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Objective: To identify possible risk factors for exposure, dyspareunia, and pain after insertion of tension-free vaginal mesh in pelvic organ prolapse surgery.Methods: This was a prospective observational cohort study. Consecutive women who underwent surgery with a trocar-guided tension-free vaginal mesh kit were included and evaluated at 6 weeks and at 6 and 12 months after surgery with respect to anatomy and complications. Logistic regression analysis was performed to identify risk factors for exposure, dyspareunia, and pain.Results: Two hundred ninety-four patients were included. Exposure was found in 34 patients (12%). Smoking and total mesh were risk factors for exposure (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.1-8.7 and OR 3.0, 95% CI 1.2-7.0, respectively). Clinical and surgical experience were inversely related to the risk of exposure (OR 0.5, 95% CI 0.3-0.8 per decade). Pain (OR 3.2, 95% CI 1.2-8.4) and dyspareunia (OR 4.7, 95% CI 1.7-12.8) before surgery were predictive for pain and dyspareunia after surgery, respectively. Pain after surgery was found in 35 out of 275 (13%) patients and dyspareunia was found in 77 out of 171 (45%) patients.Level Of Evidence: Smoking, total tension-free vaginal mesh, and experience were predictive factors for mesh exposure. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The objective of the study was to compare the 1 year conventional and composite outcomes of trocar-guided vaginal mesh surgery and the identification of the predictors of failure. STUDY DESIGN: This was a prospective observational cohort study. Failure outcome definitions were as follows: I, prolapse stage II or greater in mesh treated compartments; II, overall prolapse stage II or greater; III, composite outcome of overall prolapse greater than the hymen and the presence of bulge symptoms or repeat surgery. We used logistic regression to identify predictors of failure. RESULTS: The results of the study were 1 year follow-up of 433 patients. Treated compartment failure (I) was 15% (95% confidence interval [CI], 12-19). Overall prolapse failure (II) was 41% (95% CI, 36-45). Composite failure (III) was 9% (95% CI, 7-13). Predictor of failure in all outcomes was the combined anterior/posterior mesh with the uterus in situ. CONCLUSION: Outcome of prolapse surgery depends on outcome definition. The mesh treated compartment failure outcome (I) and the composite failure outcome (III) appeared not to be statistically different. Consistent factor for failure in all outcomes was the combined anterior/posterior mesh insertion with the uterus in situ. [ABSTRACT FROM AUTHOR]

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: Pregnancy and childbirth are risk factors for the development of stress urinary incontinence (SUI). Urinary continence depends on normal urethral support, which is provided by normal levator ani muscle function. Our objective was to compare mean echogenicity and the area of the puborectalis muscle between women with and those without SUI during and after their first pregnancy., Methods: We examined 280 nulliparous women at a gestational age of 12 weeks, 36 weeks, and 6 months after delivery. They filled out the validated Urogenital Distress Inventory and underwent perineal ultrasounds. SUI was considered present if the woman answered positively to the question "do you experience urine leakage related to physical activity, coughing, or sneezing?" Mean echogenicity of the puborectalis muscle (MEP) and puborectalis muscle area (PMA) were calculated. The MEP and PMA during pregnancy and after delivery in women with and without SUI were compared using independent Student's t test., Results: After delivery the MEP was higher in women with SUI if the pelvic floor was at rest or in contraction, with effect sizes of 0.30 and 0.31 respectively. No difference was found in the area of the puborectalis muscle between women with and those without SUI., Conclusions: Women with SUI after delivery had a statistically significant higher mean echogenicity of the puborectalis muscle compared with non-SUI women when the pelvic floor was at rest and in contraction; the effect sizes were small. This higher MEP is indicative of a relatively higher intramuscular extracellular matrix component and could represent diminished contractile function., Competing Interests: Compliance with ethical standards Financial disclaimers None. Conflicts of interest None. Sources of funding None.

