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Transvaginal mesh (TVM) insertion for the treatment of pelvic organ prolapse (POP) is significantly associated with lower failure rates, although its use remains controversial due to the potential risk of mesh-related complications. In this review, we collected the published literature regarding the use of TVM to treat POP in an attempt to assess both the efficacy and complications related to TVM usage in Taiwan. We searched 25 English language articles using PubMed related to TVM in Taiwan from 2010 to 2019. The present article focuses on the efficacy and complications of TVM and analyzes the data. There were 25 studies on TVM selected for this review. Regarding their success rate, 21 out of the 22 studies (95.5%) had more than a 90% objective success rate. Twenty studies (90.9%) had less than 10% major complications of TVM. Twenty out of the 25 studies (80.0%) had 5% or less mesh exposure. For self-cut TVM and the later single-incision TVM, both the complication rates and exposure rates decreased. The rate of de novo dyspareunia ranged from 2.6% to 14.3%, and the incidence decreased yearly from 2011 to 2019. This review showed both the high treatment efficacy and low complication rate of TVM usage for the short-term treatment of POP in Taiwan. However, a longer-term study is needed to draw a conclusion regarding the safety of this treatment., Competing Interests: Declaration of competing interest There are no conflicts of interest for any of the authors., (Copyright © 2021. Published by Elsevier B.V.)

Introduction and Hypothesis: Our aim was to evaluate the clinical outcome of continent women with high-risk predictors for de novo stress urinary incontinence (SUI) offered prophylactic midurethral sling (MUS) insertion during vaginal pelvic reconstructive surgery (PRS) for advanced pelvic organ prolapse (POP)., Materials and Methods: This was a prospective cohort study in patients with POP stage ≥ 3 and maximum urethral closure pressure (MUCP) <60 cmH 2 O and functional urethral length (FUL) <2 cm. Patients were divided into PRS and PRS + MUS groups. Surgery commenced with vaginal hysterectomy, application of Uphold® and insertion of MUS to the PRS + MUS group. Main outcome measures were incidence of de novo urodynamic stress incontinence (USI), lower urinary tract symptoms (LUTS), quality of life (QoL), and topographic and anatomical relationship of implanted mesh., Results: Based on sample size calculation, 40 patients were recruited-20 in each group. Rate of de novo USI in PRS + MUS was 5% objectively and 10% subjectively, while in the PRS it was 50% objectively and 60% subjectively. No significant difference was noted in patient demographics. Intraoperative blood loss was greater for PRS + MUS but was not statistically significant. No organ injuries, mesh exposure, or infections occurred. Postoperatively, MUCP significantly increased from 43.3 ± 8.9 to 58.5 ± 19.2 cmH 2 O and FUL from 17.2 ± 1.9 to 20.3 ± 3.1 mm in the PRS + MUS group. Residual urine significantly decreased. No patient had bladder outlet obstruction (BOO). Sonographic assessment showed no difference in mesh mobility with urethral kinking observed in 11 (55%) patients with MUS., Conclusion: Based on a validated small sample, prophylactic MUS for continent women at high risk for postoperative USI with advanced POP lowers its incidence to 5%. Continence is achieved in 95%. Concern for complications, LUTS, and QoL did not significantly differ.

