Letter to Editor: “Utility of patient decision aids (PDA) in stress urinary incontinence surgery” by Jha and Duckett 2019

Re: Abdelrahman A, Moore A, Trochez R. Use of surgical databases in urogynaecology

Commentary on ‘Surgical treatment of primary uterine prolapse: a comparison of vaginal native tissue surgical techniques’

Perineal hernia repair using permanent suture and mesh: a video case presentation Abstract Introduction Perineal hernias are an uncommon cause of pelvic bulge symptoms in women with no established ideal surgical approach. We present the case of a posterior perineal hernia repaired robotically using permanent sutures and mesh. Methods A 67-year-old woman with a posterior perineal hernia and stage III uterovaginal prolapse presented to our office and underwent minimally invasive robotics-assisted abdominal surgery. Her levator plate defect was closed primarily using permanent sutures and reinforced using polypropylene mesh. A concomitant supracervical hysterectomy and sacrocolpopexy were performed. Results Robotics-assisted transabdominal perineal hernia repair offered excellent intra-operative visualization and complete delineation of the defect. Conclusions Robotics-assisted abdominal primary repair of the perineal hernia and overlying mesh placement offered a safe and effective repair of this rare disorder.

Complete laparoscopic removal of retropubic midurethral tape (tension-free vaginal tape) from the obturator nerve: a multidisciplinary approach

Robot-assisted laparoscopic sacrocolpopexy with autologous fascia lata: technique and initial outcomes Abstract Introduction and hypothesis Pelvic reconstructive surgery is increasingly being performed with autologous grafts to avoid complications of synthetic mesh and improve the durability of a native tissue repair. Autologous fascia lata (AFL) provides a reliable source of robust connective tissue to improve surgical outcomes. We present our technique and initial experience with performing robotic sacrocolpopexy (RSC) augmented with AFL. Methods A retrospective review was conducted of patients who underwent RSC with AFL between January 2015 and November 2017. Outcomes evaluated include recurrence of prolapse on physical examination, prolapse symptoms, urinary incontinence, patient satisfaction based on the Patient Global Impression of Improvement (PGI-I) and complications. Results Twelve patients were identified with a median age of 68 years (range, 46–77 years) at the time of RSC with AFL. Eleven patients had a history of prior sling and/or vaginal mesh. The median operative time was 225 min (177–302 min). There were no intra- or postoperative complications. After a median follow-up of 14.7 months (5.7 to 39 months), the median PGI-I response was 2 (range, 1–3, very much to a little better). No recurrent or persistent apical prolapse was observed. Three patients (25%) reported recurrence of sensation of a vaginal bulge, which were all due to anterior vaginal wall prolapse. Conclusions RSC can be performed with AFL and should be considered in patients with a history of mesh complications. Overall patient satisfaction was high. While these short-term outcomes are encouraging, further studies are needed to assess long-term durability of anatomic results.

The association of vulvar pain and urological urgency and frequency: findings from a community-based case–control study Abstract Introduction and hypothesis Vulvodynia is chronic debilitating burning vulvar pain or pain on contact. Although women who suffer from vulvodynia are more likely than others to experience co-morbid interstitial cystitis (IC) and urinary tract infections (UTIs), few studies have explored whether women with vulvodynia experience adverse urinary symptoms (lower urinary tract symptoms [LUTS]) in the absence of urological pain. Methods Two hundred and eleven participants with and 226 participants without clinically confirmed vulvodynia completed the Pelvic Pain and Urgency/Frequency (PUF) questionnaire and were scored using all questions, and then a subset of questions relating only to their current frequency and bother of urination during day and night, and the frequency, severity and bother of urgency after voiding. Total, symptom, and bother scores were compared in women with and without vulvodynia, and regression models estimated adjusted odds ratios and 95% confidence intervals for the various LUTS symptoms. Results As expected, 40% of women with vulvodynia met the criteria for IC (PUF > 12) compared with 2% without vulvodynia. After excluding questions related to bladder or vulvovaginal pain, women with vulvodynia, compared with those without, were skewed toward higher PUF scores, including being 2.4 times more likely to report usually or always bothered by night-time voiding (95% CI 1.22–4.74), and 18 times more likely to report moderate/severe urgency after urination (95% CI 5.48–64.12). Conclusions Women with vulvodynia are substantially more likely to report voiding dysfunction and symptoms of urgency than women with no history of vulvar pain. These findings are independent of comorbid interstitial cystitis or history of UTIs.