Introduction and Hypothesis: Three-dimensional (3D) and four-dimensional (4D) volume transperineal ultrasound imaging is increasingly used to assess changes in the dimensions of the pelvic floor during pregnancy and after delivery. Little is known with regard to the area of the puborectalis muscle and its structural changes. Echogenicity measurement, a parameter that provides information on the structure of muscles, is increasingly used in orthopaedics and neuromuscular disease evaluation. This study is aimed at assessing the changes in the mean echogenicity of the puborectalis muscle (MEP) and the puborectalis muscle area (PMA) during first pregnancy and after childbirth., Methods: The MEP and PMA of 254 women during first pregnancy were measured at 12 and 36 weeks' gestation and 6 months postpartum. To determine the effect of child-birth on MEP and PMA, the results at 6 months postpartum were separately analysed for vaginal deliveries, operative vaginal deliveries (ventouse) and caesarean section deliveries. Mean differences in MEP and PMA were analysed using ANOVA statistics., Results: The MEP at 6 months postpartum was, independent of manoeuvre, significantly (p < 0.001) lower than MEP values during pregnancy. After caesarean delivery, the PMA was significantly smaller at maximum pelvic floor contraction than PMA after vaginal delivery (p = 0.003) or operative vaginal delivery (p = 0.002)., Conclusion: Our study indicates that structural changes in the puborectalis muscle during and after pregnancy, as measured by MEP, occur and can be analysed. In addition, the mode of delivery affects the area of the puborectalis during contraction after delivery. For true volume analysis, as part of an assessment of contractility of the puborectalis muscle we will need 3D volume analysis.

Introduction: The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report., Methods: This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus)., Results: A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 year) review is anticipated to keep the document updated and as widely acceptable as possible., Conclusion: A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research.

Introduction: The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report., Methods: This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus)., Results: A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 year) review is anticipated to keep the document updated and as widely acceptable as possible., Conclusion: A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research., (© 2016 Wiley Periodicals, Inc., and The International Urogynecological Association.)

Introduction and Hypothesis: We compared cure rates and complication rates in patients who had undergone primary or recurrent (secondary) surgery for stress urinary incontinence (SUI)., Methods: A retrospective cohort study that included patients who underwent surgery to treat SUI in a tertiary referral center was carried out. All patients had, predominantly, SUI. Exclusion criteria were patients with a neurogenic bladder or a neobladder and patients without postoperative follow-up (FU). The primary objective was to assess the success rate, defined as cured SUI or improved SUI at six weeks and at the latest available moment of FU. The secondary objective was to assess complications., Results: A total of 541 women with SUI underwent surgery for SUI between 2002 and 2010. After exclusion of 102 patients a total of 242 patients with primary SUI and 197 patients with recurrent SUI were identified. The success rate at first FU was 89 %. At last FU (median 205 days) the success rate was 83 % (P < 0.01). There were no significant differences in success rate between primary and recurrent surgery at first FU. The overall success rate of primary surgery was 86 %; for recurrent surgery it was 79 %. During surgery, 27 bladder injuries occurred (6.2 %), with no significant difference between the two groups. At last FU, 11 patients (2.6 %) had persistent residual volume, necessitating prolonged clean intermittent self-catheterization., Conclusions: The results of recurrent surgery to treat recurrent or persistent SUI are still good in experienced hands and do not significantly differ from results of primary surgery. The complication rates are comparable to those of primary surgery.

Objectives: To develop a semi-automated method to assess puborectalis muscle echogenicity on three-dimensional/four-dimensional (3D/4D) volume transperineal ultrasound images using 4D View and Matlab® software and evaluate its intra- and interobserver reliability., Method: The data of 23 women in their first trimester were included. 3D/4D volume datasets were obtained at rest. Two inexperienced observers were trained by an experienced observer to construct tomographic ultrasound images (TUI) from the original data and to delineate all structures. Puborectalis muscle area (PMA) and the mean echogenicity of the puborectalis muscle (MEP) were calculated offline. Intra- and interobserver reliability were determined by intraclass correlation coefficients (ICC) and their 95% CIs., Results: The development of a semi-automated method to calculate puborectalis area and echogenicity is described in detail. PMA and MEP measurements in pregnant women demonstrated almost perfect intraobserver reliability for both inexperienced observers, with ICC values ranging from 0.88 to 0.99. The interobserver reliability showed ICCs of 0.63 for PMA and almost perfect ICC values, of 0.96-0.98, for echogenicity. The majority of intraobserver mismatch between two delineations of PMA occurred near the borders., Conclusions: Matlab software can be used to provide reliable measurements of the area and echogenicity of the puborectalis muscle. As the latter can be used to assess structural changes in the puborectalis muscle, it appears a promising new tool for studying pelvic floor structural anatomy., (Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.)