Introduction and Hypothesis: To determine the clinical outcomes of adding a tension-releasing suture (TRS) appendage for manipulation of over-tensioned single-incision slings (SIS) as a means to relieve postoperative voiding dysfunction., Methods: A retrospective observational study conducted from January 2010 to July 2017. The records of patients with urodynamic stress incontinence (USI) without needing concurrent procedures who underwent anti-incontinence surgery using MiniArc, Solyx, and Ajust with voiding dysfunction were collated and analyzed. The primary outcome measure was the recovery of normal post-void residual urine (PVR) after TRS manipulation. The secondary outcome measures were the pain intensity noted during manipulation (quantified by visual analog scale) and the continence rate [assessed by (1) objective cure: 1-h pad test weight < 2 g and absence of USI; (2) subjective cure index score ≤ 1 on question 3 of the UDI-6: "Urine leakage related to physical activity, coughing, or sneezing?"]., Results: There were 73 patients with high post-void residual (PVR) urine. The 42 (9.5%) patients with over-tensioned slings were managed with TRS manipulation while the 31 patients (7%) with high PVR and no sling over-tension were managed with intermittent catheterization. All patients in both groups regained normal PVR. The TRS-manipulated group demonstrated an objective cure rate of 92.9% (39/42) and subjective cure rate of 91% (38/42). Pain experienced during TRS manipulation was significantly higher with the Ajust system (p = 0.018). Three patients had persistence of USI, two with MiniArc and one with Solyx., Conclusions: The TRS manipulation is a well-tolerated procedure that can effectively relieve voiding dysfunction for over-tensioned SIS without affecting continence cure rates.

Aim: This study aims to identify the predictors for detrusor overactivity (DO) in women following extensive vaginal pelvic reconstructive surgery (PRS) for advanced pelvic organ prolapse (POP)., Methods: We enrolled 1503 women who had prolapse POP-Q stage ≥ 3 and underwent vaginal PRS with or without MUS from January 2006 to December 2015. All subjects completed a 72-h voiding diary, IIQ-7, UDI-6, POPDI-6, and PISQ-12. Urodynamics (UDS) was performed pre- and post-operatively., Results: Among 1503 women, 56 patients were excluded due to incomplete data. Women who had trans-vaginal mesh were 1083 of 1447 (74.8%) and concomitant MUS were 353 (24.4%). Pre-operative DO were 245 (16.9%) and 24.5% (60/245) of them continued to have persistent DO post-operatively. Women who had normal pre-operative stable detrusor were 1202 (83.1%) and 3.5% (30/1202) developed de novo DO post-operatively. The overall incidence of post-operative DO was 6.2% (90/1447). Patients with age ≥66 year, neurological factors like Cerebrovascular accident and Parkinsonian disease, pre-operative bladder outlet obstruction (BOO) maximum urethral closure pressure (MUCP) ≥60 cmH 2 O, Maximum flow rate (MFR) <15 mL/s and detrusor at maximum flow (Dmax) ≥20 cmH 2 O) and post-void residue (PVR) ≥200 mL hold a significant higher risk of developing DO either persistent or de novo following PRS., Conclusion: Age ≥66 year, neurological factors like CVA and Parkinsonian disease, pre-operative MUCP ≥60 cmH 2 O, MFR < 15 mL, Dmax ≥ 20 cmH 2 O, and PVR ≥ 200 mL are independent risk factors for developing post-operative DO following vaginal PRS for advanced POP., (© 2017 Wiley Periodicals, Inc.)

Objective: Urethral diverticulum is uncommon, therefore appropriate evaluation, preoperative planning and counseling must be done in order to make correct diagnosis and prevent complications., Materials and Methods: A case of anterior vaginal wall mass was treated elsewhere by a gynecologist as periurethral cyst abscess; incision and drainage were done but a symptom of pus discharge was observed after 2 weeks. Therefore, exploration, cyst wall excision and primary closure were done though histopathological examination surprisingly confirmed the presence of urethral tissue suggestive of diverticulum., Results: Subsequently, she developed persistent urinary leakage along with urethrovaginal fistula for which they again performed pervaginal multilayer closure. Patient was later referred to us with recurrent urethrovaginal fistula. We performed posterior urethral fistulectomy with anterior vaginal wall flap and multilayer closure. Three years follow up reveals complete recovery., Conclusion: Even urethral diverticulum is a rare condition, should be kept in mind as early diagnosis and management., (Copyright © 2017. Published by Elsevier B.V.)

