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There is a paucity of information in the literature regarding the clinical impact and treatment of histologically positive actinomycosis explanted vaginal mesh. We aimed to report the prevalence and independent predicators of Actinomyces presence in explanted meshes on histology and to compare the clinical course in those with and without Actinomyces. Our hypothesis is that Actinomyces may act as a commensal rather than a pathogen when identified in extracted transvaginal meshes. A single-center retrospective review of explanted vaginal mesh removed between 2013 and 2018 was undertaken and compared Actinomyces-positive and -negative cohorts on histology. Uni- and multivariate logistic regression analysis evaluated possible risk factors for positive Actinomyces including patient demographics, smoking, diabetes, hormone replacement therapy (vaginal/systemic), hysterectomy in primary surgery, rate and indication for prior mesh removal. The rate of symptom resolution or need for subsequent mesh excisions is compared between the two cohorts. Actinomycosis was identified in 11% (31/278) of explanted mesh. After multivariant analysis, only voiding dysfunction as an indication for mesh removal was statistically significantly associated with Actinomyces-negative histology (14 vs 0%, p

The aim was to develop and validate (internally and externally) a prediction model for the presence and diagnosis of pelvic floor dysfunction (PFD) in women, including pelvic organ prolapse, stress urinary incontinence and/or overactive bladder via a patient-completed online tool. Using a retrospective cohort of women aged >18 years, from multiple tertiary gynaecology units within Queensland, Australia (2014–2018), the prediction model was developed via penalized logistic regression with internal and external validation utilizing multiple clinical predictors (42 questions from the Australian Pelvic Floor Questionnaire and demographics: age, body mass index, parity and mode of delivery). The main outcome measures were the accuracy of the model in predicting a diagnosis of pelvic floor dysfunction and its specific conditions of prolapse and incontinence. A total of 3,501 women were utilized for model development and internal validation and 449 for external validation. On internal validation the model correctly identified those with PFD with 97% sensitivity, 74% specificity and a concordance index (C-index) of 0.96. Predictions of pelvic organ prolapse were also accurate, with 86% sensitivity, 83% specificity, C-index 0.83, as was stress urinary incontinence, 84% sensitivity, 87% specificity, C-index 0.87, and overactive bladder, 76% sensitivity, 77% specificity, C-index 0.77. External validation confirmed the model’s accuracy with a similar C-index in all parameters. This model provides an accurate online tool to differentiate between those with and without PFD and diagnoses of common pelvic floor disorders. It serves as a valuable self-assessment for women and primary care providers.

The aim of this study was to establish the minimal important difference (MID) of the Australian Pelvic Floor Questionnaire (APFQ) in women undergoing surgery for stress urinary incontinence or symptomatic pelvic organ prolapse. A further aim was to estimate dysfunction scores dependent on the bothersomeness in a community cohort. The APFQ was completed before and 6 weeks after pelvic floor surgery by 183 women (n = 80 suburethral tape insertion; n = 103 laparoscopic sacrocolpopexy). Distribution and anchor-based methods were used to establish the effect size, standardised response mean and MID (calculated as the difference between women who stated no change or a little better in the Patient Global Impression of Improvement [PGI-I]). In a community cohort of 470 women aged 42–80 years, the APFQ was analysed according to disclosed bothersomeness. For the suburethral tape group, the effect size in the bladder domain was 1.5 and the PGI-I-based MID 1.3. For the POP surgery, group the effect size in the prolapse domain was calculated at 2.2 and the PGI-I-based MID at 1.0. The domain scores for women who declared no bother were significantly different from those who were a little bothered (bladder domain 2.2 vs 4.0, bowel 0.6 vs 1.7, POP 0.1 vs 3.2, sex 1.8 vs 3.0) with wide variations. The MID of the APFQ ranged from 1.0 to 1.3 in the domains after POP or continence surgery respectively. This is corroborated by the differences in domain scores from community-based women who were bothered versus not bothered by pelvic floor symptoms.