Comparing the effectiveness of functional electrical stimulation via sexual cognitive/behavioral therapy of pelvic floor muscles versus local injection of botulinum toxin on the sexual functioning of patients with primary vaginismus: a randomized clinical trial Abstract Introduction and hypothesis Most patients suffering from vaginismus feel sinful, anxious, and incompetent, with reduced self-confidence. This study was aimed at comparing the effectiveness of the physiotherapy of pelvic floor muscles as a standard treatment and local injection of botulinum toxin on the sexual functioning of patients with primary vaginismus. Methods In this randomized clinical trial (RCT), the study population included women with primary vaginismus referred to the Sexual Health and Gynecologic Clinics of Imam Khomeini Hospital during 2013–2014. They were diagnosed according to DSM-5 criteria and underwent treatments with botulinum injection (intervention group) and physiotherapy as the current treatment (control group). The participants’ primary and secondary outcomes were measured based on successful intercourse and sexual functioning of each group. Results The results indicated that the overall standard physiotherapy, along with other measurements, such as functional electrical stimulation and desensitization, could effectively improve the patients’ Female Sexual Function Index compared with botulinum treatment. At the end of the study, it was found that 20 and 26 patients out of the 30 and 28 patients in the intervention and control groups managed to have successful intercourse respectively (P = 0.014). Also, sexual dysfunction frequencies were seen to be decreased by 26.6% and 50% in the mentioned groups respectively (p = 0.008 and p < 0.001). Conclusions Considering the higher efficacy of physiotherapy procedures compared with those of the desensitization and electrical stimulation techniques, this therapeutic method should be considered the first-line treatment of vaginismus (IRCT2016061828486N1).

Outcomes of intravesical chondroitin-sulfate and combined hyaluronic-acid/chondroitin-sulfate therapy on female sexual function in bladder pain syndrome Abstract Introduction and hypothesis Our aim was to determine the efficacy of intravesical chondroitin sulfate (CS) and combined hyaluronic acid/chondroitin sufate (HA/CS) treatment and their effects on sexual function of females with interstitial cystitis/bladder pain syndrome (IC/BPS). Methods A total of 68 female patients with IC/BPS between 2012 and 2018 were reviewed. Thirty-three patients were treated with combined HA/CS and 28 patients were treated with CS. Instillations were performed weekly for the first month, biweekly for the second month, and monthly in the third and fourth months. Before and after the sixth month of the treatment, all patients were evaluated with the Female Sexual Function Index (FSFI), visual analog pain scale (VAS), interstitial cystitis symptom index (ICSI), interstitial cystitis problem index (ICPI), and voiding diary, and changes were recorded. Results A statistically significant improvement was determined for FSFI, VAS, ICSI, and ICPI scores after treatment in both groups. Among baseline characteristics, a weak but significant negative correlation was determined only between the ICSI score improvement and age (rho: −0.38; p = 0.03) on statistical analysis. Compared with CS, combined HA/CS treatment was superior in terms of ICSI, ICPI, and daytime and nighttime frequency improvement (0.042, 0.038, 0.039, and 0.045; respectively). All domains of the sexual function index were significantly improved at the sixth month of intravesical therapy in both groups. A statistical difference was not found between the two groups. Conclusions Although it seems that intravesical HA/CS combination is superior to CS alone in terms of symptom reduction, both of them have beneficial effects on sexual function.

Surgical treatment of primary uterine prolapse: a comparison of vaginal native tissue surgical techniques Abstract Introduction and hypothesis Uterine prolapse is a common diagnosis. Today no consensus exists on which operation technique is ideal to treat apical prolapse. Vaginal hysterectomy (VH) with suspension of the vaginal cuff is the most frequently used. The popularity of uterus-preserving techniques is increasing. The aim of this study was to compare the efficiency of vaginal native tissue operations to treat primary apical prolapse, evaluated on risk of relapse surgery. Methods Data were obtained from the Danish National Patient Registry (NPR), which contains all operations performed in Denmark. Patients operated on for primary apical prolapse in Denmark 2010–2016 were included and followed until 2017. Clinical data were obtained from the Danish Urogynecological Database. Patients who were previously hysterectomized or operated on for prolapse in the apical compartment were excluded. Data were analyzed using Cox proportional hazard regression analysis and adjusted for age, BMI, smoking, preoperative prolapse stage and previous POP operations. Results In total, 7247 operations were included. The hazard ratio (HR) for relapse operation in the apical compartment was significantly higher after sacrospinous hysteropexy (SH) compared with the Manchester-Fothergill procedure (MP) [40.2 confidence interval (CI) 21.6–74.7] and VH (8.5 CI: 6.0–12.1). Likewise, the HR was higher in the anterior compartment after SH compared with MP (4.3 CI: 2.9–6.4) and VH (2.8 CI: 2.0–4.0). No convincing difference was found in the posterior compartment. The 5-year reoperation rates were 30%, 7% and 11% after SH, MP, and VH, respectively. Conclusions Sacrospinous hysteropexy has exceedingly high numbers of reoperations due to prolapse recurrence.