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The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherap...

This article discusses various pelvic floor ultrasonographic modalities and the clinical applications of ultrasonography of the pelvic floor. Ultrasonography provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variabilities and pathologic conditions, such as prolapse, fecal incontinence, urinary symptoms, vaginal wall cysts, synthetic implanted material, and pelvic pain, are assessed with pelvic floor ultrasonography. This imaging modality is an important adjunct to the evaluation and diagnosis of pelvic floor disorders.

OBJECTIVE To determine whether use of an intravaginal motion-based digital therapeutic device for pelvic floor muscle training (PFMT) was superior to PFMT alone in women with stress-predominant urinary incontinence (SUI). METHODS A multicenter, randomized-controlled trial was conducted where women with SUI or SUI-predominant mixed urinary incontinence were treated with either PFMT using the device (intervention group) or PFMT alone (control group). Primary outcomes, measured at 8 weeks, included change in Urinary Distress Inventory, short-version and improvement in the Patient Global Impression of Improvement, defined as "much better" or "very much better." Participants also completed Pelvic Organ Prolapse and Colorectal-anal Distress Inventories, Pelvic-Floor-Impact Questionnaire and a 3-day bladder diary. Primary analysis used a modified intention-to-treat approach. Statistical analysis used Student t test and χ2 test. The trial was prematurely halted due to device technical considerations. RESULTS Seventy-seven women were randomized, and final analysis included 61 participants: 29 in intervention and 32 in control group. There was no statistical difference in Urinary Distress Inventory, short-version scores between the intervention (-13.7 ± 18.7) and the control group (-8.7 ± 21.8; P = 0.85), or in Patient Global Impression of Improvement (intervention 51.7% and control group 40.6%; P = 0.47). Pelvic Organ Prolapse and Colorectal-anal Distress Inventories and Pelvic-Floor-Impact Questionnaire scores improved significantly more in the intervention group than the control group (all P < 0.05). Median number of SUI episodes decreased from baseline to 8 weeks by -1.7 per-day [(-3)-0] in the intervention group and -0.7[(-1)-0] in the control group, (P = 0.047). CONCLUSIONS In this prematurely terminated trial, there were no statistically significant differences in primary outcomes; however, PFMT with this digital therapeutic device resulted in significantly fewer SUI episodes and greater improvement in symptom-specific quality of life outcomes. A larger powered trial is underway.

Background The occurrence of retained surgical instruments in vaginal surgery, although low, carries unique complications. Appropriate imaging to find retained surgical instruments allows for timely diagnosis and retrieval of the vaginal foreign body. Case The patient is a 33-year-old woman with recurrent cervical cancer who was undergoing radiation therapy. During interstitial implantation, a reverse cutting needle was broken into the anterior vaginal wall. Three-dimensional endoluminal ultrasonography allowed for timely retrieval with minimal surgical exploration in the operating room. Conclusion Intraoperative three-dimensional endoluminal ultrasonography allows for accurate visualization and mapping of a vaginal foreign body. This highlights an innovative and highly useful feature of this imaging technique.

Objectives The objective of this study was to identify differences in pain perception and satisfaction with pain control in women receiving nonsteroidal anti-inflammatory drugs postoperatively. Methods This was a prospective, randomized controlled trial including urogynecology surgical patients. After surgery, all patients were randomized to receive either intravenous (IV) ketorolac or ibuprofen. The patients completed 3 visual analog scales (VAS) assessing pain at rest, pain with ambulation, and satisfaction with pain control. Postoperative opioid use was also measured. Results A total of 224 patients (112 in each arm) were included. Pain scores (SD) at rest in all patients who received ketorolac versus those who received ibuprofen was 2.30 (2.1) versus 2.68 (2.34) (P = 0.20). Pain scores (SD) with ambulation was 3.94 (2.57) versus 4.16 (2.73) (P = 0.57) in patients who received ketorolac and ibuprofen, respectively. Patients who received ketorolac rated their satisfaction with their pain regimen similarly to those who received ibuprofen (P = 0.50). The average amount (SD) of hydromorphone used in the ketorolac and ibuprofen arm was 3.68 (4.58) mg and 4.04 (4.97) mg, respectively (P = 0.58). A subgroup analysis based on type of surgery showed decreased pain at rest (VAS, 2.77 vs 4.88; P = 0.04) and increased satisfaction (VAS, 1.69 vs 4.67; P = 0.003) in patients who had laparotomy and received ketorolac. Conclusions There was no difference in pain and satisfaction with IV ketorolac compared with IV ibuprofen in patients who underwent all modalities of urogynecologic surgery. A subgroup of patients who underwent laparotomy had less pain with ketorolac.

OBJECTIVE: The goal of this study was to evaluate differences in levator ani hematoma formation within 3 days of delivery between adult women after their first vaginal delivery and adult women who have had multiple vaginal deliveries. METHODS: This was a cross-sectional study at a single institution from 2013 to 2015 using a high-resolution endovaginal ultrasound transducer to identify postvaginal delivery hematoma formation. Logistic regression was used to examine the association between hematoma formation and vaginal parity while considering potential confounders including induction, vaginal operative delivery, vaginal birth after cesarean, fetal weight, fetal head circumference, race and ethnicity, body mass index, age at delivery, gestational age, and length of second-stage labor. RESULTS: Ninety women (46 vaginal-primiparous; 44 vaginal-multiparous) were included in this study. After adjusting for oxytocin use, length of second-stage labor, and body mass index, the odds of pelvic floor hematoma of 1000 mm(3) or greater were 2.93 (95% confidence interval, 0.78–10.91) times greater in women after their first vaginal delivery compared with women with a history of multiple vaginal deliveries. The adjusted odds of pelvic floor hematoma of 1500 mm(3) or greater were 6.02 (95% confidence interval, 1.09–33.24) times greater in vaginal-primiparous compared with vaginal-multiparous women. CONCLUSIONS: Although the prevalence of pelvic floor hematoma was higher in vaginal-primiparous women than vaginal-multiparous women after vaginal delivery, hematomas were present in both groups. Future prospective studies are needed to evaluate the additive effect of multiple vaginal deliveries on the pelvic floor.

Objectives The aim of this study was to determine the prevalence of opioid pain medication use among patients presenting for a new visit to the urogynecology clinic compared with those presenting to general gynecology. Methods We identified all patients who presented for new patient visits to the urogynecology and gynecology clinics between January 1, 2016, and December 31, 2016. Any previous or current opioid use was extracted from the electronic medical record medication list. Statistical analysis was performed using χ and Fisher exact tests for comparisons of categorical variables. Modified Poisson regression models were used to estimate prevalence proportion ratios (PPRs). Results There were 1835 (955 gynecology, 880 urogynecology) patients included. Median age was 47 years (interquartile range, 29 years), and median body mass index was 28.15 kg/m (interquartile range, 9.96 kg/m). Prevalence of opioid use was lowest among women who identified as Asian or other race and highest among black and Native American women; however, when compared by ethnicity, use was lowest among Hispanic women (P = 0.01). Among new urogynecology patients, 14% had self-reported opioid pain medication usage. Opioid use was almost twice as likely in the urogynecology group (PPR, 1.86; 95% confidence interval, 1.4-2.4). When adjusted for confounders, the urogynecology group was 1.3 times as likely to report opioid use (PPR 1.29; 95% confidence interval, 1.0-1.8), with this result approaching statistical significance. Conclusions Opioid use is greater in patients presenting to the urogynecology clinic compared with general gynecology. Urogynecologists need to know this information for planning and optimizing pain management in this population.