Introduction and Hypothesis: The objective of this study was to correlate dynamic magnetic resonance imaging (MRI) with Pelvic Organ Prolapse Quantification (POP-Q) measurements and pelvic floor symptoms in order to determine the value of dynamic MRI for evaluating vaginal vault prolapse both before and 6 months after laparoscopic sacrocolpopexy., Methods: This was a prospective, single-center cohort study in 43 patients who underwent a modified laparoscopic sacrocolpopexy/hysteropexy operation using bone-anchor fixation and synthetic mesh. The study included dynamic MRI, POP-Q staging, and validated questionnaires before and 6 months after laparoscopic sacrocolpopexy. To assess MRI data, the pubococcygeal reference line and specifically defined anatomical landmarks for the separate compartments were used. Differences between pre- and postoperative measurements were evaluated with the Wilcoxon signed-rank test, and correlations at the 0.05 level were considered to be significant (Pearson correlation, two tailed)., Results: At 6 months, a statistically significant improvement was seen in POP-Q staging for all compartments. Dynamic MRI measurements only revealed a significant improvement after surgery for the apical compartment. The correlation between (changes in) MRI measurements, POP-Q measurements, and validated questionnaires was poor., Conclusions: The value of dynamic MRI for evaluating and documenting changes in vaginal vault support and position after laparoscopic sacrocolpopexy is limited due to the poor correlation with both POP-Q staging and pelvic floor symptoms.

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.

Aims: This study focused on the changes in urinary incontinence (UI) rates pre- and postoperatively and identified risk factors which predict the presence of symptoms of urgency urinary incontinence (UUI) or stress urinary incontinence (SUI) after surgery for pelvic organ prolapse (POP) without concomitant or previous anti-incontinence surgery., Methods: All consecutive women who underwent POP surgery without concomitant or previous anti-incontinence surgery in the years 2004-2010 were included. Assessments were performed preoperatively and at 1-year follow-up, including pelvic organ prolapse quantification score and a standardized urogynecological questionnaire (Urogenital Distress Inventory, UDI). Primary outcome of this study was stress and/or urgency UI postoperatively. Furthermore, this study measured the improvement or worsening of UI following surgery using the UDI. Univariable- and multivariable logistic regression with forward selection procedure was used to identify the risk factors., Results: Nine hundred seven patients were included. De novo SUI appeared in 22% and de novo UUI occurred in 21% of the women. At 1-year 42% were cured for UUI and 39% were recovered from SUI by POP surgery alone. The best predictor for the occurrence of postoperative SUI or UUI was the presence of preoperative SUI or UUI. BMI and chronic obstructive pulmonary disease (COPD) were identified as independent risk factors for postoperative SUI. A recurrence in the anterior compartment protected against SUI postoperatively., Conclusions: Preoperative SUI or UUI is the most important predictor of SUI and UUI postoperatively. BMI and COPD were identified as important risk factors for SUI., (Copyright © 2012 Wiley Periodicals, Inc.)