Introduction and Hypothesis: The objective of this study was to identify the predictors of postoperative voiding dysfunction in women following extensive vaginal pelvic reconstructive surgery., Methods: We enrolled 1,425 women who had pelvic organ prolapse of POP-Q stage III or IV and had undergone vaginal pelvic reconstructive surgery with or without transvaginal mesh insertion from January 2006 to December 2014. All subjects were required to complete a 72-h voiding diary, and the IIQ-7, UDI-6, POPDI-6 and PISQ-12 questionnaires. Urodynamic study was performed preoperatively and postoperatively., Results: Of the 1,425 women, 54 were excluded due to incomplete data, and 1,017 of the remaining 1,371 (74.2 %) had transvaginal mesh surgery and 247 (18 %) had concurrent midurethral sling insertion. Of 380 women (27.7 %) with preoperative voiding dysfunction, 37 (9.7 %) continued to have voiding dysfunction postoperatively. Of the remaining 991 women (72.3 %) with normal preoperative voiding function, 11 (1.1 %) developed de novo voiding dysfunction postoperatively. The overall incidence of postoperative voiding dysfunction was 3.5 % (48/1,371). Those with concurrent midurethral sling insertion were at higher risk of developing voiding dysfunction postoperatively (OR 3.12, 95 % CI 1.79 - 5.46, p < 0.001). Diabetes mellitus, preoperative detrusor pressure at maximal flow (Dmax) <10 cm H 2 O and postvoid residual volume ≥200 ml were significant risk factors for the development of postoperative voiding dysfunction (OR 3.07, 1.84 and 2.15, respectively; 95 % CI 1.69 - 5.60, 1.39 - 2.91 and 1.10 - 3.21, respectively)., Conclusions: Diabetes mellitus, concurrent midurethral sling insertion, preoperative Dmax <10 cm H 2 O and postvoid residual volume ≥200 ml in patients with advanced pelvic organ prolapse were risk factors for the development of postoperative voiding dysfunction after vaginal pelvic reconstructive surgery. Therefore, counseling is worthwhile before considering vaginal pelvic reconstructive surgery.

Objective: Voiding dysfunction following a midurethral sling procedure is still a relevant consequence that can affect patients' quality of life. Various invasive methods have been described to manage this problem. We hypothesize that we if we could diagnose the condition early using noninvasive tools, we would be able to offer appropriate effective management. We sought to study the effectiveness of attaching a tension-releasing suture on a single-incision sling (SIS) tape as a prophylactic measure for the treatment of immediate postoperative voiding dysfunctions, and secondarily, to evaluate the objective and subjective cure rates of the treatment for stress urinary incontinence., Materials and Methods: It is a prospective observational study. A tension-releasing suture was prepared by appending a polyglactin suture to one end of the MiniArc sling tip fiber, which could be used to manipulate the sling tip when postoperative voiding dysfunction was identified. Primary outcome measure was the number of patients requiring tension-releasing suture manipulation to treat postoperative voiding dysfunctions successfully., Results: Twelve of the 131 (9.2%) patients who underwent SIS procedure for urodynamic stress incontinence surgery required tension-releasing suture manipulation due to voiding dysfunction during the immediate postoperative period with a good outcome. Postoperative overall objective and subjective cure rates were 90.5% and 88.9% (126 available patients at 1-year follow up, mean 19.2 ± 8.0 months), respectively. The subanalysis of the objective and subjective cure rates of the group with tension-releasing suture manipulation were 91.7% (11/12) and 91.7% (11/12), and those of the group without tension-releasing suture manipulation were 90.4% (103/114) and 88.6% (101/114), respectively, at 1-year follow up., Conclusion: Tension-releasing suture is effective in the management of immediate postoperative voiding dysfunction in an SIS procedure. SIS operation has good short-term objective and subjective cure rates for female urodynamic stress incontinence., (Copyright © 2016. Published by Elsevier B.V.)