The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report. 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). 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. 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. Neurourol. Urodynam. © 2016 Wiley Periodicals, Inc., and The International Urogynecological Association.

Results of interobserver reliability studies for the International Urogynecological Association-International Continence Society (IUGA-ICS) Complication Classification coding can be greatly influenced by study design factors such as participant instruction, motivation, and test-question clarity. We attempted to optimize these factors.After a 15-min instructional lecture with eight clinical case examples (including images) and with classification/coding charts available, those clinicians attending an IUGA Surgical Complications workshop were presented with eight similar-style test cases over 10 min and asked to code them using the Category, Time and Site classification. Answers were compared to predetermined correct codes obtained by five instigators of the IUGA-ICS prostheses and grafts complications classification. Prelecture and postquiz participant confidence levels using a five-step Likert scale were assessed.Complete sets of answers to the questions (24 codings) were provided by 34 respondents, only three of whom reported prior use of the charts. Average score [n (%)] out of eight, as well as median score (range) for each coding category were: (i) Category: 7.3 (91 %); 7 (4-8); (ii) Time: 7.8 (98 %); 7 (6-8); (iii) Site: 7.2 (90 %); 7 (5-8). Overall, the equivalent calculations (out of 24) were 22.3 (93 %) and 22 (18-24). Mean prelecture confidence was 1.37 (out of 5), rising to 3.85 postquiz. Urogynecologists had the highest correlation with correct coding, followed closely by fellows and general gynecologists.Optimizing training and study design can lead to excellent results for interobserver reliability of the IUGA-ICS Complication Classification coding, with increased participant confidence in complication-coding ability.

The aim was to review the impact of pelvic organ prolapse surgery on sexual function. Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence” from level 2/3 studies or Delphi process expert opinion. Grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without formal analytical process, such as by Delphi. With regard to the anterior compartment, the use of mesh is associated with neither a worsening in sexual function nor an increase in de novo dyspareunia compared with traditional anterior colporrhaphy (grade B). There is insufficient information to provide evidence-based recommendations on sexual function after vaginal mesh in the posterior compartment or after new lightweight or absorbable meshes (grade D). There is a paucity of data on the impact of prolapse surgery on sexual function. Sexual function and dyspareunia rates are similar after anterior polypropylene mesh and anterior colporrhaphy (grade B). We recommend using validated questionnaires measuring sexual function in women before and after prolapse surgery and reporting sexual activity and dyspareunia rates pre- and post-intervention in all patients.

The objective of this observational study is to define vaginal invagination identified at vaginal prolapse surgery and to report the prevalence and risk factors for its development.All women undergoing vaginal prolapse surgery between January and December 2010 were prospectively evaluated intraoperatively for invagination of the vagina. The preoperative details and characteristics of the invagination were recorded and the area of vaginal mucosa released was quantified in square centimetres. Vaginal topography was evaluated using the Pelvic Organ Prolapse Quantification system.Intraoperative assessment demonstrated that vaginal invagination occurred in 8 % (25/295) and was characterized by a tight, fixed and tethered portion of vaginal mucosa at the vault which was bilateral in 14 (56 %) women. Prior gynaecological surgery with hysterectomy being the most common surgery and vaginal route the most frequent approach were identified as overall risk factors. The gain (mean ± SD) of vaginal mucosa after releasing entrapped tissue was 3.5 ± 0.63 cm(2).Vaginal invagination is diagnosed intraoperatively as a fixed and tight area of vaginal mucosa at the vault. The identification and release of the invaginated vagina ensures a safer access to the pelvic sidewall and increases vaginal mucosal area.

