstetrics and gynecology at our institution for a complication of transvaginal mesh placed for prolapse was performed. Demographics, presenting symptoms, surgical procedures, and postoperative symptoms were abstracted. Comparative statistics were performed using the X² or Fisher's exact test with significance at P<.05. RESULTS: Between January 2008 and April 2012, 90 patients had surgery for complications related to vaginal mesh and 84 had follow-up data. The most common presenting signs and symptoms were: mesh exposure, 62% (n=56); pain, 64% (n=58); and dyspareunia, 48% (n=43). During operative management, mesh erosion was encountered unexpectedly in a second area of the vagina in 5% (n=4), in the bladder in 1% (n=l), and in the bowel in 2% (n=2). After vaginal mesh removal, 51% (n=43) had resolution of all presenting symptoms. Mesh exposure was treated successfully in 95% of patients, whereas pain was only successfully treated in 51% of patients. CONCLUSION: Removal of vaginal mesh is helpful in relieving symptoms of presentation. Patients can be reassured that exposed mesh can almost always be successfully managed surgically, but pain and dyspareunia are only resolved completely in half of patients. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The uterus can prolapse acutely during pregnancy. We report national trends, characteristics, and obstetric outcomes of women with uterine prolapse (UP). METHODS: Retrospective cohort study using the HCUP-NIS database. Our study cohort included women admitted for delivery between 2004 and 2014 inclusively and had a diagnosis of UP. Multivariate logistic regression analyses compared obstetric outcomes among pregnancies complicated by UP versus those without, while adjusting for confounding variables. RESULTS: Among the 9,096,788 deliveries during our study period, 713 received a diagnosis of UP. The incidence of UP increased over time (P ≤0.0001). Women with UP were likelier to be older, multigravida, smokers, have endometriosis, or fibroids (P ≤0.002, all). They were less likely to have had a previous cesarean delivery (CD) (P <.0001), or multiple gestation (P =.03). Women with UP had lower odds of pregnancy-induced hypertension (aOR, 0.38; 95% CI, 0.25–0.58), preeclampsia (aOR, 0.27; 95% CI, 0.13–0.57), operative vaginal delivery (aOR, 0.41; 95% CI, 0.26–0.64), and CD (aOR, 0.30; 95% CI, 0.23–0.39). They had higher odds of having a spontaneous vaginal delivery (aOR, 3.46; 95% CI, 2.73–4.39), para-delivery hysterectomy (aOR, 21.5; 95% CI, 11.78–29.25), postpartum hemorrhage (aOR, 2.12; 95% CI, 1.56–2.87), wound complications (aOR, 2.72; 95% CI, 1.22–6.09), blood transfusion (aOR, 2.39; 95% CI, 1.43–3.10) or birth of neonates with major congenital abnormalities (aOR, 2.48; 95% CI, 1.18–5.22). CONCLUSION: Women with UP are at higher risk of obstetric complications and neonatal morbidity. These findings elucidate risk factors that may improve prenatal counseling, perinatal surgical management, and clinical practice and policy guidelines. [ABSTRACT FROM AUTHOR]

The article presents research on vaginal prolapse after uterosacral ligament suspension and other vaginal repairs. The retrospective cohort study assesses the risk of the procedure on the recurrent vaginal prolapse among normal-weight versus overweight or obese women. It discusses anterior, posterior, and apical prolapse among the subject patients.