OBJECTIVE The objective of this study was to investigate the ultrasound characteristics of vaginal mesh in women with vaginal mesh complications. METHODS This was a cross-sectional study of women presenting with extrusion complications from vaginal mesh kit for prolapse at our tertiary care center between years 2009 and 2014. We included women who concurrently underwent a 3-dimensional endovaginal ultrasound (EVUS) as part of the clinical evaluation. We excluded women with incomplete charts and poor imaging quality. Subjects were categorized by the presence or absence of associated pelvic pain. Based on ultrasound findings, we compared the location of mesh, the appearance of mesh pattern (flat, folding, prominence, convoluted), and other EVUS characteristics of mesh. RESULTS Forty-six women with vaginal mesh complications and good image quality were included. When comparing mesh length between posterior and anterior compartments, the posterior meshes were significantly longer than the anterior meshes (42.1 [SD, 11.9] mm vs 25.8 [SD, 9] mm; P < 0.0001) and more often associated with pain. In the posterior compartment, the mean mesh length seen on EVUS was significantly longer in women with pain than in women without pain (46.5 [SD, 9] mm vs 31.8 [SD, 12.1] mm; P = 0.0001). There was also a higher proportion of a "flat" mesh pattern, 14 (58.3%) of 25, in the posterior compartment associated with the presence of pain (P = 0.013). In the posterior compartment, a smaller distance between the distal edge of the mesh and the anal sphincter was significantly associated with the presence of pain (8 mm [0-37] vs 21 mm [8-35], P = 0.024). In both compartments, the EVUS had 100% sensitivity for detection of mesh extrusions. CONCLUSIONS In this population of patients presenting with mesh complications, the posterior meshes were more often visualized as a "flat" pattern with a higher frequency of pain. Mesh complications of the anterior compartment had a higher frequency of folding and shrinkage.

Objective To investigate the association between the minimal levator hiatus (MLH) area at rest with its surrounding soft-tissue and bony structures in nulliparous asymptomatic women with a normal levator ani muscle. Methods A subanalysis was undertaken of a prospective study of the appearance of the levator ani in asymptomatic nulliparous women conducted between September 2010 and September 2011. The subanalysis included women with a normal levator ani muscle. Three-dimensional ultrasonography volumes were used to obtain pelvic floor measurements. Results The analysis included 56 women with mean age of 43.0 ± 13.4 years. The mean MLH area was 13.1 ± 1.8 cm2 (range 9.0–17.3). The pubic arch angle had no influence on the MLH area (Pearson correlation coefficient r = 0.13). Height and pubic arch length were positively correlated with the MLH area (r = 0.26 [P = 0.52] and r = 0.50 [P Conclusion The MLH size of nulliparous women varied widely and was positively correlated with the height and pubic arch length of the women. Therefore, caution is warranted when interpreting the MLH area as an indicator of a levator ani defect or a predictor of pelvic organ prolapse without taking a woman’s pelvic bone characteristics into account.

Objectives To use 3-dimensional endovaginal ultrasound to describe the location and distribution of bulking agent after an uncomplicated transurethral injection. Methods Endovaginal ultrasound was performed in 24 treatment-naive patients immediately after bulking agent was injected. The distance between the center of the hyperechoic density of bulking agent and the urethrovesical junction (UVJ) was measured in the sagittal and axial views. This was calculated in percentile length of urethra. Also, the pattern of tracking of bulking agent was assessed if it is presented. Results After the 2 subjects were excluded because of the poor quality of images, 22 patients were included in this study. Eighteen (82%) subjects showed 2 sites of bulking agents, and mostly, they were located around 3- and 9-o'clock positions. The average distance of bulking agent from left UVJ was at 16.9% of the length of the urethra (6.2 mm; range, 0.5-17 mm) and at 25.5% of the length of the urethra (8.9 mm; range, 0-24.8 mm) in the right side. The average length of urethra was 36.7 mm. Eleven of the 22 subjects (50%) had both sides within upper one third of urethra. The difference in distance between the 2 sides was less than 10 mm in 12 of 22 patients (54%). Nine of the 22 patients (41%) had a significant spread of bulking agent mostly either into the bladder neck or toward the distal urethra. Conclusions Although the bulking agent is most often found at 3- and 9-o'clock positions as intended, the distance from the UVJ is highly variable after an uncomplicated office-based transurethral injection. The bulking material does not form the characteristic spheres in 41% of cases and tracks toward the bladder neck or the distal urethra.

OBJECTIVE: The aim of this study was to characterize clinical success, impact on quality of life, and durability up to 1 year in women with fecal incontinence (FI) responsive to an initial test period with a trial vaginal bowel control system. METHODS: This was a prospective open-label study in subjects with FI and successfully fit who underwent an initial 2-week trial period. Those achieving 50% or greater reduction in FI episodes were provided the long-term system. Primary outcome was success at 3 months defined as 50% or greater reduction in baseline FI episodes, also assessed at 6 and 12 months. Secondary outcomes included symptom impact measured with Fecal Incontinence Quality of Life scale, symptom severity by the St Mark’s (Vaizey) questionnaire, Patient Global Impression of Improvement, and satisfaction. Adverse events were collected. Primary analysis was intention to treat (ITT). RESULTS: Seventy-three subjects with baseline mean of 14.1 ± 12.15 FI episodes over 2 weeks entered the treatment period. Success rate at 3 months was 72.6% (53/73, P < 0.0001); per-protocol, 84.1% (53/63, P < 0.0001). Significant improvement in all Fecal Incontinence Quality of Life subscales and St Mark’s questionnaire meeting minimally important differences was noted. Satisfaction was 91.7%, 89.7%, and 94.4% at 3, 6, and 12 months, respectively; 77.4%, 77.6%, and 79.6% were very much/much better on the Patient Global Impression of Improvement at 3, 6, and 12 months, respectively. Most common adverse event was vaginal wall injury, with most adverse events (90/134, 67%) occurring during fitting period. CONCLUSIONS: In women with successful fitting and initial treatment response, durable efficacy was seen at 3, 6, and 12 months by objective and subjective measures, with favorable safety.