Introduction and Hypothesis Standardized terminology has yet to be developed for reporting the outcomes for surgery for pelvic organ prolapse (POP). Methods: This report combines the input of the Terminology and Standardization Committees of the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a joint Working Group on this topic, as well as expert external referees. The aim was to present a standardized terminology for the definitions of surgery and propose a structure for reporting the outcomes of surgical procedures for POP. An extensive drafting and review process was undertaken, as well as open review on both IUGA and ICS websites. Results: A terminology report was developed outlining the recommended structure for reporting outcomes of surgical trials involving POP. This document does not define success and failure. The report includes patientreported subjective and objective outcomes to enable researchers to report on their results and compare them with other studies. Conclusions: A consensus- based method for standardizing terminology for reporting outcome measures of POP surgery was developed to aid clinicians working in this area of research. Neurourol. Urodynam. 31: 415421, 2012. (C) 2012 Wiley Periodicals, Inc.

A terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery. This report on the above terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many expert external referees. An extensive process of 11 rounds of internal and external review took place with exhaustive examination of each aspect of the terminology and classification. Decision-making was by collective opinion (consensus). A terminology and classification of complications related directly to the insertion of prostheses and grafts in female pelvic floor surgery has been developed, with the classification based on category (C), time (T) and site (S) classes and divisions, that should encompass all conceivable scenarios for describing insertion complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids ( www.icsoffice.org/complication ). A consensus-based terminology and classification report for prosthess and grafts complications in female pelvic floor surgery has been produced, aimed at being a significant aid to clinical practice and research.

Introduction and hypothesis The aim of this study was to validate a self-administered version of the already validated interviewer-administered Australian pelvic floor questionnaire. Methods The questionnaire was completed by 163 women attending an urogynecological clinic. Face and convergent validity was assessed. Reliability testing and comparison with the interviewer-administered version was performed in a subset of 105 patients. Responsiveness was evaluated in a subset of 73 women. Results Missing data did not exceed 4% for any question. Cronbach’s alpha coefficients were acceptable in all domains. Kappa coefficients for the test–retest analyses varied from 0.64–1.0. Prolapse symptoms correlated significantly with the pelvic organ prolapse quantification. Urodynamics confirmed the reported symptom stress incontinence in 70%. The self and intervieweradministered questionnaires demonstrated equivalence. Effect sizes ranged from 0.6 to 1.4. Conclusions This self-administered pelvic floor questionnaire assessed pelvic floor function in a reproducible and valid fashion and due to its responsiveness, can be used for routine clinical assessment and outcome research.

Our objective was to evaluate the outcome of laparoscopic Burch colposuspension in women with recurrent stress urinary incontinence after failed primary sub-urethral tape procedures. A total of 16 patients were identified, and their data from symptom-specific questionnaires, urodynamic studies and urogynaecological assessment were collected. At a median follow-up of 24.5 months, objective and subjective cure rates were 54.5% and 92.9%, respectively. Average satisfaction score regarding outcome after surgery was 9.3 on a rating scale from 0 to 10. All but one patient had symptoms of urge incontinence pre-operatively with 64.3% experiencing cure or improvement post-operatively. Voiding difficulties were observed in one patient, and post-operative urodynamics revealed a significant decrease in urinary flow rate (p < 0.05) but with no difference in urinary residuals or maximum urethral closure pressure. Severe peri-urethral fibrosis was identified in 62.5% of the patients. Laparoscopic Burch colposuspension is an effective and safe surgical option.

This study retrospectively compared 34 women who had a sacrospinous hysteropexy and 36 who had a vaginal hysterectomy and sacrospinous fixation for symptomatic uterine prolapse. All women underwent independent review and examination, with a mean follow-up of 36 months in the hysterectomy group and 26 months in the hysteropexy group. The subjective success rate was 86% in the hysterectomy group and 78% in the hysteropexy group (P = 0.70). The objective success rate was 72% and 74%, respectively (P = 1.00). The patient-determined satisfaction rate was 86% in the hysterectomy group and 85% in the hysteropexy group (P = 1.00). The operating time in the hysterectomy group was 91 minutes, compared to 59 minutes in the hysteropexy group (P