Objective: To evaluate the difference in thickness of the anterior vaginal wall removed after different surgical dissecting techniques of anterior colporrhaphy., Study Design: In patients undergoing primary anterior colporrhaphy, trimmed vaginal tissue was taken following different surgical techniques of vaginal wall dissection. Tissues were preserved in formalin and stained with hematoxylin-eosin and elastica-van Giesen stains. The examiner was an experienced pathologist blinded to the surgical technique. The specimens were examined for the epithelial thickness (ET), lamina propria thickness (LPT), muscular layer thickness (MT) and total thickness (TT)., Results: Tissue was analysed in 93 women who underwent anterior compartment pelvic organ prolapse surgery. There was no difference between the different surgical techniques in thickness measured in the three histological layers and for the total thickness. The use of hydrodissection was the only independent factor leading to thicker removed vaginal tissue., Conclusions: Dissecting the vaginal wall as thin as possible does not result in a thinner vaginal layer than dissecting in the most optimal surgical plane. The use of hydrodissection provides a thicker trimmed tissue., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: Controversial data are available as to whether to perform a simultaneous abdominal or vaginal colposuspension operation in laparoscopic sacrocolpopexy procedures. We wanted to evaluate the effect of a modified laparoscopic operation technique on urodynamic parameters and lower urinary tract symptoms., Design: Prospective single center cohort study., Setting: Teaching hospital., Population: Forty-nine consecutive patients who underwent a modified laparoscopic sacrocolpopexy/hysteropexy operation using bone anchor fixation and synthetic mesh, performed by the same laparoscopic surgeons., Methods: Pre- and postoperative multichannel urodynamic evaluation and validated questionnaires. The same urologist, blinded to the results of the questionnaire survey, interpreted all urodynamic evaluations., Main Outcome Measures: The effects of surgery on pelvic anatomy and patient satisfaction, urodynamic observations and diagnoses and symptom scores in validated questionnaires., Results: Forty-two patients consented to pre- and postoperative urodynamic evaluation. Laparoscopic sacrocolpopexy successfully corrected vaginal vault prolapse in all 42 patients with urodynamic evaluation six months after surgery. The bladder volume at first desire to void was significantly increased and the maximal detrusor pressure at voiding phase was significantly decreased. In the questionnaires, irritative and storage voiding symptoms were significantly decreased., Conclusions: The results of the study demonstrate that there are no adverse urodynamic findings following this modified technique for laparoscopic sacrocolpopexy. The statistically significant urodynamic improvements are in accordance with the scores on the Urogenital Distress Inventory questionnaires. These results do not support a simultaneous routine prophylactic colposuspension procedure., (© 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2012 Nordic Federation of Societies of Obstetrics and Gynecology.)

Introduction and Hypothesis: The aim of this study was to evaluate short-term anatomic and functional outcomes and safety of laparoscopic sacrocolpopexy with bone anchor fixation., Methods: A prospective cohort study of women undergoing laparoscopic sacrocolpopexy between 2004 and 2009. Anatomic outcome was assessed using the pelvic organ prolapse quantification score (POP-Q). Functional outcomes were assessed using the Urogenital Distress Inventory, Defecatory Distress Inventory, and the Incontinence Impact Questionnaire preoperatively and at 6 months postoperatively. The Wilcoxon signed rank test was used to test differences between related samples., Results: Forty-nine women underwent laparoscopic sacrocolpopexy. The objective success rate in the apical compartment was 98%, subjective success rate was 79%. One mesh exposure (2%) was found. One conversion was necessary due to injury to the ileum., Conclusions: Laparoscopic sacrocolpopexy with bone anchor fixation is a safe and efficacious treatment for apical compartment prolapse. It provides excellent apical support and good functional outcome 6 months postoperatively.

Objective: To compare the de novo prolapse rate in the untreated vaginal compartments following conventional vaginal prolapse repair and tension-free vaginal mesh repair., Design: Secondary analysis of a randomised controlled trial., Setting: Thirteen centres in the Netherlands., Population: Women with recurrent pelvic organ prolapse stage II or higher., Methods: Random assignment to either conventional vaginal native tissue repair or vaginal mesh insertion., Primary Outcome: de novo pelvic organ prolapse stage II or higher in the untreated vaginal compartments at 12 months after surgery., Secondary Outcomes: de novo pelvic organ prolapse at and beyond the hymen, de novo prolapse beyond the hymen and prolapse domain scores of the Urogenital Distress Inventory., Results: At 12 months ten of 59 women (17%) in the conventional group versus 29 of 62 women (47%) in the mesh group were diagnosed with a de novo pelvic organ prolapse stage II or higher in the untreated compartment (P < 0.001, odds ratio 4.3, 95% confidence interval 1.9-10.0). Additional apical support to a mesh-augmented anterior repair significantly reduced the de novo prolapse rate. Women with a de novo prolapse in the mesh-treated group demonstrated significantly higher mean bother scores on the domain genital prolapse of the Urogenital Distress Inventory score (13.1 ± 24.2) compared with those without de novo prolapse (2.9 ± 13.9) (P = 0.03)., Conclusion: Mesh-augmented prolapse repair in only one vaginal compartment is associated with a higher de novo prolapse rate in the untreated compartments compared with conventional vaginal native tissue repair in women with recurrent pelvic organ prolapse., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

