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The purpose of the study was to analyze anatomical and functional outcomes after sacrocolpopexy (SCP) for vaginal vault prolapse pelvic organ prolapse quantification (POPQ) II–III by random use of absorbable (Vicryl) and non-absorbable sutures (Ethibond) for vaginal mesh fixation. This study was designed as a two-center randomized controlled study (RCT). The primary objective was to evaluate the anatomical outcome. Success was defined when the vaginal apex (point C; POPQ) did not descend more than 50% of the total vaginal length (tvl) during Valsalva. Patients completed a pelvic examination incorporating the POPQ and questionnaires (the German pelvic floor questionnaire and the PISQ-12 questionnaire) at baseline and 6 months postsurgery. Perioperative adverse events (AE) were recorded. Sample size calculations, based on a 10% non-inferiority limit required 100 participants per group, with power = 90%. In 190 out of 195 women (ETH group n = 96; VIC group n = 94) anatomical success was achieved. The relative risk of anatomical success failure in the VIC group versus the ETH group was 0.69, with a 95% confidence interval 0.12–4.02. The change in the symptom scores did not differ significantly between the ETH and the VIC group. In the ETH group, three suture penetrations into the vagina were observed, and none in the VIC group 6 months postoperatively. Anatomical success after SCP for vaginal vault prolapse POPQ II–III is not affected by suture type for vaginal monofilament mesh attachment. Moreover, we did not see any differences in functional outcomes between the two groups. Three suture penetrations into the vagina were observed in the ETH group, and none in the VIC group 6 months postoperatively.

Introduction and hypothesis Ongoing debate exists about whether the rectovaginal septum (Denonvilliers’ fascia) is myth or reality. This study evaluates magnetic resonance images (MRI) of women with Mullerian agenesis for the presence of fascial layers between the rectum and the bladder to test the hypothesis that this layer exists in the absence of the vagina. Methods This isa secondary analysisof astudy describing MRI aspects in women with vaginal agenesis before and after laparoscopic Vecchietti procedure. Study participants (n=16) had a multiplanar pelvic MR scan. Images were evaluated independently by two investigators (MH, JOLD) for the appearance of layers separate from the bladder and rectum in the area of interest, with characteristic anatomical features of the septum. Results Participants’meanagewas19.4±2.6years± standard deviation (SD). In 12 of 16 patients (75 %) a distinct layer between rectum and bladder was identified in either the axial (4/16; 25 %) or sagittal (12/16; 75 %) scan or both. Characteristic anatomical features included lateral attachment to the levator ani muscle, cranial fusion to the cul-de-sac peritoneum, and caudal insertion into the perineal body. Conclusions Three quarters of women with Mullerian agenesis have a visible layer between bladder and rectum. As none of the participants hadavagina,theseresults support the existence of a rectovaginal septum, separate from a vaginal adventitia.

The uterosacral ligament (USL) is part of the pelvic floor connecting the uterus to the dorsal body wall and stabilizing it. In samples obtained from hysterectomy patients, the smooth muscle component of the cervical third of the USL was studied by smooth muscle actin (SMA) immunohistochemistry as indicator for structural abnormalities and by morphometric determination of nuclear size as measure for the functional state. From a total of 40 patients, 18 were matched according to age, parity, and premenopausal status. Immunohistochemistry showed a granular patchy distribution of SMA in the pelvic organ prolapse (POP) group. In patients with POP, the size of smooth muscle cell nuclei was significantly reduced in comparison to patients without POP (25.45+/-1.92 microm(2) vs 28.87+/-2.92 microm(2), p0.05). We conclude that the smooth muscle component of the USL is impaired in POP patients, indicating a possible role of smooth muscle in the pathogenesis of POP.

