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Introduction and hypothesisOf women with symptomatic prolapse, 13-39% experience voiding dysfunction (VD). The aim of our observational cohort study was to determine the effect of prolapse surgery on voiding function.MethodsRetrospective analysis of 392 women who underwent surgery between May 2005 and August 2020. All had a standardized interview, POP-Q, uroflowmetry and 3D/4D transperineal ultrasound (TPUS) pre-and postoperatively. Primary outcome was change in VD symptoms. Secondary outcomes were changes in maximum urinary flow rate (MFR) centile and post-void residual urine (PVR). Explanatory measures were change in pelvic organ descent as seen on POP-Q and TPUS.ResultsOf 392 women, 81 were excluded due to missing data, leaving 311. Mean age and BMI were 58 years and 30 kg/m(2), respectively. Procedures performed included anterior repair (n = 187, 60.1%), posterior repair (n = 245, 78.8%), vaginal hysterectomy (n = 85, 27.3%), sacrospinous colpopexy (n = 170, 54.7%) and mid-urethral sling (MUS) (n = 192, 61.7%). Mean follow-up was 7 (1-61) months. Pre-operatively, 135 (43.3%) women reported symptoms of VD. Postoperatively, this decreased to 69 (22.2%) (p < 0.001), and of those, 32 (10.3%) reported de novo VD. The difference remained significant after excluding concomitant MUS surgery (n = 119, p < 0.001). Postoperatively, there was a significant decrease in mean PVR (n = 311, p < 0.001). After excluding concomitant MUS surgery, there was a significant increase in mean MFR centile (p = 0.046).ConclusionsProlapse repair significantly reduces symptoms of VD and improves PVR and flowmetry.

Background The negative media attention surrounding vaginal mesh procedures has seen a rise in demand for minimally invasive non-mesh options for the treatment of stress urinary incontinence (SUI). The laparoscopic Burch colposuspension (LBC) is a non-mesh alternative to synthetic midurethral slings (MUS) with similar short-term outcomes. However, long-term outcomes are not well established. Aims To evaluate the long-term outcomes of LBC for treatment of SUI in women. Material and methods One hundred and fifty-one cases of LBC were performed by a single surgeon over two private hospital settings between January 2010 and January 2016. Follow-up subjective outcomes were obtained in 137 cases (90.7%) utilising standardised questionnaires. Primary outcome was successful treatment of SUI, defined as subjective cure or significant improvement of stress incontinence symptoms. Secondary outcomes included new-onset or worsened symptoms of overactive bladder (OAB), voiding dysfunction, prolapse, and perioperative complications. Results One hundred and thirty-seven patients were analysed with a mean follow-up of 50.6 months (range: 13-89 months). Primary outcome of successful treatment was achieved in 90.5% of women. New-onset or worsened symptoms of OAB was reported in 10.2%, with a further 8.8% of women experiencing symptomatic voiding dysfunction. Sixteen patients (11.7%) reported new-onset or worsening symptoms of prolapse. There were no major surgical complications. Conclusions LBC is a safe and effective long-term treatment for SUI, with low failure rates and minimal adverse outcomes. It is a suitable alternative for women with contraindications to mesh or those having concomitant laparoscopic procedures.

Aim To compare 2-year outcomes of laparoscopic sacrocolpopexy (LSCP) either with polyvinylidene fluoride (PVDF) or hybrid polypropylene containing a resorbable polyglecaprone (PP+ PG) mesh. Materials and methods Retrospective audit on 105 consecutive patients undergoing LSCP a with PVDF-mesh (DynaMesh, FEG Textiltechniken), matched by prolapse stage and cervicopexy or vault suspension to 105 controls undergoing LSCP with a hybrid PP + PG-mesh (Ultrapro, Ethicon). Patients are part of an ongoing prospective study. The primary outcome measure was the Patient Global Impression of Change score (PGIC), the coprimary variable was failure rate at the vault (≤1 cm). Other outcomes were intraoperative and postoperative complications within 3 months categorized by the Clavien-Dindo classification, reinterventions, graft-related complications (GRCs) and functional outcomes. All assessments were performed by an independent assessor. Data are reported as median (interquartile range) number and percent as appropriate, the Mann-Whitney U, χ2 , or Fisher exact were used for comparison. Results Patient satisfaction in the PVDF group, as measured with the PGIC, was high (90.9% PGIC, ≥4) as well as was the anatomical success (97.3%) at a follow-up of 26 months. These outcomes were comparable to those of PP + PG-patients (84.8% PGIC, ≥4; 94.9% anatomical success). There were five patients (2.4%) with Dindo-III or higher complications and three patients had GRCs (1.5%), without differences between mesh type. Level-II posterior defects (Bp ≥ -1) were less likely in PVDF patients (34.1% vs 50% for PP + PG-patients; P = .003). Women in the PVDF group also were less bothered by prolapse (7.5% vs 26.4%; P = .001), yet they complained more of constipation (15.0% vs 9.0%; P = .01). Conclusion There were no differences in patient satisfaction and anatomical outcomes after LSCP either with PVDF or PP + PG mesh.