Introduction and Hypothesis: The objective of this study is to evaluate the complications and anatomical and functional outcomes of the surgical treatment of mesh-related complications., Methods: A retrospective cohort study of patients who underwent complete or partial mesh excision to treat complications after prior mesh-augmented pelvic floor reconstructive surgery was conducted., Results: Seventy-three patients underwent 30 complete and 51 partial mesh excisions. Intraoperative complications occurred in 4 cases, postoperative complications in 13. Symptom relief was achieved in 92% of patients. Recurrence of pelvic organ prolapse (POP) occurred in 29% of complete and 5% of partial excisions of mesh used in POP surgery. De novo stress urinary incontinence (SUI) occurred in 36% of patients who underwent excision of a suburethral sling., Conclusions: Mesh excision relieves mesh-related complications effectively, although with a substantial risk of serious complications and recurrence of POP or SUI. More complex excisions should be performed in skilled centers.

Introduction: Surgical treatment of pelvic organ prolapse (POP) affects sexual function. Generally, this results in improved sexual function, but deterioration is reported also., Aim: The purpose of this study was to evaluate and compare sexual function in patients with recurrent POP undergoing either a vaginal surgical repair with native tissue or a trocar-guided mesh insertion., Methods: Sexually active patients randomly assigned to either native tissue repair or trocar-guided mesh insertion, which had completed the pelvic organ prolapse (POP)/urinary incontinence sexual questionnaire (PISQ-12) both at baseline and at 12 months, were included. Total, subscale, and individual question analysis were performed. Logistic regression was used to identify factors that were independently associated with improvement/deterioration in total PISQ-12 scores., Main Outcome Measures: Primary outcome was sexual function at 12 months following surgery, measured by the short form of the pelvic organ prolapse/urinary incontinence sexual questionnaire (PISQ-12). Secondary outcomes were the identification of factors independently associated with change in PISQ-12 scores and changes in individual PISQ-12 question scores., Results: Sixty patients were included; 32 in the mesh arm and 28 in the native tissue arm. At 12 months, PISQ-12 scores were not different in both treatment arms (34.3, standard deviation [SD] 6.7 vs. 34.7, SD 5.7), but improvement was detected in the native tissue arm, whereas PISQ-12 total score remained unchanged in the mesh arm. Deteriorations were observed in the behavioral/emotive subscale and partner-related items in the mesh arm. In the native tissue arm, significant improvements in the physical and partner-related subscales were observed. The presence of mesh exposure was independently associated with deterioration in total PISQ-12 score., Conclusion: At 12 months, PISQ-12 scores were not different in either treatment arm, but were affected differently by trocar-guided mesh insertion or by native tissue repair. Mesh exposure was independently associated with deterioration in sexual function., (© 2011 International Society for Sexual Medicine.)

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.

We present a case in which a polypropylene mesh was placed over the posterior vaginal wall and was fixed to the sacrospinous ligaments on both sides. Postoperative a rectal obstruction developed which was only resolved after splitting the entire mesh in the midline. It is hypothesised that the obstruction was due to the fixation of the mesh with irresolvable suture material to the sacrospinous ligaments acting as a hinge on which the bowel folded.

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.

Objective: To compare efficacy and safety of trocar-guided tension-free vaginal mesh insertion with conventional vaginal prolapse repair in patients with recurrent pelvic organ prolapse., Methods: Patients with recurrent pelvic organ prolapse stage II or higher were randomly assigned to either conventional vaginal prolapse surgery or polypropylene mesh insertion. Primary outcome was anatomic failure (pelvic organ prolapse stage II or higher) in the treated vaginal compartments. Secondary outcomes were subjective improvement, effects on bother, quality of life, and adverse events. Questionnaires such as the Incontinence Impact Questionnaire and Urogenital Distress Inventory were administered at baseline, 6 months, and 12 months. Anatomic outcomes were assessed by an unblinded surgeon. Power calculation with α=0.05 and β=0.80 indicated that 194 patients were needed., Results: Ninety-seven women underwent conventional repair and 93 mesh repair. The follow-up rate after 12 months was 186 of 190 patients (98%). Twelve months postsurgery, anatomic failure in the treated compartment was observed in 38 of 84 patients (45.2%) in the conventional group and in eight of 83 patients (9.6%) in the mesh group (P<.001; odds ratio, 7.7; 95% confidence interval, 3.3-18). Patients in either group reported less bulge and overactive bladder symptoms. Subjective improvement was reported by 64 of 80 patients (80%) in the conventional group compared with 63 of 78 patients (81%) in the mesh group. Mesh exposure was detected in 14 of 83 patients (16.9%)., Conclusion: At 12 months, the number of anatomic failures observed after tension-free vaginal mesh insertion was less than after conventional vaginal prolapse repair. Symptom decrease and improvement of quality of life were equal in both groups., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00372190., Level of Evidence: I.