Objective: To report on anatomical and functional outcomes, patient satisfaction, and associated morbidity and mortality in patients undergoing LeFort colpocleisis.Methods: This was a retrospective case series of LeFort colpocleisis performed from January 2000 to October 2011. Data obtained from a urogynecologic database included demographics, comorbidities, medications, and urinary and bowel symptoms. Prolapse was quantified using the pelvic organ prolapse quantification (POP-Q) examination. Operative characteristics were recorded. All patients underwent pelvic examination and POP-Q assessment at follow-up visits. Patients also were asked about urinary and bowel symptoms as well as overall satisfaction. All intraoperative and postoperative surgical complications were recorded.Results: Three hundred twenty-five patients underwent LeFort colpocleisis. Fifteen patients were excluded from the analysis because of incomplete data. The mean age was 81.3±5.3 years. Comorbidities were common, with 74.1% of the patients having at least one concomitant medical condition. The procedure was performed under spinal anesthesia in 67%. Additional procedures at the time of colpocleisis included incontinence procedures (79%) and dilation and curettage (46%). Mean follow-up was 45 (range 2-392) weeks. Anatomical success rate was 98.1% and patients were highly satisfied, with 92.9% reported being "cured" or "greatly improved." Complication and mortality rates were 15.2% and 1.3%, respectively.Conclusion: Colpocleisis is an effective and low-risk procedure with high anatomical success rates and patient satisfaction. Associated morbidity and mortality related to the procedure are low. Colpocleisis remains an excellent surgical option for the elderly patient with advanced pelvic organ prolapse.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

The article discusses the results of a study that examines the rates of perioperative complications and reoperations associated with slings and prolapse surgeries using mesh and biologic grafts. The study showed that in sling procedures, trocar-related bladder perforations are more common than urethral perforations. It concludes that reoperations for complications associated with the use of mesh occurred more after a transvaginal mesh placement in the anterior vagina.

The article discusses the results of a 2-year randomized controlled trial that compares the standard anterior colporrhaphy with reinforced vaginal paravaginal repair that used a synthetic mesh or xenograft in women diagnosed with symptomatic anterior vaginal wall prolapse. The study shows that women with mesh have lower anatomic failure rate that those with porcine and colporrhaphy. It concludes that vaginal paravaginal repair with polypropylene mesh has low anatomic failure rate.

The article focuses on a study which compared the efficacy and safety of trocar-guided tension-free vaginal mesh insertion with conventional vaginal prolapse repair in women with recurrent pelvic organ prolapse. The study included patients diagnosed with recurrent pelvic organ prolapse stage II or higher, who were randomly assigned to either conventional vaginal prolapse surgery or polypropylene mesh insertion. Study authors found lesser anatomic failures following tension-free vaginal mesh insertion compared to conventional vaginal prolapse repair.

The author discusses various issues concerning the use of polypropylene vaginal mesh grafts in gynecology for prolapse and stress incontinence repair. He argues that inserting polypropylene mesh devices into the vagina without bacterial contamination is impossible despite the use of standard antibiotics. He explains the reasons for mesh erosion, along with the factors relevant to the use of mesh grafts for adjunctive therapy of the pelvic organ.

The article discusses the results of a randomized controlled study which compared the outcomes between a vaginal prolapse surgery without mesh and one with mesh. The study noted that about five of the 32 patients in the group of vaginal prolapse with mesh had developed erosions. The U.S. Food and Drug Administration (FDA) has released a notification in October 2008 about the complications from using mesh such as infection, incontinence and visceral injury. Also noted is the benefit and disadvantage of using synthetic interpositional polypropylene mesh.

The article presents the findings of a study aimed at determining success rates after pelvic organ prolapse surgery using different definitions. In the study, 18 different surgical success definitions were evaluated in participants who underwent abdominal sacrocolpopexy and it was revealed that definition of success firmly affected treatment success rates after surgery and was also found that absence of vaginal bulge symptoms postoperatively is related to patient's assessment of improvement.

The article presents a randomized study which compares prospectively the outcomes of anterior colporrhaphy alone with anterior colporrhaphy reinforced with bovine pericardium graft in women with anterior vaginal wall prolapse. It was found that the use of bovine pericardium graft for vaginal prolapse does not have higher complication rates. No significant improvement was observed for anterior colporrhaphy with bovine pericardium reinforcement over colporrhaphy alone at 1- and 2-year follow-up.