The aim of this study was to compare the pubovaginal sling with a new Vicryl mesh rectus fascia (VMRF) sling in the surgical treatment of low urethral pressure genuine stress incontinence. Fifty-one consecutive women who had a VMRF (n = 27) or a pubovaginal sling (n = 24) procedure between March 1995 and December 1997 were evaluated. The patient-determined subjective success rate of the VMRF sling (85%) was significantly higher than that of the pubovaginal sling (58%) in women with low urethral pressure stress incontinence (P=0.03). The objective success rates following the VMRF and the pubovaginal sling were 52% and 50%, respectively. The prevalence of postoperative symptomatic voiding dysfunction and de novo detrusor instability was 7% after the VMRF sling and 25% following the pubovaginal sling (P = 0.08). The VMRF sling had a higher patient-determined success rate and a lower complication rate than the pubovaginal sling, and should be considered in the surgical management of women with low urethral pressure stress incontinence.

To review the safety and efficacy of uterine preservation surgery.Every four years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence" from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.A wide variety of surgical options remain for women presenting with uterine prolapse without contraindications to uterine preservation. However, long-term data are limited and the need for subsequent hysterectomy unknown (grade C). Sacrospinous hysteropexy is as effective as vaginal hysterectomy and repair in retrospective comparative studies and in a meta-analysis with reduced operating time, blood loss and recovery time. However, in a single RCT there was a higher recurrence rate associated with sacrospinous hysteropexy compared with vaginal hysterectomy (grade D). Severe prolapse increases the risk of recurrent prolapse after sacrospinous hysteropexy. In consistent level 2 evidence sacrospinous hysteropexy with mesh augmentation of the anterior compartment was as effective as hysterectomy and mesh augmentation with no significant difference in the rate of mesh exposure between the groups (grade B). Level 1 evidence from a single RCT suggests that vaginal hysterectomy and uterosacral suspension were superior to sacral hysteropexy based on reoperation rates, despite similar anatomical and symptomatic improvement (grade C). Consistent level 2 and 3 evidence suggests that sacral hysteropexy (open or laparoscopic) was as effective as sacral colpopexy and hysterectomy in anatomical outcomes; however, the sacral colpopexy and hysterectomy were associated with a five times higher rate of mesh exposure compared with sacral hysteropexy (grade B). Performing hysterectomy at sacral colpopexy was associated with a four times higher risk of mesh exposure compared with sacral colpopexy without hysterectomy (grade B).While uterine preservation is a viable option for the surgical management of uterine prolapse the evidence on safety and efficacy is currently lacking.

The aim was to review the economic costs associated with pelvic organ prolapse surgery. Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence” from level 2/3 studies or Delphi processed expert opinion. Grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. The annual economic costs of pelvic organ prolapse surgeries are significant and over the next decades will grow at twice the rate of population growth because of our aging population. In a single institution study vaginal reconstructive surgery and pessary use were more cost-effective than expectant management, traditional abdominal sacral colpopexy (ASC) or robot-assisted sacral colpopexy (RSC; grade C). Two studies have demonstrated that ASC incurs lower inpatient costs than LSC or RSC (grade C). Data from a single RCT demonstrated the LSC to incur lower inpatient costs than RSC specifically relating to shorter operating times in the LSC group (grade B). Data from a single RCT demonstrated LSC to be a more effective cost-minimising surgery than total vaginal mesh for vaginal vault prolapse (grade B). Data from a meta-analysis of anterior vaginal compartment prolapse operations demonstrated that commercial mesh kits for anterior repair are less cost-effective than non-kit mesh and anterior colporrhaphy (grade B). There is a paucity of good economic data relating to pelvic organ prolapse surgery. Transvaginal mesh surgeries have not been proven to be cost-effective. It is recommended that all randomised controlled trials relating to prolapse surgery include a formal cost analysis.

