An animal experimental study on pubourethral ligament restoration with platelet rich plasma for the treatment of stress urinary incontinence.

Introduction: Minimally invasive methods for injured ligament and tendon restoration have been developed and gained popularity in recent years. Injury and relaxation of the pubourethral ligament (PUL) can lead to stress urinary incontinence (SUI). The aim of this study was to investigate the impact of injecting platelet rich plasma (PRP) into the PUL following its surgical transection resulting in SUI, confirmed by leak point pressure (LPP) measurements pre- and post-intervention in an experimental animal model. Material and methods: Twenty female adult Sprague-Dawley rats were assigned in 2 groups: 1) treatment group with transection of the PUL and application of PRP at the time of transection and at one month follow-up and 2) a control group, with transection of the PUL only. Leak point pressures (LPPs) were measured prior to transection, immediately following the transection and at 1 and 2 months in both groups. Results: The median LPPs for the control group were: LPP - preT: 35.6 (29.8-44.8) cmH2O, LPP - postT: 14.6 (5.8-19.0) cmH2O, LPP - 1 month: 27.3 (19.2-33.8) cmH2O, LPP - 2 months: 29.0 (27.0-34.0) cmH2O, whereas for the PRP group were: LPP-preT: 40.5 (33.2-46.3) cmH2O, LPP - postT: 15.7 (3.0-24.0) cmH2O, LPP - 1month: 31.6 (24.8-37.4) cmH2O, LPP - 2 months: 36.8 (32.5-45.4) cmH2O. PRP injections on transected PULs significantly increased LPPs at one month follow-up [31.6 cmH2O vs. 27.3 cmH2O, p = .043]. This effect was confirmed at two months [36.8 cmH2O vs. 29.0 cmH2O, p <.001]. Conclusions: Injection of PRP into transected PULs significantly improved LPPs at one and two months' follow-up. However, further experimental and clinical research is needed to evaluate the safety and efficacy of this treatment, in clinical practice

Mesh-Free Laparoscopic High Uterosacral Ligament Suspension during Total Laparoscopic Hysterectomy for Uterine Prolapse.

STUDY OBJECTIVE: To demonstrate a mesh-free approach for uterine prolapse during a hysterectomy. DESIGN: Technical video (Canadian Task Force classification III). SETTING: Benign gynecology department at a university hospital. PATIENT: A 50-year-old woman. INTERVENTION: Laparoscopic high uterosacral ligament suspension technique. MEASUREMENTS AND MAIN RESULTS: A 50-year-old woman presented with irregular vaginal bleeding and grade 3 uterine prolapse. The patient was concerned regarding the use of mesh and erosion. After counseling the patient agreed to a mesh-free single procedure. The use of mesh for the treatment of pelvic organ prolapse has become the subject of controversy and litigation. Complications of mesh erosion have resulted in the US Food and Drug Administration reclassifying transvaginal meshes as high-risk devices in 2016 [1]. Mesh erosion risk is up to 23% with hysterectomy and concomitant laparoscopic sacrocolpopexy [2] and 3% with sacrohysteropexy [3]. We present an alternative laparoscopic approach of treating uterine prolapse with high uterosacral suspension during laparoscopic hysterectomy. Our method avoids the use of mesh, sacrocervicopexy and morcellation, or an interval sacrocolpopexy. Although high uterosacral ligament suspension can be performed vaginally, it carries up to an 11% risk of ureteric injury [4]. CONCLUSION: In this video a bilateral ureterolysis is performed, before hysterectomy, isolating the uterosacral ligaments. These are then suspended to the vaginal vault in a purse-string fashion using Vicryl 0 (polyglactin 910) and intracorporeal knot-tying. Postprocedure the vault is well supported with a vaginal length of 12 cm

A protocol for developing, disseminating, and implementing a core outcome set (COS) for childbirth pelvic floor trauma research.

BACKGROUND: More than 85% of women sustain different degrees of trauma during vaginal birth. Randomized controlled trials on childbirth pelvic floor trauma have reported a wide range of outcomes and used different outcome measures. This variation restricts effective data synthesis, impairing the ability of research to inform clinical practice. The development and use of a core outcome set (COS) for childbirth pelvic floor trauma aims to ensure consistent use of outcome measures and reporting of outcomes. METHODS: An international steering group, within CHORUS, an International Collaboration for Harmonising Outcomes, Research and Standards in Urogynaecology and Women's Health, including academic community members, researchers, healthcare professionals, policy makers and women with childbirth pelvic floor trauma will lead the development of this COS. Relevant outcome parameters will be identified through comprehensive literature reviews. The selected outcomes will be entered into an international, multi-perspective online Delphi survey. Subsequently and based on the results of the Delphi surveys consensus will be sought on 'core' outcomes. DISCUSSION: Dissemination and implementation of the resulting COS within an international context will be supported and promoted. Embedding the COS for childbirth pelvic floor trauma within future clinical trials, systematic reviews, and clinical practice guidelines is expected to enrich opportunities for comparison of future clinical trials and allow better synthesis of outcomes, and will enhance mother and child care. The infrastructure created by developing a COS for childbirth pelvic floor trauma could be leveraged in other settings, for example, advancing research priorities and clinical practice guideline development

Influence of prior delivery mode on perineal trauma risk.