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 the study was to report anatomic and functional outcome of midline fascial plication under continuous digital transrectal control and to identify predictors of anatomic failure., Methods: Prospective observational cohort. Anatomic success defined as POP-Q stage or= II underwent midline fascial plication under continuous digital transrectal control. Median follow-up was 14 months (12-35 months), and anatomic success was 80.3% (95% CI 75-86). Independent predictors of failure were posterior compartment POP stage >or= III [OR 8.7 (95% CI 2.7-28.1)] and prior colposuspension [OR 5.6 (95% CI 1.1-27.8)]. Sixty-three percent of patients bothered by obstructed defaecation experienced relief after surgery., Conclusions: Anatomic and functional outcomes were good. Risk factors for anatomic failure were initial size of posterior POP (stage >or= III) and prior colposuspension.

Introduction and Hypothesis: The objective of this study was to assess the effect of the tension-free vaginal mesh (Prolift) procedure on the non-treated and initially unaffected vaginal compartments., Methods: This prospective observational cohort study involved 150 patients who underwent a Prolift procedure. Pelvic organ prolapse (POP) quantification and evaluation of prolapse symptoms with validated questionnaires was performed pre-operatively and 6 and 12 months postoperatively. Primary outcome was the rate of POP stage > or = II in the non-treated vaginal compartments., Results: Twenty-three percent of all patients developed a de novo POP stage > or = II in the untreated compartment. This occurred in 46% and 25% of patients after an isolated anterior and isolated posterior Prolift, respectively., Conclusion: Tension-free vaginal mesh treatment of one vaginal compartment seems to provoke the development of vaginal prolapse in initially unaffected vaginal compartments, particularly after an isolated anterior Prolift procedure.

Introduction and Hypothesis: The objective of this study is to evaluate cervical amputation with uterosacral ligament plication (modified Manchester) and compare it to vaginal hysterectomy with high uterosacral ligament plication procedure with special regard to the middle compartment., Methods: Consecutive women with pelvic organ prolapse who underwent either vaginal hysterectomy or a modified Manchester procedure were included. Assessments were made preoperatively and at 1-year follow-up, including physical examination with pelvic organ prolapse quantification standardised questionnaires (incontinence impact questionnaire, urogenital distress inventory, and defaecatory distress inventory)., Results: Between 2002 and 2007, 156 patients were included. Ninety-eight patients returned for a 1-year follow-up. In the modified Manchester group, we found no middle compartment recurrence versus two (4%) in the vaginal hysterectomy group. Anterior and posterior compartment prolapse recurrences (stage >or=2) were similar (approximately 50%). Considering operating time and blood loss, modified Manchester was more favourable. There was no difference in the pre- and postoperative subjective scores. The overall functional outcome was acceptable., Conclusions: We found an excellent performance of both procedures regarding middle compartment recurrences.

Introduction and Hypothesis: The objective of this study was to report 1 year anatomical and functional outcomes of trocar-guided total tension-free vaginal mesh (Prolift) repair for post-hysterectomy vaginal vault prolapse with one continuous piece of polypropylene mesh., Methods: We conducted a prospective observational cohort study of 46 patients. A minimum sample size of 35 patients was needed to detect a recurrence rate of less than 20% at 12 months. Instruments of measurement used were pelvic organ prolapse quantification and validated questionnaires., Results: Overall anatomical success was 91% (95% confidence interval 83-99), with significant improvement in experienced bother and quality of life. Mesh exposure occurred in seven patients (15%). No adverse effects on sexual function could be detected., Conclusions: Trocar-guided total tension-free vaginal mesh (Prolift) repair with one continuous piece of mesh for post-hysterectomy vaginal vault prolapse is well tolerated and anatomically and functionally highly effective. Results of controlled trials will determine its position in the operative armamentarium.