The aim was to determine the impact of pelvic organ prolapse surgery on bladder function.Every 4 years, and as part of the Fifth International Collaboration on Incontinence we reviewed the English-langauage scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence" from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.Continent women undergoing anterior compartment prolapse surgery have a lower rate of de novo stress urinary incontinence (SUI) after anterior repair than armed mesh procedures (grade A). Data are conflicting on whether colposuspension should be performed prophylactically in continent women undergoing sacral colpopexy (grade C). No clear conclusion can be made regarding the management of continent women undergoing prolapse surgery without occult SUI. In continent women undergoing POP surgery with occult SUI the addition of continence surgery reduces the rate of postoperative SUI (grade A). In women with prolapse and SUI symptoms prolapse procedures alone (transobturator mesh and anterior repair) are associated with low success rates for SUI. Concomitant continence procedures reduce the risk of postoperative SUI (grade B). Preoperative bladder overactivity may resolve in 40% undergoing POP surgery and de novo bladder overactivity occurs in 12%. No valid conclusions regarding voiding dysfunction following POP surgery can be drawn from the available data.SUI and occult stress urinary incontinence should be treated at the time of prolapse surgery.

To review the safety and efficacy of anterior vaginal compartment pelvic organ prolapse surgery. Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and the Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. A grade A recommendation usually depends on consistent level 1 evidence. A grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. A grade C recommendation usually depends on level studies or “majority evidence” from level 2/3 studies or Delphi processed expert opinion. A grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. Absorbable mesh augmentation of anterior compartment native tissue repair improves the anatomical outcome compared with native tissue repair alone with no increased complication rate in meta-analysis of 2 RCTS (grade B). Biological grafts in meta-analysis have improved anatomical outcomes with no change in subjective outcomes compared with native tissue repairs (grade B). There is conflicting level 1 evidence to support porcine dermis and a single RCT to support small intestine submucosa as graft agents in anterior compartment prolapse surgery (grade B). Consistent level 1 data support a superior anatomical outcome for polypropylene mesh compared with a biological graft in the anterior compartment. Mesh exposure rate was significantly higher in the polypropylene mesh group (grade A). Consistent level 1 evidence demonstrates superior subjective and objective outcomes following anterior transvaginal polypropylene mesh as compared to anterior colporrhaphy (grade A). These outcomes did not translate into improved functional results using validated questionnaires or a lower reoperation rate for prolapse. The mesh group was also associated with longer operating time, greater blood loss and apical or posterior compartment prolapse as compared with anterior repair. Anterior polypropylene mesh had a mesh extrusion rate of 10.4 % with 6.3 % requiring a surgical correction (grade B). Single level 3 evidence does not support the use of transvaginal polypropylene mesh for recurrent anterior vaginal wall prolapse (grade C). Polypropylene anterior compartment mesh offers improved objective and subjective outcomes compared with native tissue repair; however, these benefits must be considered in the context of increased morbidity associated with anterior polypropylene transvaginal mesh.

The aim was to review the safety and efficacy of surgery for posterior vaginal wall prolapse. Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence‟ from level 2/3 studies or Delphi processed expert opinion. Grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. Level 1 and 2 evidence suggest that midline plication posterior repair without levatorplasty might have superior objective outcomes compared with site-specific posterior reopair (grade B). Higher dyspareunia rates are reported when levatorplasty is employed (grade C). The transvaginal approach is superior to the transanal approach for repair of posterior wall prolapse (grade A). To date, no studies have shown any benefit of mesh overlay or augmentation of a suture repair for posterior vaginal wall prolapse (grade B). While modified abdominal sacrocolpopexy results have been reported, data on how these results would compare with traditional transvaginal repair of posterior vaginal wall prolapse are lacking. Midline fascial plication without levatorplasty is the procedure of choice for posterior compartment prolapse. No evidence supports the use of polypropylene mesh or biological graft in posterior vaginal compartment prolapse surgery.