OBJECTIVE: To evaluate the impact of a previous pregnancy and delivery on perineal trauma rates in the subsequent vaginal birth. METHODS: Retrospective cohort study. The perineal outcomes of secundiparous women with history of previous (first) delivery in one of three categories: failed operative vaginal delivery (FOVD) and second stage emergency caesarean section (EmCS); elective caesarean section (ELCS), and vaginal delivery (VD) with intact perineum, were compared with a control primiparous group. RESULTS: The percentage OASIs at first vaginal delivery after prior FOVD+EmCS was 17.3%(n=9), 12.9%(n=18) after previous ELCS, and 0.6%(n=9) after prior VD maintaining an intact perineum, compared with 6%(n=1193) in the control primiparous group of women. Multivariate regression analysis demonstrated prior FOVD+EmCS and ELCS were associated with a statistically significant increased risk of OASIs of 180% and 110% when compared to control (odds ratio (OR): 2.80; 95% confidence interval (CI): 1.35-5.78 and OR: 2.10; 95%CI: 1.27-3.48) respectively. Prior VD with intact perineum was associated with a statistically significantly reduced risk of OASIs (OR: 0.09; 95%CI: 0.04-0.17). CONCLUSIONS: Previous FOVD+EmCS and ELCS were associated with increased risk of OASIs in subsequent vaginal delivery compared to control, whilst previous VD with intact perineum was associated with decreased risk

Comparison between the Valsalva maneuver and intraoperative traction measurements in pelvic organ prolapse assessment.

OBJECTIVE: To compare the assessment of pelvic organ prolapse (POP) between the Pelvic Organ Prolapse Quantification (POP-Q) system with Valsalva maneuver and intraoperative measurement with mechanical traction. METHODS: A prospective observational study included 100 women with POP attending a tertiary urogynecology clinic in the UK and undergoing vaginal prolapse surgical procedures between October 2011 and October 2014. The women were examined in the clinic using POP-Q with the Valsalva maneuver and in the operating theater under general anesthesia with mechanical traction. The two sets of measurements were compared. RESULTS: All POP-Q measurements obtained with traction demonstrated significantly higher descent as compared with those measured by Valsalva maneuver (mean differences: Aa 0.64 cm; Ap 1.32 cm; Ba 0.96 cm; Bp 1.34 cm; C 3.57 cm; D 3.40 cm; all P<0.001). The perineal body and total vaginal lengths did not differ significantly. CONCLUSION: Measurements of six POP-Q points obtained with traction showed a higher grade of POP than those assessed with Valsalva maneuver. On this basis, surgeons might decide on the extent of surgical procedure after examination under anesthesia; however, preoperative patient counselling would be essential to obtain consent for this approach. The clinical significance of the findings requires further evaluation

Three-Dimensional Volume Rendering of Pelvic Floor Anatomy with Focus on Fibroids in Relation to the Lower Urogenital Tract Based on Cross-Sectional MRI Images.

We aimed to assess the feasibility of developing three-dimensional (3D) models of pelvic organs using cross-sectional MRI images of patients with uterine fibroids and urinary symptoms and of obtaining anatomical information unavailable in 2D imaging modalities. We also aimed to compare two image processing applications. We performed a feasibility study analysing MRI scans from three women, aged 30 to 58 years old, with fibroids and urinary symptoms. Cross-sectional images were used to render 3D models of pelvic anatomy, including bladder, uterus and fibroids, using 3D Slicer and OsiriX. Dimensions, volumes and anatomical relationships of the pelvic organs were evaluated. Comparisons between anatomical landmarks and measurements obtained from the two image processing applications were undertaken. Rendered 3D pelvic models yielded detailed anatomical information and data on spatial relationships that were unobtainable from cross-sectional images. Models were rendered in sufficient resolution to aid understanding of spatial relationships between urinary bladder, uterus and fibroid(s). Measurements of fibroid volumes ranged from 5,336 to 418,012 mm3 and distances between the fibroid and urinary bladder ranged from 0.10 to 83.60 mm. Statistical analysis of measurements showed no significant differences in measurements between the two image processing applications. To date, limited data exist on the use of 3D volume reconstructions of routine MRI scans, to investigate pelvic pathologies such as fibroids in women with urinary symptoms. This study suggests that post-MRI image processing can provide additional information over standard MRI. Further studies are required to assess the role of these data in clinical practice, surgical planning and training. Three-dimensional reconstruction of routine two-dimensional magnetic resonance imaging provides additional anatomical information and may improve our understanding of anatomical relationships, their role in clinical presentations and possibly guide clinical and surgical management

Impact of COVID-19 on management of urogynaecology patients: a rapid review of the literature.