The article presents a study which compares postoperative complication and reoperation rates after apical vaginal prolapse surgical repair. Clinical trials and observational studies regarding apical prolapse repair and recurrence rates were included in the study. Results show the rate of complications requiring reoperation.

The article presents a study which examines the anatomic and symptomatic efficacy of graft use in transvaginal pelvic organ prolapse (POP) repair and describes the scope of adverse events associated with it. The study used the transvaginal prolapse repair studies which compared graft use with either tissue repair or repair with different graft for assessing its efficacy. It provides details on the sources, study selection, results, and conclusion drawn from the study.

The article presents a study which investigated the effect of pessary use on the size of the genital hiatus in women wearing a pessary for pelvic organ prolapse in Pittsburgh, Pennsylvania. The study describes the characteristics of patients who continue using pessary and assessed changes in pelvic floor symptoms. It notes the assessment conducted on 90 women seeking nonsurgical management of symptomatic prolapse. It indicates that pessary use decreases the size of genital hiatus.

The article evaluates the effect of a high-fiber diet on constipation in women with pelvic floor disorders. According to the authors, increasing fiber intake gradually to the amount recommended by the U.S. National Academy of Sciences Institute of Medicine improves constipation and its associated symptoms. They add that reducing the incidence and severity of straining in constipated women may help a risk factor for the onset, progression or recurrence of prolapse.

The article discusses the outcome of a randomized controlled trial comparing polypropylene mesh-reinforced anterior vaginal prolapse repair with anterior colporrhaphy. According to the authors, anterior vaginal prolapse repair with polypropylene mesh reinforcement offers lower anatomic recurrence than anterior colporrhaphy at one year. However, the authors add that quality of life and sexual symptoms scores improved in both groups.

The article presents a study that investigates on the role of simulated apical support in anterior and posterior vaginal prolapse appearance. The study was carried out using a modified Pelvic Organ Prolapse Quantification (POP-Q) examination on 197 women with prolapse stage II. It reveals that performance of POP-Q examination is effective with apical support on the position of anterior and posterior vagina.

The article determines whether reinforcement of traditional anterior colporrhaphy with self-tailored low-weight polypropylene mesh would decrease the recurrent prolapse rate in postmenopausal women with anterior vaginal wall prolapse to the hymen or beyond. According to the authors, 38.5% of women in the no-mesh and 6.7% in the mesh group experienced a recurrence of anterior wall prolapse at 12 months. They add 23% with mesh and 10% with no mesh reported stress urinary incontinence.

The article presents obstetrics and gynecology research that estimates the relationship between straining Q-tip angle and pelvic organ prolapse quantification (POP-Q) point Aa in women with stress incontinence and urethral hypermobility. Urethral mobility is a prognostic factor and preoperative criterion for surgery in women.

The article focuses on a study describing the natural history of pelvic organ prolapse and risk factors for changes in vaginal descent in older women. One-year and three-year incidence and resolution risks for prolapse and estimated progression and regression rates and risk factors are examined. Prolapse is defined as maximal vaginal descent to or beyond the hymen.

The article presents the two cases of postoperative pelvic hematomas confirmed on computerized tomography scan after anterior repair with a mesh-augmented anterior vaginal prolapse repair system. Both resolved without requiring drainage, although one patient did require a blood transfusion. Significant complications may arise from this new technology. Further studies are needed to determine whether the benefits of this technology outweigh its risk of use.

The article investigates the role of vaginal delivery and familial factors in the development of pelvic organ prolapse by comparing the prevalence of the condition in nulliparous postmenopausal women with those in their biological sisters who have had at least one vaginal delivery. A familial predisposition is suggested by a high concordance of pelvic organ prolapse in nulliparous and parous sister pairs. Vaginal delivery appears to confer a higher risk for more advanced pelvic organ prolapse.

The article reports on the use of a biomechanical model to explore how impairment of the pubovisceral portion of the levator ani muscle, the apical vaginal suspension complex, or both might interact to affect the anterior vaginal wall prolapse severity. A description of the biomechanical model is presented. An impairment of the muscular and apical supports of the anterior vagina wall could result in the development of a pelvic organ prolapse.