Obstetric trauma leading to rectovaginal fistula (RVF) formation results from perineal laceration and/or from prolonged ischemia and necrosis following obstructed labor. Due to modern obstetric care fistulas are rare in industrialized countries. Patients undergoing surgery for a RVF between January 2005 and December 2014 at the Department of Obstetrics and Gynecology, Tuebingen, Germany, were identified and their records were reviewed retrospectively. Of 48 patients, 13 developed RVF of obstetric etiology. Parity ranged from 2 to 4. RVF repair was performed in all patients using a transvaginal approach: fistula excision and multilayer closure (7 of 13) with Martius flap interposition (1 of 7) and sphincteroplasty (5 of 13). One RVF closed spontaneously. Due to significant destruction of the anal canal, large RVF and RVF recurrence, 4 of the 13 patients needed a temporary protective ileostomy. Fistula closure was achieved in 12 of 13 patients. The choice of RVF repair should be tailored to the underlying pathology and type of repair done previously and the patient’s wishes

A sixty-year-old woman with stress urinary incontinence had undergone a placement of an IVS (Tyco Health Care UK) in another hospital in February 2003. Seventeen months after the procedure, she complained about a suppurative discharge from the vagina and a recurrent severe stress urinary incontinence. The gynecological examination revealed an erosion of the sling into the vagina and a large urethrovaginal fistula bordered by granuloma. After removal of the sling, the urethrovaginal fistula was closed using a vaginal flap. A subsequent conservative treatment regime with duloxetine and pelvic floor training improved the stress urinary incontinence to the patient's satisfaction.

A 54-year-old woman with voiding difficulties was referred to our department. She complained about a slow urine stream, hesitancy, straining when voiding and the feeling of incomplete emptying. The gynaecological examination revealed a 4 × 3 cm pelvic tumour. The tumour was well circumscribed in the retropubic space between the symphysis and the bladder neck sonographically and by magnetic resonance imaging and was closed off from neighbouring structures. After removal of the tumour, the voiding problems were reversed, and the patient has remained asymptomatic. The histological examination showed a leiomyoma with high vascularisation. This case report showed that retropubic tumours can obstruct the urethra and cause voiding dysfunctions. Consequently, this needs to be considered in the differential diagnosis.

Seven women with urethrovaginal fistulae and penetration of tension-free vaginal tape into the urethra were treated at our department between July 2007 and March 2013. Fistulae were diagnosed 1 month to 10 years after midurethral sling placement. All were managed surgically. Five patients developed recurrent postoperative stress urinary incontinence, which was treated conservatively in all cases. In three cases, additional surgical treatment using a midurethral sling was performed.

Dear Editor, We read with great interest the case-control study by Forsgren et al. in your journal [1]. The study aimed to determine the prevalence of bowel dysfunction after sacrocolpopexy. Abdominal sacrocolpopexy is considered the gold standard for pelvic organ prolapse repair. Forsgren et al. compared 78 women who underwent sacrocolpopexy with matched controls of 233 hysterectomized women without sacrocolpopexy, using a bowel function questionnaire and the Cleveland Clinic Incontinence Score. Sacrocolpopexy was associated with an increased prevalence of difficulty emptying the rectum, incomplete rectal evacuation, digitally assisted rectal emptying, and use of enemas. Constipation after sacral colpopexy was described by other authors as well; Virtanen et al. noted that 26 % of the patients had de novo constipation after abdominal sacropexy [2]. Forsgren et al. stated in their discussion that the constipation after sacrocolpopexy may be explained by a change of the anorectal angulation at defecation. With this letter we would like to propose that the constipation can be explained by injury of the autonomic nerves in the presacral space during sacrocolpopexy. Recent findings by our group [3] have emphasized that the risk of injury to the autonomic nerves in the presacral space is high. At the level of the promontory or just below, the superior hypogastric plexus branches into the hypogastric nerves (Fig. 1a, b). At this level preservation of the pelvic autonomic nerves is often difficult, because these nerves are not distinctly visible in the surgical field due to their delicate structure. Our results emphasize that topographic knowledge of the neural anatomy of the presacral