OBJECTIVE To analyze the characteristics of providers performing stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures in the United States. METHODS The Centers for Medicare Services public database, released for years 2012 through 2014, was queried for SUI-related and POP-related Healthcare Common Procedure Coding System. Providers were categorized as Female Pelvic Medicine and Reconstructive Surgery (FPMRS) providers and non-FPMRS providers, using a list of FPMRS board-certified providers compiled through the American Board of Medical Subspecialties website. Other physician specialties that submitted SUI and POP procedures claims were tabulated. RESULTS Six hundred twenty-nine FPMRS and 833 non-FPMRS providers submitted claims for SUI and POP procedures. The SUI procedures claims had the following provider specialty distribution: obstetrics and gynecology (OB/GYN)-FPMRS, 46.7%; urology, 26.3%; OB/GYN, 12.2%; and urology-FPMRS, 13.9%, with the remaining 0.9% being performed by other specialties. The POP procedures had the following specialty distribution: OB/GYN-FPMRS, 63.4%; OB/GYN, 16.7%; urology, 8.3%; and urology-FPMRS, 7.1%, with the remaining 4.5% being performed by other specialties.Provider distribution was compared between transvaginal mesh and sling insertion procedures to transvaginal mesh and sling removal procedures. The FPMRS providers claimed 63.6% of sling and transvaginal mesh insertion procedures and performed 84.9% of mesh and sling removal procedures. CONCLUSIONS Medicare reimbursement data provides a unique insight into the distribution of provider specialties performing SUI-related and POP-related procedures in the Medicare population. The OB/GYN-FPMRS providers submitted the majority of claims for SUI and POP procedures from 2012 to 2014. The FPMRS providers are also performing the majority of mesh removal procedures.

Objectives The aims of this study were to determine the association between x-ray funneling and ultrasound urethral sphincter complex measurements and to compare the reliability of funneling versus urethral volume measurement in the detection of intrinsic sphincter deficiency (ISD). Methods This was a retrospective analysis, which included 54 stress incontinent women dichotomized into those with (1) ISD and (2) no ISD. The presence of bladder neck funneling was diagnosed by fluoroscopic images obtained at the time of video-urodynamics testing. Measurements of the urethral sphincter complex were obtained from ultrasound volumes. Reliability measures were obtained for both funneling and urethral volume measurements. Results Rhabdomyosphincter length and area were found to be smaller in patients with funneling compared with those with no funneling (P = 0.0161, P = 0.0359). The urethral volume was significantly smaller in the ISD versus no-ISD group (P = 0.0002). For those who had funneling, the ISD group had smaller urethral volume compared with the no-ISD group (P = 0.0019). For those who did not have funneling, the ISD group still had a smaller urethral volume compared with the no-ISD group (P = 0.0054). An ultrasound urethral volume of less than 3.5 cm had a sensitivity of 81% and a specificity of 64% for the presence of ISD, whereas x-ray funneling had a sensitivity of 76% and a specificity of 73%. Conclusions Smaller rhabdomyosphincter length and area on ultrasound are associated with x-ray funneling. Ultrasound urethral volume of 3.5 cm as a cutoff provides the same reliability as x-ray funneling for the diagnosis of ISD.

Introduction and hypothesis Three-dimensional endovaginal ultrasound has been used for evaluation of levator ani muscle deficiency. The aim of this study was to assess interrater agreement/reliability of 3D endovaginal ultrasound for scoring levator ani deficiency (LAD).

Our aim was to determine the association between visualizing periurethral structures in the midsagittal plane with 3D endovaginal ultrasonography (EVUS) and stress urinary incontinence (SUI) status. In a cross-sectional study, we measured urethral length and scored for presence or absence of the following in midsagittal plane in patients with and without stress SUI: striated urogenital sphincter, longitudinal/circular smooth muscle, vesical trigone, trigonal plate, trigonal ring, and compressor urethra. Summary statistics were calculated for the study population. Fisher’s exact test was used to compare continuous data. Categorical data was compared with the chi-square. Data from 161 patients was available for review. Mean patient age was 54.4 [±15.6 standard deviation (SD)] years, and median parity was two (range 0–5). Among these women, 137/161(85 %) did not have SUI and 24/(15 %) did; 20/161 (12 %) had anterior-compartment prolapse stage 2 or greater, and among them, only two had urinary incontinence (UI). No association was found between UI and visualization of the periurethral structures. Mean urethral lengths did not differ between groups (p = 0.37). Visualization of periurethral structures by 3D EVUS in the midsagittal plane is not associated with SUI status.

Objective To determine the muscles comprising the minimal levator hiatus. Design Cross-sectional study. Setting The University of Oklahoma Health Sciences Center, USA. Population Eight female fresh frozen pelves and 80 nulliparouswomen. Methods Three-dimensional endovaginal ultrasound was performed in eight fresh frozen female pelves. The structures of the levator hiatus were tagged with needles and the cadavers were dissected to identify the tagged structures. A group of 80 nullipara underwent 3D endovaginal ultrasound, and the minimal levator hiatus area, puborectalis area, and anorectal angle were assessed, and normal values were obtained. Main outcome measures Anatomic borders of minimal levator hiatus and normality in pelvic floor measurements. Results The pubococcygeus forms the inner lateral border and anterior attachment of the minimal levator hiatus to the pubic bone. The puboanalis fibres are immediately lateral to pubococcygeus attachments. There are variable contributions of the puborectalis fibres lateral to the puboanalis attachment. The posterior border of the minimal levator hiatus is formed by the levator plate. Eighty community-dwelling nulliparous women underwent 3D endovaginal ultrasound. The median age was 47 years (range 22–70 years). The mean of minimal levator hiatus and puborectalis hiatus areas were 13.4 cm2 (±1.89 cm2 SD) and 14.8 cm2 (±2.16 cm2 SD). The mean anorectal and levator plate descent angles were 156° (±10.04° SD) and 15.9° (±8.28° SD). Conclusion Anterior and lateral borders of the minimal levator hiatus are formed mostly by pubococcygeus. The puborectalis, pubococcygeus, and iliococcygeus form the bulk of the levator plate.

This article discusses the background and appraisal of endoluminal ultrasound of the pelvic floor. It provides a detailed anatomic assessment of the muscles and surrounding organs of the pelvic floor. Different anatomic variability and pathology, such as prolapse, fecal incontinence, urinary incontinence, vaginal wall cysts, synthetic implanted material, and pelvic pain, are easily assessed with endoluminal vaginal ultrasound. With pelvic organ prolapse in particular, not only is the prolapse itself seen but the underlying cause related to the anatomic and functional abnormalities of the pelvic floor muscle structures are also visualized.