The objective was to assess the effectiveness of supportive underwear (Pro-Portare) in women with pelvic organ prolapse. Symptomatic women with all stages of prolapse participated in the study and were followed up for 4 weeks. The effectiveness of Pro-Portare was measured by three validated disease-specific quality-of-life questionnaires, a daily diary and a questionnaire on comfort and effectiveness. Thirteen women were included in the study. No improvement on quality of life was found with the use of Pro-Portare. None of the women regarded Pro-Portare as very effective, whereas five women regarded the device as (reasonably) effective. The women's major concern was on the size, shape and hard consistency of the inlet. Two women experienced worsening of their prolapse. Pro-Portare was not effective in the alleviation of prolapse symptoms and was no final solution in any of the women.

Objectives: To determine the safety and efficacy of ultra lightweight titanium coated polypropylene mesh to augment conventional vaginal prolapse repair in women with recurrent symptomatic prolapse stage II or more or primary prolapse stage III or more., Study Design: A prospective observational cohort study was performed at two urogynecological centres in The Netherlands. Women with recurrent symptomatic prolapse at least stage II or primary vaginal prolapse ICS POP stage III or more participated in the study. POP-Q and validated urogynecological questionnaires were used pre- and post-operatively. Outcome measures were mesh-related morbidity and prolapse recurrence, defined as ICS POP stage II, as well as changes in domain scores on urogenital distress- and defaecatory distress inventory (UDI and DDI), incontinence impact questionnaire (IIQ) as well as sexual functioning. Wilcoxon's signed ranks test for paired variables and 95% confidence intervals, respectively were used to analyse these data., Results: The study group comprised 71 patients with a median follow-up of 9 months (6-14). Mesh erosions were detected in four patients (5.6%), all on the posterior vaginal wall. After Ti-mesh((R)) augmentation in 14 patients (36%) the anterior vaginal wall and in 7 patients (18%) the posterior vaginal wall, was categorised as ICS POP stage II and were thus considered failures. UDI and DDI domain scores all improved significantly, except for the domains of incontinence and pain, respectively. Three out of five domains of the IIQ showed significant improvement. Surgery did not have any significant negative impact on sexual functioning., Conclusion: Ultra lightweight titanized polypropylene mesh to augment conventional vaginal prolapse repair surgery showed minimal morbidity, but no additional value compared to conventional surgery at short-term follow-up.

A 28-year-old female sustained an anorectal rupture after a fall from a jet ski. The rupture was sutured and a double-loop colostomy was created. Three months later, following a test of functional continence, the colostomy was removed. The patient recovered without complications and with preservation of faecal continence. During a fall from a jet ski at high speeds, the water behaves as a solid object that penetrates the body. The choice oftreatment depends on the anatomical location and extent of the injury, on the comorbidity, and on a possible delay in the presentation of the symptoms. Wearing ofwetsuits is proposed as a possible preventive measure.

Background: Tension free vaginal tape (TVT) has proven to be successful. Nevertheless, complications of the TVT have been reported. The aim of this study was to describe factors that might influence the efficacy and safety of the TVT procedure in our clinic., Methods: Medical records of all patients who underwent TVT surgery between 1 January 2001 and 1 May 2004 were reviewed. To achieve subjective follow-up, in 2004 and 2005, we sent all patients standardised validated questionnaires. Data were analysed with SPSS., Results: A total of 198 TVT procedures were performed. In 75 cases (37.9%), the procedure was combined with vaginal prolapse surgery. Complications were found in 19.7% of all TVT procedures. Most patients (71%) returned the questionnaire. Median follow-up was 27 months (range: 9-49). Subjective success rate was 73%. Logistic regression analysis showed that success rate of the TVT procedure was not influenced by any of the factors we studied. Complications were not more common in patients who had undergone prior incontinence or prolapse surgery. Concomitant prolapse surgery with the TVT, however, was found to be the only risk factor for complications, mainly prolonged catheterisation., Conclusions: In this study, we found no factor that influenced the success rate of the TVT. In the literature, the experience of the surgeon is marked as a factor influencing the success rate. We, therefore, gradually reduced the number of gynecologists who perform TVT. Concomitant prolapse surgery, however, was shown to be an independent risk factor for complications. Therefore, we prefer to 'separate' prolapse and incontinence surgery.