The article presents the five-year anatomic and functional outcomes of the high uterosacral vaginal vault suspension in a study of patients with advanced symptomatic uterovaginal or posthysterectomy prolapse treated between January 1997 and January 2000. A durable procedure for vaginal repair of enterocele and vaginal vault prolapse may be uterosacral ligament vaginal vault fixation. Lower urinary tract, bowel and sexual function may be maintained or improved.

OBJECTIVE: As pelvic organ prolapse progresses, the morphology of the vagina dramatically changes. The objective of this study was to determine whether these changes observed clinically correlate with histologic and biochemical evidence of tissue remodeling METHODS: After informed consent, full-thickness biopsies of the vaginal apex were obtained at the time of surgery from 77 women. The tissue of 15 premenopausal women with less than stage II prolapse (controls) was compared with that of 62 women with prolapse divided according to their menopausal status. All specimens were examined histologically. Scanning confocal microscopic analysis of fluorescent micrographs was used to quantitate collagen subtypes I, III, and V. Collagen fiber orientation was analyzed by scanning electron microscopy. Gelatin zymography was used to quantitate the expression of the proenzyme and active forms of matrix metalloproteinases (MMP) -2 and -9. Median values were compared using Mann-Whitney U or Kruskal-Wallis tests, where appropriate RESULTS: Vaginal collagen fibers are arranged in a whorled pattern, with collagen III as the predominant fibrillar collagen. The amount of total collagen in the vagina was increased in women with prolapse relative to women without prolapse (P = .054) primarily due to increased expression of collagen III (P = .031). There was no difference in the expression of proMMP-2, active MMP-2, or proMMP-9; however, active MMP-9 was increased in patients with prolapse (P = .030) CONCLUSION: The increase in collagen III and active MMP-9 expression in the vaginal tissues of patients with prolapse suggests that this tissue is actively remodeling under the biomechanical stresses associated with prolapse. [ABSTRACT FROM AUTHOR]

Pelvic organ prolapse, including anterior and posterior vaginal prolapse, uterine prolapse, and enterocele, is a common group of clinical conditions affecting millions of American women. This article, designed for the practicing clinician, highlights the clinical importance of prolapse, its pathophysiology, and approaches to diagnosis and therapy. Prolapse encompasses a range of disorders, from asymptomatic altered vaginal anatomy to complete vaginal eversion associated with severe urinary, defecatory, and sexual dysfunction. The pathophysiology of prolapse is multifactorial and may operate under a "multiple-hit" process in which genetically susceptible women are exposed to life events that ultimately result in the development of clinically important prolapse. The evaluation of women with prolapse requires a comprehensive approach, with attention to function in all pelvic compartments based on a detailed patient history, physical examination, and limited testing. Although prolapse is associated with many symptoms, few are specific for prolapse; it is often challenging for the clinician to determine which symptoms are attributable to the prolapse itself and will therefore improve or resolve once the prolapse is treated. When treatment is warranted based on specific symptoms, prolapse management choices fall into 2 broad categories: nonsurgical, which includes pelvic floor muscle training and pessary use; and surgical, which can be reconstructive (eg, sacral colpopexy) or obliterative (eg, colpocleisis). Concomitant symptoms require additional management. Virtually all women with prolapse can be treated and their symptoms improved, even if not completely resolved. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Use axial magnetic resonance imaging to test the null hypothesis that no difference exists in apparent vaginal thickness between women with and those without prolapse. METHODS: Magnetic resonance imaging studies of 24 patients with prolapse at least 2 cm beyond the introitus were selected from an ongoing study comparing women with prolapse with normal control subjects. The magnetic resonance scans of 24 women with prolapse (cases) and 24 women without prolapse (controls) were selected from those of women of similar age, race, and parity. The magnetic resonance files were imported into an experimental modeling program, and 3-dimensional models of each vagina were created. The minimum transverse plane cross-sectional area, mid-sagittal plane diameter, and transverse plane perimeter of each vaginal model were calculated. RESULTS: Neither the mean age (cases 58.6 years ± standard deviation [SD] 14.4 versus controls 59.4 years ± SD 13.2) nor the mean body mass index (cases 24.1 kg/m²± SD 3.3, controls 25.7 kg/m²± SD 3.7) differed significantly between groups. Minimum mid-sagittal vaginal diameters did not differ between groups. Patients with prolapse had larger minimum vaginal cross-sectional areas than controls (5.71 cm²± standard error of the mean [SEM] 0.25 versus 4.76 cm²± SEM 0.20, respectively; P = .005). The perimeter of the vagina was also larger in the prolapse group (11.10 cm ± SEM 0.24) compared with controls (9.96 cm ± SEM 0.22) P = .001. Subgroup analysis of patients with endogenous or exogenous estrogen showed prolapse patients had larger vaginal cross-sectional area (P = .030); in patients without estrogen group differences were not significant (P = .099). CONCLUSION: Vaginal thickness is similar in women with and those without pelvic organ prolapse. The vaginal perimeter and cross-sectional areas are 11% and 20% larger in prolapse patients, respectively. Estrogen status did not affect differences found between groups. [ABSTRACT FROM AUTHOR]