We used direct histologic comparison to validate the use of 3D endovaginal ultrasound (EVUS) as a novel and emerging technology for evaluating the structures found in the anterior and posterior pelvic floor compartments.A young nulliparous female pelvis specimen was dissected and histologic slides were prepared by making 8-Micron-thick sagittal cuts. The slides were stained with Mallory trichrome and arranged to form large sections encompassing each anterior and posterior sagittal plane. Healthy nulliparous women underwent 3D EVUS to obtain 3D cubes of the anterior and posterior compartments. Two investigators independently evaluated the anterior and posterior midsagittal structures. The investigators mutually viewed the images and calculated urethral and anal sphincter measurements.Thirty-one nulliparous women underwent 3D EVUS; 77% of the participants were Caucasian, with mean age 31.8 [standard deviation (SD) 5.8] and mean body mass index (BMI) of 28.5 (SD 7.9). The following mean (SD) measurements were obtained: urethral length 36 mm (± 5); striated urogenital sphincter area 0.6 cm(2) (± 0.16); longitudinal and circular smooth muscle area 1.1 cm(2) (± 0.4); urethral complex width 14 mm (± 2); urethral complex area 1.3 cm(2) (± 0.4); internal anal sphincter length 26 mm (± 4); internal anal sphincter thickness 3.2 mm (± 0.8); and rectovaginal septum length 31 mm (± 5). The agreement for visualization of structures was as follows: vesical trigone 96% (κ = 0.65), trigonal ring 94% (κ = 0.8), trigonal plate 84% (κ = 0.6); longitudinal and circular smooth muscle 100%; compressor urethra 97% (κ = 0.85); striated urogenital sphincter 97% (κ = 0.85); rectovaginal septum 100%; internal anal sphincter 100%; external anal sphincter subdivisions 100%.Three-dimensional EVUS can be used to visualize structures of the anterior and posterior compartments in nullipara.

We sought to describe maternal satisfaction with childbirth among women planning either cesarean or vaginal birth. We enrolled primiparous women planning cesarean birth and a comparison group planning vaginal birth. After delivery, the maternal subjective experience was assessed with a visual analogue satisfaction scale and the Salmon questionnaire, with scale scores for these aspects of the maternal experience of birth: fulfillment, distress, and difficulty. The sample included 160 women planning vaginal birth and 44 women planning cesarean. Eight weeks postpartum, women planning cesarean reported higher satisfaction ratings ( P = 0.023), higher scores for fulfillment ( P = 0.017), lower scores for distress ( P = 0.010), and lower scores for difficulty ( P < 0.001). The least favorable scores were associated with unplanned cesarean ( N = 48). Women planning cesarean reported a more favorable birth experience than women planning vaginal birth, due in part to low satisfaction associated with unplanned cesarean. Maternal satisfaction with childbirth may be improved by efforts to reduce unplanned cesarean, but also by support for maternal-choice cesarean.

We sought to compare rates of recurrent cystocele following sacrocolpopexy with and without paravaginal repair (PVR). This retrospective cohort study compared outcomes for patients undergoing sacrocolpopexy with (group A) and without (group B) concomitant PVR. Defining anterior failure as point Ba ≥ −1 cm, we compared anatomic outcomes and reoperation rates for recurrence of cystocele. One hundred seventy patients undergoing sacrocolpopexy had anterior wall prolapse at or beyond the hymen before surgery (62 in group A and 108 in group B). Ten (16.1%) patients in group A and 29 (26.9%) in group B experienced anterior wall prolapse to or beyond −1 cm (p = 0.13, power 0.38). Among these groups, one (1.6%) and five (4.6%) underwent reoperation for cystocele recurrence (p = 0.42, power

We sought to compare the complications and efficacy of tension-free vaginal tape (TVT) and Pelvilace. Chart reviews and telephone questionnaires documented complications, urinary symptoms [Urogenital Distress Inventory short form (UDI-6) and Patient Global Impression of Improvement (PGII)], and re-operations. Failure was defined as PGII > or = 4 (no change or worse) or reoperation for urinary incontinence. There were 91 TVT and 22 Pelvilace slings. The TVT group had lower rates of urinary retention beyond 1 week (8% vs. 43%, p < 0.001) and reoperation for retention (1% vs. 19%, p < 0.001). Median changes in UDI-6 scores were -33.3 for the TVT group and -29.6 for the Pelvilace group (p = 0.21). Median PGII scores were 1 for the TVT group and 2 for the Pelvilace group (p = 0.024). Ten percent of the TVT group and 24% of the Pelvilace group (p = 0.095) were failures. Urinary retention was more common after Pelvilace than TVT slings. Symptomatic outcomes and failure rates were similar.

To investigate perioperative complications of mesh removal performed in the operating room from a single-site, tertiary care center with a large volume of referrals for mesh removal and to compare the morbidity associated with single-compartment mesh removal compared with removal from multiple vaginal compartments.A retrospective review was performed on all patients who underwent mesh removal from January 2008 to April 2014. Patients were identified based on Current Procedural Terminology codes for removal of vaginal mesh or sling. Summary statistics were calculated for the patient population. Complications were compared between single-compartment mesh removal surgery and multicompartment mesh removal surgery. A P value of.05 was considered significant for all analyses.During a 75-month period, a total of 398 procedures were performed for the removal of vaginally placed mesh. A total of 326 (82%) patients underwent single-compartment surgery, 48 (12%) underwent multicompartment surgery, and in 26 (6%), the type of surgery was unclear. The indications for mesh removal included: pain (63%), dyspareunia (57%), mesh exposure (54%), and voiding dysfunction (39%). The mean length of mesh removed was 4 cm (standard deviation±2.8). Those with multicompartment surgery had approximately three times higher estimated blood loss compared with single-compartment surgery (P.001). The odds of blood transfusion after multicompartment surgery were more than nine times higher than the odds of transfusion after a single-compartment surgery (odds ratio 9.7, 95% confidence interval 2.1-44.6; P.01).Bleeding complications are higher with concomitant removal of mesh from multiple vaginal compartments.III.

Objectives: The objectives of this study were to review the recent literature on surgical pain management strategies and to identify those pertinent to urogynecologic surgery. Methods: A literature search using Pubmed and MEDLINE was performed for trials on pain management in gynecologic surgery. Evidenced-based recommendations for preoperative, intraoperative, and postoperative pain control strategies for gynecologic procedures by various surgical routes were identified. Articles specifically describing urogynecologic procedures were sought, but quality, randomized trials on pain management modalities in other gynecologic procedures were also included. Results: Although few randomized trials on pain management strategies in urogynecologic surgery exist, quality evidence suggests that several preemptive and multimodal analgesia strategies reduce pain and opioid-related adverse events in abdominal, laparoscopic, and vaginal surgery. Evidence supporting these strategies is outlined. Many are likely applicable to urogynecologic procedures. Conclusions: Evidence guiding pain management in specific urogynecologic procedures is sparse and should be sought in future studies. When possible, procedure-specific strategies, including preemptive and multimodal techniques, should be implemented.