Background Data concerning laparoscopic sacrocolpopexy (LSCP) in elder women are scarce. We compared intra-operative and early-postoperative complications associated with laparoscopic colpo-, cervico-, or hysteropexy in women under and above 70 years. Methods Retrospective assessment by an independent investigator of a prospective cohort of 571 consecutive women undergoing LSCP in a tertiary unit over an 18-year period. Data included were patient demographics, operative variables, intra-operative, and early (≤ 3 months) postoperative complications. Complications were graded according to the Clavien-Dindo classification and mesh complications categorized using the International Urogynaecological Association (IUGA)-classification. Findings Median age was 66 (IQR 15, range 27-91) and 204 (35.7%) patients were older than 70 years. There were no deaths. Strategic conversion rate was 2.3% (13/571), the majority because of extensive adhesions yet early in our experience. Reactive conversion rate was 0.7% (4/571). Among 554 patients who had a completed LSCP, there were 20 intra-operative complications (3.6%), mostly bladder (1.3%) and vaginal (1.1%) injuries. Eighty-four patients had a total of 95 early-postoperative Dindo ≥ II complications (15.1%). Most common complications were infectious and treated medically (Dindo II). Clinically major complications are rare (III = 3.1% and IV = 0.2%). Reoperation for suspected bleeding (IIIb = 0.7%) was the most common reintervention, typically without demonstrable cause. Most mesh complications were vaginal exposures. Septuagenarians were not more likely to have an intra-operative (4.0 vs 3.3% p = 0.686) or early-postoperative complication (13.6 vs 16.0% p = 0.455) than younger patients. Mesh complications were also equally uncommon. Conclusions LSCP is as well-tolerated by women above 70 years as by younger women.

Endometriosis is a common gynecological condition which affects 5-10% of women of reproductive age and up to 50% of women with pelvic pain and infertility. The most commonly affected areas are the pelvic peritoneum, ovaries and rectovaginal septum. Isolated endometriosis of the sciatic nerve is very rare. Our patient suffered from worsening right hip and buttock pain with severe exacerbation during menstruation. Several different imaging modalities (ultrasound of her pelvis and right hip, as well as X-rays and computed tomography scans of her right hip and lumbosacral spine) failed to identify any pathology. Magnetic resonance imaging scans of her pelvis revealed a 3.5 cm endometriotic lesion over the pelvic segment of her right sciatic nerve. Following a multidisciplinary discussion, the patient underwent laparoscopic excision of endometriosis. The patient recovered well from her surgery. She successfully conceived with in vitro fertilization 3 years after her surgery, following a failed course of Clomid (Clomiphene citrate) for ovulatory dysfunction.

Introduction and hypothesis Vaginal flatus is an embarrassing condition that can impair women's quality of life. The underlying pathophysiology is unclear. We aimed to evaluate the association between vaginal flatus and pelvic floor anatomy. Methods Retrospective observational study on women seen in a tertiary urogynaecological service. All had undergone a standardised interview, clinical examination and four-dimensional transperineal ultrasound. Offline analysis of volume data was performed blinded against clinical data. Results Datasets of 570 women were analysed. Five hundred twelve (90%) were vaginally parous. Vaginal flatus was reported by 190 (33%). Mean bother score was 4.2 (SD 3.4, range 0-10). One hundred eighty-five reported frequency of vaginal flatus: it occurred < once a month in 25 (14%), once a month in 70 (38%), once a week in 47 (25%), once daily in 28 (15%) and > once daily in 15 (8%). One hundred two women identified the following precipitating factors: intercourse in 72 (71%), postural change in 22 (22%) and physical activities in 9 (9%). Vaginal birth, central and posterior compartment prolapse, anal incontinence, higher levator resting tone and younger age were associated with vaginal flatus. The latter was moderately correlated with symptom bother (correlation coefficient - 0.21). Conclusions Vaginal flatus is a prevalent and bothersome condition affecting one-third of our study population. The condition is associated with pelvic floor functional anatomy. A higher resting tone may confer a higher resistance against which trapped air is expelled during physical activities. Younger age was moderately correlated with symptom bother.