Objective: To assess morbidity and development in childhood of infants born after temporising management of severe early onset pre-eclampsia., Design: Cohort study with matched controls., Setting: University centre for high risk obstetrics., Samples: Three groups of neonates matched for gender and year of birth: one born after temporising treatment of severe early onset (<32 weeks) pre-eclampsia with an average delay of delivery of two weeks (n= 193); one born at the duration of pregnancy [1 week] of the pre-eclamptic mother on admission (control group I, n = 192); and one born at the same gestational age [1 week] as the infant of the pre-eclamptic mother (control group II, n= 189)., Method: Follow up at four years of age or more using medical records and questionnaires., Main Outcome Measures: The presence of various morbidities including mental retardation, cerebral palsy, motor skill problems, visual handicap, hearing loss, speech and language problems, education level and acute or chronic respiratory problems., Results: Median follow up of seven years (range 4-12) was achieved in 159 infants in the study group (83%), 122 in control group I (64%) and 110 in control group II (58%). Missing data analysis showed no differences in neonatal characteristics and morbidity between infants with and without follow up in the study group. All major and minor handicaps were less frequent in the study group than in control group I but statistical significance was reached only for acute and chronic respiratory disorders in the study group (13.8%) compared with control group I (27%)., Conclusion: Average delay of delivery of two weeks with temporising management in severe early onset pre-eclampsia is associated with a reduced risk of respiratory disorders in childhood.

Background: A laparoscopic modification of the sacrocolpopexy procedure with mesh and bone anchor fixation with the Franciscan laparoscopic bone anchor inserter was developed., Methods: We developed a laparoscopic bone anchor inserter for the placement of a titanium bone anchor in sacral segment 3 as fixation for the mesh in laparoscopic sacrocolpopexy procedures performed in women with posthysterectomy vault prolapse., Results: Surgery successfully corrected vaginal vault prolapse. Laparoscopic bone anchor insertion with this new and simple device took 2 minutes and provided a firm anchor for mesh fixation. MRI demonstrated an anatomically preferable vaginal axis toward the hollow of the sacrum., Conclusion: Application of the newly developed Franciscan laparoscopic bone anchor inserter in laparoscopic sacrocolpopexy is an easy and safe procedure that provides firm fixation and excellent anatomical results.

Objective: To assess the effect of prolongation of pregnancy on neonatal outcome by means of hemodynamic treatment in patients with early-onset preeclampsia., Study Design: A retrospective case-controlled study of 222 liveborn infants of patients with early-onset (24--31 weeks) preeclampsia, who underwent temporizing hemodynamic treatment. Of the two control groups of liveborn preterm infants of non-preeclamptic mothers one group was matched with the study group for gestational age on admission (group I), one for gestational age at birth (group II). Primary outcome measures were neonatal and infant mortality and variables of neonatal morbidity., Results: Median gestation in the study group of preeclamptic patients was prolonged from 29.3 to 31.3 weeks. No difference in neonatal or infant mortality was observed between infants from preeclamptic mothers and in the control groups. The study population showed better results than control group I with regard to admission to NICU (P<0.01), mechanical ventilation (P<0.001) and intracranial hemorrhage (P<0.01). Control group II had better results than the study group with respect to birthweight (P<0.001), bronchopulmonary dysplasia (P<0.01), patent ductus arteriosus (P<0.01), and retinopathy (P<0.01)., Conclusion: Prolongation of gestation in patients with early-onset preeclampsia may reduce neonatal morbidity, but neonates of the same gestational age without a preeclamptic mother still have a better prognosis.

Osteomyelitis of the proximal femur was diagnosed in a 5-month-old girl after BCG vaccination at the age of 2 weeks. The diagnosis was confirmed by biochemical and molecular techniques (DNA fingerprinting). The girl responded well to antituberculous treatment.