We aimed to evaluate the association between obstructive defecatory symptoms in women with levator ani deficiency (LAD), worsened minimum levator hiatus measurements, widened anorectal angle (ARA), and increased levator-plate descent angle (LPDA).Using a cross-sectional study design, patients who had undergone 3D endovaginal ultrasound (3D EVUS) imaging of the pelvic floor were sampled and categorized into two groups: those with and those without obstructive defecatory symptoms (ODS) based on their Colorectal and Anal Distress Index (CRADI-8) questionnaire. The levator ani (LA) muscle was scored based on severity of defect. ARA and LPDA were measured and dichotomized (ARA ± 170°; LPDA ± 9°.One hundred patients were analyzed: 52 asymptomatic and 48 with ODS. The mean (standard deviation ) age was 59 years (SD ±14.97). There was no difference in the distribution of LAD severity between groups (p = 0.1438) or mean minimal levator hiatus (MLH) (p = 0.3326). ARA and LPDA were significantly different in those with ODS compared with their asymptomatic counterparts (p 0.0001 and 0.0004, respectively) (Table 1). On multivariable logistic regression, ARA and LPDA were included in the final model. Patients with an ARA170° had seven times the odds of ODS than those with ARA ≤170° [odds ratio (OR) = 7.01, 95 % confidence interval (CI) 2.30-21.35; p = 0.0006). Patients with an LPDA9° had 3 times the odds of ODS than those with an LPDA ≥9° (OR = 3.30, 95 % CI 1.22, 8.96, p = 0.0190).This study demonstrates that increased levator plate descent and widened ARA as measured on 3D endovaginal ultrasound imaging are associated with ODS.

Objective This study aimed to pilot a cystoscopy training program for community gynecologists that is validated by posttraining examination. Methods Twenty-eight gynecologists were trained to perform cystoscopy using a competency-based training approach. Baseline information included years in practice and number of incontinence procedures and/or cystoscopies performed per month. Three 5-hour workshops were administered that included applied practice. After learners individually trained until they felt comfortable with their skills on a model, they were individually tested on a cadaver. Performance was evaluated with 2 instruments, namely, a task-specific checklist and a global rating scale based on the objective structured assessment of technical skill model. Failure was defined as inability to independently complete elements of the task-specific checklist for cystoscopic examination. Likert-type self-report scales were used during pretesting and posttesting, assessing confidence to perform component tasks for diagnostic cystoscopy. Results Twenty-four of 28 trainees successfully performed a systematic cadaveric bladder examination during the primary posttest. After debriefing, the 4 trainees who initially failed successfully performed cystoscopy during a second trial. Median age was 51 years and median time in practice was 19.5 years. All participants reported high confidence in identifying ureteral injury at the course's conclusion. Conclusions A task-specific training program can successfully improve the confidence and skill of community gynecologists to perform intraoperative diagnostic cystoscopy. Professionals may not be able to define when they have received enough instruction in terms of hands-on training with models, before acquisition of technical skills. Formal evaluation of technical skills is recommended after training to ensure competence.

The objective was to investigate the relationship between new onset postoperative stress urinary incontinence (SUI) after sacrocolpopexy (SCP) and anatomical change/surgical approach. We analyzed a retrospective cohort of patients with negative preoperative testing for SUI who underwent SCP from 2005 to 2012. Our primary outcome was new onset postoperative SUI. Logistic regression was used to examine the relationship among anatomical change, defined as ΔAa, ΔBa, ΔC, and ΔTVL, and surgical approach, categorized as abdominal (ASCP) for open cases and minimally invasive (MISCP) for laparoscopic and robot-assisted cases, and postoperative SUI. Of 795 cases, 33 ASCP (43%) and 44 MISCP (57%) met the inclusion criteria for analysis. New onset SUI was demonstrated by 15 patients (45%) of the ASCP group and 7 patients (15%) of the MISCP group (p = 0.005). New onset SUI was significantly associated with route of SCP and ΔAa (p = 0.006 and p = 0.033 respectively). Controlling for ΔAa, the odds of new onset SUI were 4.4 times higher in the ASCP group compared with the MISCP group (OR 4.37, 95% CI 1.42, 13.48). Controlling for route of SCP, the odds of new onset SUI were 2.2 times higher with moderate ΔAa compared with low ΔAa (OR 2.16 95% CI 1.07, 4.38). The odds of new onset SUI was 4.7 times higher in those with high ΔAa than in those with low ΔAa (OR 4.67 95% CI 1.14, 19.22). ΔBa, ΔC, and ΔTVL were not associated with new onset SUI. Greater reduction in point Aa and abdominal surgical route are risk factors for new onset postoperative SUI after SCP.

The puborectalis muscle is an important muscle for the maintenance of fecal continence. We present a novel surgical technique for repair of symptomatic avulsed puborectalis muscle.This woman presented with dyspareunia and fecal incontinence since the vaginal birth of her child 2 years before. The diagnosis of an avulsed right puborectalis was made by physical examination and confirmed by magnetic resonance imaging and three-dimensional ultrasonography. Fascia lata was harvested from the patient's thigh and used to reconstitute the missing portion of the puborectalis muscle. At 12 months postoperatively, the patient was continent of stool and relieved of dyspareunia.The patient's dyspareunia and fecal incontinence were alleviated by restoring normal anatomy.

The purpose of this study is to review our experience with a technique for diagnosing small rectovaginal fistulas that occasionally permit passage of air or mucus.During an in-office visit suspicious areas of the vagina were probed with a cone-tip catheter and injected with a contrast dye to visualize the suspected fistula tract communicating to the rectum under fluoroscopic guidance. The fistulous tracts were further isolated using a flexi-tip glide wire.Five out of nine patients were found to have fistulas not diagnosed by other means. Three patients had recurrent rectovaginal fistula after a vaginal delivery, one patient was identified with a high rectovaginal fistula due to diverticular disease, and one patient had a rectovaginal fistula due to prior hemorrhoidectomy. One patient had a negative test, and the fistula that was diagnosed intraoperatively was due to underlying Crohn's disease.Direct fistulography is a useful technique to visualize otherwise elusive symptomatic rectovaginal fistula tracts.

Patients with anorectal dysfunction are common and can be quite challenging to diagnose. The common underlying causes for such conditions are usually anatomical in nature, which may be difficult to fully evaluate by clinical examination alone. The aim of this video was to demonstrate how multicompartmental ultrasound imaging can be utilized clinically in the evaluation of patients with anorectal dysfunction.Pertinent ultrasound findings of the common anatomical causes of defecatory dysfunction were discussed in this video.Different ultrasound techniques were shown.In conclusion, multicompartmental ultrasound imaging is an easy, cost-efficient, and valuable tool in the evaluation of patients with anorectal dysfunction.