To report long-term outcomes after laparoscopic sacrocolpopexy.We conducted a prospective descriptive cohort study on 331 consecutive patients who underwent laparoscopic sacrocolpopexy for symptomatic prolapse (Pelvic Organ Prolapse Quantification [POP-Q] system stage 2 or greater) at one center, with minimum 1.5 years of follow-up by April 30, 2014. Primary outcome measures were Patient Global Impression of Change score and failure at the apex (C≥-1 cm; POP-Q stage 2 or greater). Secondary outcomes were anatomical failure in other compartments, duration of follow-up, occurrence and time point of complications, reinterventions, and functional outcomes by response to a standardized 24-question interview on prolapse and bladder, bowel, and sexual function. Assessment was by an experienced clinician not involved in patient management.The follow-up rate was 84.6% (280/331); 185 of 331 (55.9%) patients were both physically examined and interviewed, and 95 of 331 (25.7%) were interviewed only. The median age at interview was 72 years (interquartile range 13 years), with a follow-up period of 85.5 months (interquartile range 46 months). Approximately 83% (231/280) reported improvement; 5.7% (16/280) were unchanged, 5.7% (16/280) felt slightly worse, and 6.8% (17/280) reported clear deterioration. Anatomical failure at point-C was 8.6% (16/185); anterior (22.2%, 41/185) and posterior (28.6%, 53/185) prolapse were more common than apical prolapse. Of those with level-I anatomical cure, 10.1% (17/185) felt worse; half of them (9/17) because of prolapse in another compartment. The others had urinary problems (41.2%, 7/17), obstructive defecation (11.8%, 2/17), or dyspareunia (11.8%, 2/17). Conversely, the majority of patients with recurrence at the vault (62.5%, 10/16) self-reported to be improved. The reoperation rate was 17.8% (48/270), including 19 (7.0%) for graft-related complications and nine (3.3%) for prolapse.More than four out of five patients (82.5%) felt improved 86 months after laparoscopic sacrocolpopexy. Of those not improved, two thirds had recurrent prolapse; however, typically mid-vaginal. The other third reported urinary or bowel problems or dyspareunia. Reintervention for prolapse was 3.3%. The most common reasons for reoperation were graft-related complications (7.0%) and urinary incontinence (6.7%).

Postoperative pain is related to the gas used for laparoscopy as demonstrated for 100 % nitrous oxide in 2002 by Tsereteli. In a previous trial, we demonstrated that the use of full conditioning adding 10 % nitrous oxide and 4 % oxygen to the CO2 pneumoperitoneum with humidification and altering the temperature of the insufflation gas, the use of Hyalobarrier gel, and the administration of 5 mg dexamethasone significantly reduced postoperative pain and decreased adhesions. As we believed that just altering the insufflation gas by adding 10 % of nitrous oxide and 4 % of oxygen would reduce pain and adhesions by itself, we performed a randomized controlled trial on women undergoing robot-assisted laparoscopic myomectomy. Fourteen women undergoing robot-assisted laparoscopic myomectomy were randomized 1:1 receiving 86 % CO2 + 10 % N2O + 4 % O2 or 100 % CO2. Outcome parameters were postoperative pain (visual analog scale (VAS)) and adhesions observed at second-look laparoscopy after 14 days. Pain and painkiller intake were significantly reduced by using the altered insufflation gas (p < 0.05). Adhesions did not show a significant difference, although the study group tended to have less adhesions (p < 0.21). Addition of 10 % N2O and 4 % O2 to the pneumoperitoneum significantly decreased postoperative pain, even in a low number of participants, which suggests a strong effect.

The improved cosmesis and recovery from minimally invasive techniques has seen a dramatic rise in its popularity. Unfortunately, the laparoscopic myomectomy for large fibroids presents a unique challenge to the surgeon. It is reputed to be difficult and time consuming, with a high risk of conversion to laparotomy. As laparoscopic techniques improve, the laparoscopic myomectomy for larger fibroids is becoming more feasible. This article outlines the case of laparoscopic removal of a 4.2 kg fibroid with the assistance of a minilaparotomy.

We herein describe the operative approach of a postmenopausal woman with a history of surgically corrected congenital bladder exstrophy-epispadias who presented with long-standing complete procidentia. The patient was initially treated by laparoscopic sacral colpopexy in conjunction with a modified Elevate mesh kit anterior vaginal repair with and posterior vaginal wall repair in the form of native tissue suture plication repair. Her prolapse recurred 8 months' later due to a detachment of the mesh at the level of the promontorium. During the second-look laparoscopy, a resuspension of this mesh was deemed unsatisfactory; therefore, with patients' consent, a successful colpocleisis was performed. This case report emphasizes the complexity of pelvic organ prolapse (POP) in the context of a bladder exstrophy-epispadias complex. These women are more likely to fail the more conventional current surgical treatments for POP, coercing to revert to colpocleisis.

Complications and satisfaction with anterior and/or posterior prolapse repair using a transobturator polypropylene mesh (Prolift) in a single center prospective cohort was assessed. Among 30 women six mesh erosions were noted, five (17%) after anterior and one (3%) with combined anterior and posterior procedures. The patients' impression after six months was 'better' to 'much better' in 25 (84%), no change in four (13%) and one was worse (3%). At six months one patient had suffered re-appearance of an anterior prolapse and one had relapse of both an anterior and posterior prolapse. Concomitant procedures were not significantly related to risk of erosion, but the erosion group was younger (mean age 58 vs. 67 years, p < 0.0001). After polypropylene transobturator mesh for pelvic organ prolapse relapses do occur. Safety may be hampered by a high rate of mesh erosions.