OBIECTIVE: To compare the anatomic and functional outcomes of site-specific rectocele repair and standard posterior colporrhaphy. METHODS: We reviewed charts of all patients who underwent repair of advanced posterior vaginal prolapse in our institution between July 1998 and June 2002 with at least 1 year of follow-up. RESULTS: This study comprised 124 consecutive patients following site-specific rectocele repair and 183 consecutive patients following standard posterior colporrhaphy without levator ani plication. Baseline characteristics, including age, body mass index, parity, previous pelvic surgeries, and preoperative prolapse were not significantly different between the 2 study groups. Recurrence of rectocele beyond the midvaginal plane (33% versus 14%, P = .001) and beyond the hymenal ring (11% versus 4%, P = .02), recurrence of a symptomatic bulge (11% versus 4%, P = .02), and postoperative Bp point (-2.2 versus -2.7 cm, P = .001) were significantly higher after the site-specific rectocele repair. Rates of postoperative dyspareunia (16% versus 17%), constipation (37% versus 34%), and fecal incontinence (19% versus 18%) were not significantly different between the 2 study groups. CONCLUSION: Site-specific rectocele repair is associated with higher anatomic recurrence rates and similar rates of dyspareunia and bowel symptoms than standard posterior colporrhaphy. [ABSTRACT FROM AUTHOR]

Pelvic organ prolapse is a common and growing condition for which women seek help and frequently undergo surgical management. Prolapse of the posterior vaginal wall, alone or in combination with other compartment defects, can be a challenge for the pelvic surgeon. A dear under- standing of the normal anatomy, interactions of the connective tissue and muscular supports of the pelvis, and the relationship or lack of relationship between anatomy and function is required. Vaginal support defects occur with and without symptoms, and many of the symptoms attributed to pelvic organ prolapse can result from other causes. Pelvic pressure, the need to splint the perineum to defecate, impaired sexual relations, difficult defecation, and fecal incontinence are some of the symptoms that have been correlated with rectoceles. Whether the prolapse is the cause of these symptoms or is a result of straining and stretching of support tissues in women with defecation disorders is still unknown. We will present the current literature on these relationships and what evaluations are useful when caring for a woman with a rectocele and defecation disorders. Either pessaries or surgery can be used for treating rectoceles. Several surgical techniques have been described, including transvaginal, trans anal, abdominal, and the use of graft materials to treat both anatomical defects and functional symptoms. The success, rationale, and complications of each approach, induding anatomic cure, impact on defecation, and sexual function, are presented. [ABSTRACT FROM AUTHOR]