The aim of our study was to determine the association between the severity of anal incontinence and levator ani deficiency, anal sphincter defects, anorectal angle, and colonic motility abnormalities. This was a retrospective study. Subjects were categorized into three groups: normal, minor anal incontinence, and major anal incontinence according to their answers to the PFDI-20 questionnaire. 3D endovaginal ultrasound was utilized to assess levator ani muscle and the anorectal angle. Levator ani muscle subdivisions were scored based on avulsion from the pubic bone and muscle thickness, based on our previous work. 3D endoanal ultrasound was utilized to assess anal sphincters. Colonic motility abnormalities were defined as diarrhea, constipation or both. Ninety-seven patients were included in the analysis: 45 with major anal incontinence, 29 with minor anal incontinence, and 23 continent women. On multivariate logistic regression, sphincter defect, anorectal angle, and colonic motility abnormalities were associated with anal incontinence severity. Women with an external anal sphincter defect had a 20.36-fold chance of having severe anal incontinence compared with patients with no defect (OR 20.36, 95 % CI 5.4, 76.6); those with both defective sphincters had a 102.5-fold chance of having severe anal incontinence (OR 102.5, 95 % CI 10.2, >999). Anorectal angle ≥170° was significantly associated with the severity of anal incontinence (OR = 4.07, 95 % CI 1.53, 10.79), as was the presence of colonic mobility abnormality (OR 5.31, 95 % CI 1.86, 15.19). 3D pelvic floor ultrasound can be an efficient tool for anal incontinence evaluation in women. Anal sphincter defects, colonic motility abnormalities, and anorectal angle were associated with the severity of anal incontinence. While there was a trend toward worsening levator ani deficiency among those with major anal incontinence, this did not reach statistical significance.

To estimate whether levator ani deficiency severity is a predictor of clinically significant pelvic organ prolapse (POP) and to determine whether there is a levator ani deficiency threshold above which POP occurs.Two-hundred twenty three-dimensional ultrasound scans performed on urogynecologic clinic patients were reviewed, and each levator ani muscle subdivision was individually scored (0=no defect, 1=50% or less defect, 2=more than 50% defect, 3=total absence of the muscle) on each side. A levator ani deficiency score was calculated and categorized as mild (score 0-6), moderate (score 7-12), and severe (score more than 13). Clinically significant prolapse was defined as stage 2 or higher.The mean age was 56.50 (standard deviation ±15.58) and median parity was 2 (range 0-6). A mild positive correlation was demonstrated between levator ani deficiency category and prolapse stage (rs=0.44; P.001). Score distribution significantly differed by prolapse stage (P.001). No patients with stage 3 prolapse had a levator ani score less than 6, and no patients with stage 4 prolapse had a levator ani score less than 9. In patients with prolapse, those with moderate levator ani deficiency had 3.2 times the odds of POP compared with patients with a minimal defect; those with severe levator ani deficiency had 6.4 times the odds of prolapse than those with minimal deficiency.Levator ani deficiency severity is associated with clinically significant prolapse.II.

Objectives This study aimed to investigate the effects of age on pelvic floor symptoms (PFSs) in nulliparous women. Methods Eighty community-dwelling nulliparous women, aged 21 to 70 years, were recruited. Pelvic floor support was assessed with pelvic organ prolapse quantification system. Participants completed the Pelvic Floor Distress Inventory 20 and Pelvic Floor Impact Questionnaire 7. Sexual function was assessed with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12 and health status with the Short-Form Health Survey. The correlation between age and questionnaire scores was evaluated using Pearson coefficient. Logistic regression assessed predictors associated with PFS. Results Participants had a median age of 47 years, average body mass index of 28.3 kg/m, and most were white; 52.5% were healthy and 30% were postmenopausal. The most common stage of prolapse was stage I.Age was associated with slightly higher Pelvic Floor Distress Inventory-20 scores (r = 0.41, P = 0.002), corresponding to more bothersome PFS, and lower Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12 scores, corresponding to worsening sexual function with advancing age (r = -0.41, P = 0.0012). There was no association between age and overall Pelvic Floor Impact Questionnaire scores (P = 0.12). For symptomatic patients, logistic regression showed age to be associated with increased odds of having PFS [odds ratio (OR), 1.881; 95% confidence interval (CI), 1.216-2.91]. Menopausal status was not associated with increased odds of reporting symptoms (OR, 3.05; 95% CI, 0.80-11.62). When age and age by menopause were incorporated in the model, age remained a significant predictor of having PFS (OR, 1.78; 95% CI, 1.13-2.78). Conclusions In this population of community-dwelling nulliparous women, age was associated with worsening sexual function and slightly increased odds of reporting symptoms of pelvic floor disorders.

Our aim was to assess whether differences in the ages of nulliparous women affect: (1) interobserver reliability, and (2) visualization of the levator ani (LA) muscle subdivisions in nulliparous women using 3D endovaginal ultrasound (3D-EVUS). This was a cross-sectional study. Community-dwelling nulliparous women ages 21–70 years were recruited. Participants underwent a standard examination and a 3D-EVUS. LA subdivisions of interest included the puboperinealis, puboanalis, pubococcygeus, puborectalis, and ileococcygeus muscles. Each ultrasound (US) volume was scored using a validated scale and assessed by two observers. Defect severity was scored for each muscle from 0 (no defect) to 6 (complete muscle loss). A summed score of the two sides was grouped as normal (0), minor (1–3), or major (4–6). Bias was examined using Bland–Altman plots. Intraclass coefficients were calculated to report agreement of total scores. Spearman’s rank correlation was used to evaluate the association between age and LA scores. Eighty nulliparous women were evaluated. Exact agreement for bilateral scoring of each LA subdivision ranged from 82 % to 84 %. Bilateral scoring of the puboperinealis, puborectalis, and ileococcygeus showed moderate to substantial agreement. Bilateral scores of the puboperinealis demonstrated substantial agreement between observers, with an ICC of 0.8 and a mean difference of −0.2 using the Bland–Altman analysis. When women were analyzed by age decade, reader agreement was overall good to excellent. There was no significant correlation between increasing age and total LA muscle scores (r = 0.179, p = 0.113). Interobserver reliability or visualization of the LA muscle in nulliparous women was not affected by a woman’s age.

Separation of the levator ani muscles from pubic bone is a common major levator trauma that may occur in vaginal delivery and is associated with pelvic floor dysfunctions. We describe a novel ultrasound-guided technique to repair these muscles. A 33-year-old woman presented with a history of difficult vaginal delivery and complaint of numbness and weakness of the vagina. In evaluation, bilateral levator defects were diagnosed by physical examination, three-dimensional endovaginal ultrasound, and magnetic resonance imaging. With ultrasound guidance the detached ends of muscles were tagged and sutured to their insertion points at the pubic bone. The patient’s normal anatomy was restored with the return to normal pelvic floor tone. A follow-up ultrasound showed restored levator anatomy at 3 months.