The aim was to determine the incidence and prevalence of pelvic organ prolapse surgery and describe how outcomes are reported.Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews, level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. A grade A recommendation usually depends on consistent level 1 evidence. A grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. A grade C recommendation usually depends on level 4 studies or "majority evidence" from level 2/3 studies or Delphi processed expert opinion. A grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi .Pelvic organ prolapse (POP) when defined by symptoms has a prevalence of 3-6% and up to 50% when based upon vaginal examination. Surgery for prolapse is performed twice as commonly as continence surgery and prevalence varies widely from 6 to 18%. The incidence of POP surgery ranges from 1.5 to 1.8 per 1,000 women years and peaks in women aged 60-69. When reporting outcomes of the surgical management of prolapse, authors should include a variety of standardised anatomical and functional outcomes. Anatomical outcomes reported should include all POP-Q points and staging, utilising a traditional definition of success with the hymen as the threshold for success. Assessment should be prospective and assessors blinded as to the surgical intervention performed if possible and without any conflict of interest related to the assessment undertaken (grade C). Subjective success postoperatively should be defined as the absence of a vaginal bulge (grade C). Functional outcomes are best reported using valid, reliable and responsive symptom questionnaires and condition-specific HRQOL instruments (grade C). Sexual function is best reported utilising validated condition-specific HRQOL that assess sexual function or validated sexual function questionnaires such as the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ) or the Female Sexual Function Index (FSFI). The sexual activity status of all study participants should be reported pre- and postoperatively under the following categories: sexually active without pain, sexually active with pain or not sexually active (grade C). Prolapse surgery should be defined as primary surgery, and repeat surgery sub-classified as primary surgery different site, repeat surgery, complications related to surgery and surgery for non-prolapse-related conditions (grade C).Significant variation exists in the prevalence and incidence of pelvic organ prolapse surgery and how the outcomes are reported. Much of the variation may be improved by standardisation of definitions and outcomes of reporting on pelvic organ prolapse surgery.

Pelvic organ prolapse (POP) is a common problem affectingup to 50 % of parous women and 6.3 % of women will haveundergone a surgical correction for pelvic organ prolapse bytheageof80[1].Prolapsesurgeryisanincreasinglyimportantaspect of gynaecological practice because of our ageing pop-ulation, the decreasing rate of hysterectomy owing to alterna-tive treatments for menorrhagia, and finally decreasing ratesof cervical interventions for cervical dysplasia following theintroduction of vaccinations for human papilloma virus. Al-ready, prolapse surgery is performed at least as frequently ascontinencesurgeryand,theoperatingandadmissiontimesareat least three times greater than for continence surgery. GiventheincreasingtimeandresourcesthatwillberequiredforPOPsurgeryinthefutureitisparamountthatweperformeffective,durable, cost-effective interventions with minimal morbidity.These articles serve to outline and summarise the informationrelating to POP surgery reported in the English-languagescientific literature after searching PubMed, Medline, theCochrane library and Cochrane database of systematic re-views, published up to January 2012, with level 1 evidence(randomised controlled trials [RCT] or systematic reviews),level2(poorqualityRCT,prospectivecohortstudies)orlevel3 evidence (case series or retrospective studies) have beenincludediflevel1datawerelacking.ThecommitteeevaluatedtheliteratureandmaderecommendationsbasedontheOxfordgrading system summarised as:Grade A recommendation usually depends on consistentlevel 1 evidence and often means that the recom-mendation is effectively mandatory and placedwithin a clinical care pathway. However, therewill be occasions where excellent evidence (level1) does not lead to a grade A recommendation,forexample,ifthetherapyisprohibitivelyexpen-sive, dangerous or unethical.Grade B recommendation usually depends on consistentlevel 2 and/or 3 studies, or “majority evidence”from RCTs.Grade C recommendation usually depends on level 4 stud-ies or “majority evidence” from level 2/3 studiesor Delphi processed expert opinion.Grade D “no recommendation possible” would be usedwhere the evidence is inadequate or conflictingand when expert opinion is delivered without aformal analytical process, such as by Delphi.The recommendations serve as the conclusions of thereview and a guide to the status of the current knowledgeand future research in POP surgery.