INTRODUCTION AND HYPOTHESIS: The coronavirus (COVID-19) pandemic has impacted health systems worldwide. There is a continuing need for clinicians to adapt practice to facilitate timely provision of medical care, whilst minimising horizontal transmission. Guidance and recommendations are increasingly available, and this rapid review aimed to provide a timely evidence synthesis on the current recommendations surrounding urogynaecological care. METHODS: We performed a literature review using PubMed/Medline, Embase and Cochrane and a manual search of national and international societies for management recommendations for urogynaecological patients during the COVID-19 pandemic. RESULTS: Nine guidance documents and 17 articles, including 10 reviews, were included. Virtual clinics are recommended for new and follow-up patients, to assess and initiate treatment, as well as triage patients who require face-to-face appointments. Outpatient investigations such as urodynamics and cystoscopy for benign indications can be deferred. Prolapse and continence surgery should be suspended, except in specific circumstances such as procidentia with upper tract complications and failed pessaries. There is no evidence to support a particular route of surgery, but recommendations are made to minimise COVID-19 transmission. CONCLUSIONS: Urogynaecological patients face particular challenges owing to inherent vulnerabilities of these populations. Behavioural and medical therapies should be recommended as first line options and initiated via virtual or remote clinics, which are integral to management during the COVID-19 pandemic. Expanding the availability and accessibility of technology will be increasingly required. The majority of outpatient and inpatient procedures can be deferred, but the longer-term effects of such practices are unclear

3D-Volume Rendering of the Pelvis with Emphasis on Paraurethral Structures Based on MRI Scans and Comparisons between 3D Slicer and OsiriX®.

The feasibility of rendering three dimensional (3D) pelvic models of vaginal, urethral and paraurethral lesions from 2D MRI has been demonstrated previously. To quantitatively compare 3D models using two different image processing applications: 3D Slicer and OsiriX. Secondary analysis and processing of five MRI scan based image sets from female patients aged 29-43 years old with vaginal or paraurethral lesions. Cross sectional image sets were used to create 3D models of the pelvic structures with 3D Slicer and OsiriX image processing applications. The linear dimensions of the models created using the two different methods were compared using Bland-Altman plots. The comparisons demonstrated good agreement between measurements from the two applications. The two data sets obtained from different image processing methods demonstrated good agreement. Both 3D Slicer and OsiriX can be used interchangeably and produce almost similar results. The clinical role of this investigation modality remains to be further evaluated

A systematic review highlighting poor quality of evidence for content validity of quality of life instruments in female chronic pelvic pain.

OBJECTIVES: To evaluate the content validity of 19 patient-reported outcome measures (PROMs) used to measure quality of life (QoL) in women with chronic pelvic pain (CPP). STUDY DESIGN AND SETTING: We searched Embase, MEDLINE, PsycINFO databases and Google Scholar from inception to August 2020. We included records describing the development or studies assessing content validity of PROMs. Two reviewers independently assessed the methodological quality of PROMs using the Consensus-based Standards for the Selection of Health Measurement Instruments checklist. Evidence was synthesized for relevance, comprehensiveness, and comprehensibility. Quality of evidence was rated using a modified Grading of Recommendations, Assessment, Development, and Evaluations approach. RESULTS: PROM development was inadequate for all instruments included in this review. No high-quality evidence ratings were found for relevance, comprehensiveness, and comprehensibility. QoL was measured using generic instruments (68.42%, 13/19) rather than those specific to chronic pain (21.04%, 4/19) or pelvic pain (10.53%, 2/19). Quality of concept elicitation was inadequate for 90% of PROMs. Half of PROMs did not include patients in their development and only 40% were devised using a sample representative of the target population for which the PROM was developed. Cognitive interviews were conducted in one-fifth of PROMs and were mostly of inadequate/doubtful quality. CONCLUSION: There is poor quality of evidence for content validity of PROMs used to measure QoL in women with CPP

A meta-synthesis of qualitative literature on female chronic pelvic pain for the development of a core outcome set: a systematic review.

INTRODUCTION AND HYPOTHESIS: Qualitative research has an increasing role in the development of core outcome sets (COS) adding patient perspectives to the considerations of core outcomes. We aimed to identify priorities of women with experience of chronic pelvic pain (CPP). METHODS: The search strategy was a systematic review of qualitative studies identified from Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, MEDLINE and PsycInfo databases. Selection criteria were qualitative studies exploring the experience of women with CPP. Two independent researchers extracted data and summarized findings using thematic analysis. A CERQual assessment was performed to assess the confidence of review findings. RESULTS: We identified pertinent issues affecting women with CPP including the lack of holistic care, influence of psychosocial factors and the impact of pain on quality of life. Five meta-themes central to delivering a patient-centred approach were highlighted: acceptance of pain, quality of life, management of CPP, communication and support. Management of CPP was the most commonly reported meta-theme across seven studies and half of studies reported quality of life, management, communication and support. Quality appraisal of included studies identified only a single study that met all CASP (Critical Appraisal Skills Programme) criteria. There was high confidence in the evidence for acceptance of pain, quality of life and communication meta-themes. CONCLUSION: Meta-themes revealed by this review should be considered as a priority and reflected in outcomes reported by future studies evaluating interventions for CPP. In addition, these themes should be considered by clinicians managing women with CPP