OBJECTIVE Although gynecologists perform a large number of surgeries in close proximity to the ureters and the urinary bladder, traditionally, Obstetrics and Gynecology resident physicians are not formally taught to perform cystoscopy. The primary objective was to document resident physicians' performance in diagnostic cystoscopic instrumentation and technique. The secondary objective was to examine if reported prior cystoscopic experience was associated with superior performance. METHODS Fifty-one postgraduate year 4 residents with reported experience with cystoscopy were evaluated using an operation-specific checklist and a global ratings scale based on the Objective Structured Assessment of Technical Skill model. Before evaluation, they attended a formal training session in cystoscopy, which included practice on a bench model of a simulated bladder. RESULTS Forty-three of the 51 residents were able to successfully perform a thorough diagnostic examination immediately after the course. Six of the 8 failures were re-evaluated 2 weeks later and successfully performed a complete examination at that time. Before the course, the residents had performed a mean of 12.2 cystoscopic examinations as the primary surgeon (median, 12; range, 2-33). The number of reported cystoscopic examinations performed before the course did not correlate with the ability to perform a thorough cystoscopic examination (r = -0.109; P = 0.496). CONCLUSIONS For this group of residents, there was poor correlation between the number of reported cystoscopic examinations and the ability to perform diagnostic cystoscopy. Trainees may not be able to determine when they have received enough instruction in hands-on training with models before acquisition of technical skills.

The objective of the study was to compare office rigid cystoscopy (RC) versus flexible cystoscopy (FC) in women.This was a prospective randomized trial comparing FC to RC. Aims were to assess 1-week post-procedural complications, compare procedure pain scores, and to assess physician perception of patient discomfort. Pain scores were assessed by visual analogue scale (VAS) and 5-point verbal descriptor scale (VDS). Chi-square was used for categorical comparison and t tests or Wilcoxon test for continuous variables.One hundred women were enrolled. The mean age of participants was 59.7 years (± SD 14.6), and 91 % were Caucasian. This was the first cystoscopy for 86 % of participants. On the 1-week post-procedure questionnaire (85 % response rate), participants in the FC group reported urinary frequency more often than in the RC group (p = 0.041). The FC group reported urgency with urination lasting 1-2 days (p = 0.030) and burning with urination lasting3 days (p = 0.026), more than the RC group. These symptoms did not persist at 7 days. The duration of the procedure was slightly faster for the FC group (4.6 ± 1.8 min vs 5.7 ± 3.4 min, p = 0.046). Median VAS scores were 0.9 (0.1-2.72) for the FC group and 0.5 (0-2.4) for the RC group (p = 0.505). There were no significant differences between patient or physician perception of pain in either group.Urinary frequency and duration of urinary burning post procedure occurred more frequently in the FC group, although these symptoms were transient. Both office FC and RC are generally well tolerated in women with overall low morbidity.

In certain health care settings, most notably in rehabilitation and palliative care, patients are expected and encouraged to articulate treatment goals and desired outcomes. In obstetrics, patients may voice their preferences via birth plans.1 Birth plans are currently used by women planning both vaginal and cesarean deliveries but have been most often discussed in the context of labor and vaginal delivery. Maternal preferences are important considerations in the management of childbirth, and therefore caregivers should seek information about the values and expectations of obstetric patients. This is particularly important as obstetric providers grapple with an apparent increase in planned cesarean birth.2 Pregnant women strongly prefer a delivery that is safest for their babies and themselves.3 Studies indicate that some women widely perceive cesarean delivery to be as safe as or safer than vaginal birth.4–7 Indeed, some mothers request or agree to cesarean birth because of this belief.4 However, other than an expectation of a safe birth experience, very little is known about what women who request cesarean value regarding the birth experience. In particular, it is not known whether maternal goals for childbirth differ among women who anticipate cesarean versus vaginal birth. We previously described maternal satisfaction with childbirth among women planning either cesarean or vaginal birth.8 In this study, we sought to describe maternal wishes, goals, and expectations for childbirth among women planning cesarean birth compared with a group of women planning vaginal birth. In contrast with other studies exploring women’s reasons for choosing primary cesarean,4–7 our focus was on goals for childbirth among women who had already selected cesarean as a mode of delivery. Our objectives were (1) to develop a framework for describing maternal goals for childbirth, (2) to contrast the goals articulated by women planning vaginal birth with those planning cesarean birth, (3) to investigate goal achievement in both groups, and (4) to investigate the relationship between goal achievement and satisfaction. To our knowledge, there are no current studies comparing maternal goals between planned vaginal and cesarean delivery. Our aim was to investigate whether choice of delivery route would be strongly associated with the type of goals expressed. We also investigated whether goal achievement would be associated with satisfaction with the birth experience in both groups.

We present a novel technique for visualization of a urethrovaginal fistula. A 52-year-old patient presented with persistent urinary incontinence, after having three mid-urethral sling procedures performed within the past year. The diagnosis of a urethrovaginal fistula was made by endovaginal 3-D endovaginal ultrasound and confirmed intraoperatively. We have described a novel technique that may benefit patients with urethrovaginal fistulas that are difficult to visualize.

To formulate an evaluation system and authenticate the levator ani subdivisions visible on endovaginal three-dimensional ultrasonography.A three-dimensional endovaginal ultrasound examination was performed on five fresh-frozen female pelves. The location of the pubovaginalis, puboperinealis, puboanalis, puborectalis, and iliococcygeus muscles was identified. Three-dimensional endovaginal ultrasound scans of 22 nulliparous women with normal pelvic floors were obtained, and a three-level evaluation system was constructed. Level 1 contained the muscles as they insert into the perineal body. Level 2 evaluated the insertions into the retropubic area and typically contained the pubovaginalis, puboperinealis, puboanalis, and puborectalis. Level 3 contained muscles that were cephalad to the pubic bone. Two blinded reviewers assessed levator ani subdivision visualization at each level and individual muscle visualization by the origin-insertion points.There was 98%, 96%, and 92% agreement for levels 1, 2, and 3 muscles, with 95% confidence intervals (CIs) of 0.92-1, 0.95-0.99, and 0.88-0.95, respectively. Kappa values (95% CI) for agreement were calculated for individual muscles as follows: superficial transverse perinei and puborectalis were seen by both raters 100%, puboperinealis, pubovaginalis, and puboanalis 0.645 (0.1-1), and iliococcygeus 0.9 (0.6-1).The location of the pubovaginalis, puboperinealis, puboanalis, puborectalis, and iliococcygeus as seen by three-dimensional endovaginal ultrasonography was confirmed through anatomic dissection of fresh-frozen pelves. Subdivisions of the levator ani muscle were visualized reliably with three-dimensional ultrasonography using a systematic approach.III.