A prospective case series to assess the safety and efficacy of laparoscopic sacrocolpopexy for the surgical management of recurrent pelvic organ prolapse (POP) after transvaginal polypropylene mesh prolapse surgery. Between January and December 2010, women with post-hysterectomy recurrent prolapse (≥ stage 2 POP-Q) after transvaginal polypropylene mesh prolapse surgery were included. Perioperative morbidity and short-term complications were recorded and evaluated. Surgical outcomes were objectively assessed utilising the Pelvic Organ Prolapse Quantification system (POP-Q), the validated, condition-specific Australian Pelvic Floor Questionnaire (APFQ) and the Patient Global Impression of Improvement (PGI-I) at 12 months. All 16 women in this study had undergone surgery with trocar-guided transvaginal polypropylene mesh kits. In 75% the recurrent prolapse affected the compartment of prior mesh surgery with the anterior (81%) and apical (75%) compartment prolapse predominating. At a mean follow-up of 12 months, all women had resolution of awareness of prolapse, had < stage 2 POP-Q on examination and high levels of satisfaction on PGI-I post surgery. There were no serious peri- or postoperative complications. This preliminary study suggests that laparoscopic sacrocolpopexy for recurrent prolapse after failed transvaginal mesh surgery is feasible and safe. Further widespread evaluation is required.

Vaginal mesh kits are increasingly used in the management of pelvic organ prolapse. This study aimed to determine similarity of outcomes of the Anterior Prolift with Perigee systems for anterior compartment prolapse.Consecutive women undergoing Perigee or Anterior Prolift for symptomatic stage 2 or greater anterior vaginal prolapse were prospectively evaluated. Main outcome measures included objective and subjective success rates, perioperative outcomes, patient satisfaction, and complications.One hundred and six women (Prolift, 52; Perigee, 54) completed questionnaires, and 91 (Prolift, 46; Perigee, 45) were examined postoperatively. At follow-up (Prolift: median, 11.0; range, 5-23 months; Perigee: median, 11.5; range, 6 - 23 months), objective success rates (Prolift, 89%; Perigee, 80%; p = 0.23), subjective success rates (Prolift, 94%; Perigee, 96%; p=0.62), mean ± SD patient satisfaction (Prolift, 8.2 ± 2.0; Perigee, 8.2 ± 1.8; p = 0.91), and complication rates did not differ significantly between the two groups.The Anterior Prolift was found to not differ significantly from Perigee at 11 months.

With the increasing popularity of mesh in prolapse surgery, complications such as intravesical mesh will arise more frequently. In three cases intravesical mesh was identified in the trigone of the bladder following laparoscopic mesh hysteropexy, open sacral colpopexy, and transvaginal mesh repair and presented 9 months to 7 years later with a variety of symptoms including recurrent urinary tract infections, suprapubic pain, and constant urinary leakage. Each underwent uncomplicated laparoscopic transvesical removal of intravesical mesh. Intravesical mesh can present years following index prolapse surgery and can develop despite the bladder integrity being documented as being intact at the initial surgery. The laparoscopic approach to the removal of intravesical mesh is feasible, minimally invasive, and a precise approach to this challenging complication.

The surgical management of multi-compartment prolapse is challenging and often requires a combination of techniques. This study evaluates anterior vaginal mesh repair, sacrospinous hysteropexy and posterior fascial plication in women with anterior compartment dominated uterovaginal prolapse.Consecutive women who underwent the aforementioned surgery were prospectively evaluated. Main outcome measures included objective (pelvic organ prolapse quantification stage2) and subjective success rates, patient satisfaction, functional outcomes and complications.One hundred and seventeen women were eligible, and 100 agreed to participate. At 12 months, objective success rate at the anterior compartment was 87% and at all compartments, 75%. Subjective success was 84%, and mean patient satisfaction was 8.5/10. There were no stage 3 or 4 recurrences at any site.The combination of anterior vaginal mesh, sacrospinous hysteropexy and posterior fascial plication is reasonably effective in restoring the anatomy and achieving favourable bladder, bowel and sexual function.