We compared the short-term maternal and neonatal outcomes of women who deliver by cesarean without labor compared with women who deliver by cesarean after labor or by vaginal birth. This was a retrospective cohort study of women delivering a first baby from 1998 to 2002. Hospital discharge diagnostic coding identified unlabored cesarean deliveries (UCDs), labored cesarean deliveries (LCDs), and vaginal births (VBs). Medical records were abstracted and mode of delivery confirmed. The three outcomes of interest were maternal bleeding complications, maternal febrile morbidity, and neonatal respiratory complications. Using logistic regression for each outcome, we investigated whether mode of delivery was associated with the outcome, independent of other factors. The study groups included 513 UCDs, 261 LCDs, and 251 VBs. Compared with the UCD group, the adjusted odds of bleeding complications was higher in the LCD comparison group (odds ratio [OR] 2.3; 95% confidence interval [CI] 1.21, 4.53) and the VB comparison group (OR 1.96; 95% CI 0.95, 4.02). The incidence of febrile morbidity was similar for both cesarean groups but lower in the VB group. Both comparison groups had lower odds of neonatal complications than the UCD group (OR for LCD comparison group 0.52; 95% CI 0.27, 0.95 and OR for VB comparison group 0.26; 95% CI 0.098, 0.59). Scheduled cesarean is associated with increased odds of neonatal respiratory complications but decreased odds of maternal bleeding complications.

Urethral erosion is a rare complication after the tension-free vaginal tape (TVT) procedure. Surgical management of this complication is challenging due to the potential for significant patient morbidity. A 50-year-old patient presented with lower urinary tract symptoms (LUTS) and incomplete voiding, 6 years after a TVT procedure performed for stress incontinence. An attempt at cystoscopy revealed an almost complete occlusion of the urethral lumen by a urethral erosion of the polypropylene mesh. A transurethral resection was performed under tactile traction. This procedure is a minimally invasive approach that avoids the need for a transvaginal procedure. Careful cystourethroscopy should be performed in patients presenting with new lower LUTS after TVT in order to avoid a delay in diagnosing a mesh erosion.

Objective The objective of this study was to determine the minimum threshold level at which maximum anatomic prolapse predicts bothersome pelvic floor symptoms. Study Design We performed a cross-sectional study of women older than 40 years undergoing gynecologic and urogynecologic examinations using Pelvic Organ Prolapse Quantification (POP-Q) examinations to assess support and Pelvic Floor Distress Inventory questionnaires to assess symptoms. Across the spectrum of prolapse severity, we calculated receiver operating characteristic (ROC) curves and areas under the curves (AUCs) for each symptom. Results Of 296 participants, age was 56.3 ± 11.2 years, and 233 (79%) were white. POP-Q stage was 0 in 39 (13%), 1 in 136 (46%), 2 in 89 (30%), and 3 in 33 (11%). ROC analysis for each symptom revealed an AUC of 0.89 for bulging/protrusion; 0.81 for splinting to void; 0.55-0.62 for other prolapse and urinary symptoms; and 0.48-0.56 for bowel symptoms. Using a threshold of 0.5 cm distal to the hymen, the sensitivity (69%) and specificity (97%) were high for protrusion symptoms but poor for most other symptoms considered. Conclusion Vaginal descensus 0.5 cm distal to the hymen accurately predicts bulging/protrusion symptoms; however, we could not identify a threshold of prolapse severity that predicted other pelvic floor symptoms.

In abdominal sacrocolpopexy (ASC), a graft is used to secure the apex of the prolapsed vagina to the anterior longitudinal ligament of the sacrum. This retrospective cohort study enrolled women having ASC (abdominal sacrohysteropexy or abdominal sacral colpoperineopexy) in the years 2001–2005. Synthetic mesh was used in 52% of 259 ASC procedures; porcine dermis (Pelvicol) in 39%; and autologous fascia in 9%. Patients in whom synthetic mesh was used were older than others, more likely to have had hysterectomy, and likelier to be postmenopausal. Concomitant surgery was performed least often in the synthetic mesh group. Postoperative follow-up averaged 1.1 years. The primary outcome was anatomical failure of ASC at the apical compartment. Rates of apical failure were 11% when Pelvicol was used, 7% with autologous fascia, and 1% with synthetic mesh. All 7 reoperations necessitated for apical prolapse were in the Pelvicol group. Intraoperative and immediate postoperative complications were comparably frequent in the 3 treatment groups. Intraoperative problems included cystotomy in 6% of patients, enterotomy in 1.5%, and a single ureteral injury. Erosions occurred in 11% of the Pelvicol group. Similar numbers of reoperations for graft-related complications were required in all groups. The most common such complications were granulation tissue formation and erosion. These results show that ASC is likelier to fail when Pelvicol is used rather than synthetic mesh or autologous fascia. In addition, using Pelvicol did not lessen the risk of graft-related complications in this study population.

The purpose of this study is to describe the outcomes of partial colpocleisis for mesh erosions after sacrocolpopexy. We retrospectively report our surgical management of mesh erosion after sacrocolpopexy. Between 1998 and 2006, we performed 499 sacral colpopexies and treated 21 patients for mesh erosion, including three referrals. Mean (range) time to diagnosis was 10.3 months (1–49). Grafts materials included: Mersilene (13), Prolene (7), and Pelvicol (1). Surgical outcomes were available for 19 patients. Ten (48%) patients were cured by the initial partial colpocleisis, while nine (45%) required a second or third (2, 10%) vaginal operation. All of the second and third vaginal excisions failed. Eight patients had an abdominal excision, and two patients required a second abdominal procedure. The success rate for the first and second abdominal resections was 38% (3/8) and 100% (2/2). Abdominal surgeries had higher blood loss (84 vs 378 cc, p = 0.012) longer hospitalization (outpatient vs 4.2 days p = 0.001), and additional morbidity (18.6%). Potential contributing factors to surgical failure were the presence of Actinomyces and current smoking. We recommend initial transvaginal mesh resection with partial colpocleisis for synthetic mesh erosions after sacrocolpopexy. Vaginal failures may be better served by an abdominal excision. Potential contributors to failure include current smoking and the presence of Actinomyces.

Dear Editor, We are grateful to van der Weiden and Withagen for sharing their findings [1]. We observed an overall de novo SUI rate of almost 30 % among our cohort of open and minimally invasive sacrocolpopexy (SCP) patients with negative preoperative prolapse reduction stress testing (PRST) [2]. In our statistical model, we noted a clear specific relationship between de novo stress urinary incontinence (SUI) and Aa reduction magnitude, regardless of surgical route. Patients with a high (6 cm≥ΔAa 4 cm. Thus, we would agree with cautious and consistent anterior prolapse correction during both PRST and SCP.

score 6 (0–20), and median post-operative clinical POPQ stage 1 (0–2). On ultrasound, clear visualization was obtained in all patients. 8 patients had avulsion defects (75%, 5 bilateral) and all had ballooning on Valsalva. There was no correlation between clinical POPQ staging and ultrasound parameters of prolapse, levator hiatal dimensions or the presence of avulsion defects. Two women were found to have a urethral diverticulum on ultrasound, which was neither symptomatic nor clinically apparent. Conclusions: 4D transperineal ultrasound is an effective tool in the evaluation of vaginal anatomical and functional changes following colpocleisis. It can acquire data that may elude the clinician in view of the obliterative nature of the operation. Future study is warranted to investigate the association between ultrasound findings and patients’ subjective symptoms in a larger cohort.