Introduction and Hypothesis: The objective of this study was to identify the predictors for persistent urodynamic stress incontinence (P-USI) in women following extensive pelvic reconstructive surgery (PRS) with and without midurethral sling (MUS)., Mmethods: A total of 1,017 women who underwent pelvic organ prolapse (POP) surgery from January 2005 to December 2013 in our institutions were analyzed. We included 349 USI women who had extensive PRS for POP stage III or more of whom 209 underwent concomitant MUS., Results: Of the women who underwent extensive PRS without MUS, 64.3 % (90/140) developed P-USI compared to only 10.5 % (22/209) of those who had concomitant MUS. Those with concomitant MUS and PRS alone were at higher risk of developing P-USI if they had overt USI [odds ratio (OR) 2.2, 95 % confidence interval (CI) 1.3-4.0, p = 0.014 and OR 4.7, 95 % CI 2.0-11.3, p < 0.001, respectively], maximum urethral closure pressure (MUCP) of < 60 cm H2O (OR 5.0, 95 % CI 3.0-8.1, p < 0.001 and OR 5.3, 95 % CI 2.7-10.4, p < 0.001, respectively), and functional urethral length (FUL) of < 2 cm (OR 5.4, 95 % CI 2.7-8.8, p < 0.001 and OR 3.9, 95 % CI 2.4-6.9, p < 0.001, respectively). Parity ≥ 6 (OR 3.9, 95 % CI 1.7-5.2, p < 0.001) and Prolift T (OR 3.1, 95 % CI 1.9-4, p < 0.001) posed a higher risk of P-USI in those with concomitant surgery. Perigee and Avaulta A seemed to be protective against P-USI in those without MUS., Conclusions: Overt USI with advanced POP together with low MUCP and FUL values have a higher risk of developing P-USI. Therefore, counseling these women is worthwhile while considering the type of mesh used.

Introduction and Hypothesis: The aim of this study was to look for possible predictors preoperatively for the development of de novo stress urinary incontinence (SUI) in urodynamically continent women who underwent pelvic reconstructive surgery (PRS)., Materials and Methods: Medical records of 637 continent women who underwent PRS for severe prolapse from January 2005 to December 2013 in our institutions were included in this study. We excluded women who had urodynamic stress incontinence (UDI) either occult or overt, detrusor overactivity, neurogenic bladder-voiding dysfunction, and previous anti-incontinent surgery. Primary outcome measure was the development of de novo SUI at 6 months to 1 year post operation., Results: Of women in this study, 11 % developed postoperative de novo SUI at 6 months to 1 year of follow-up. Women older than 66 years were 2.86 times [95 % confidence interval (CI) 1.01-2.53, p = 0.14], diabetes mellitus (DM) 2.18 times (95 % CI 1.63-4.21, p = 0.002), certain type of transvaginal mesh procedure 3.5 times (95 % CI, p < 0.001), maximum urethral closure pressure (MUCP) < 60 mmH20 4.65 times (95 % CI, 2.87-8.64, p < 0.001), and functional urethral length (FUL) < 2 cm 3.48 times (95 % CI, 2.13-5.83, p < 0.001) at greater risk of developing de novo SUI., Conclusions: Continent women with advanced pelvic organ prolapse (POP) > 66 years, with DM or low MUCP and FUL values during preoperative urodynamic evaluation have higher risk of developing de novo SUI; therefore, we suggest counselling such women for concomitant PRS and anti-incontinent surgery.

Aim: To evaluate and compare the long-term outcome of sacrospinous ligament fixation (SSF) in combination with various other compartment defect native tissue repairs with hysterectomy or hysteropexy., Methods: Medical records of 159 patients who underwent surgery for pelvic organ prolapse (POP) between April 2004 and August 2008 were reviewed retrospectively. Patients were assessed at baseline and at 5-year postoperative follow-up. SSF, anterior (AC) and posterior colporrhaphy (PC), both with and without hysterectomy, were performed. Primary outcome was objective cure (POP quantification system [POP-Q] ≤1) and subjective cure (negative response to questions 2 and 3 on Pelvic Organ Prolapse Distress Inventory 6 [POPDI-6]). Subanalysis was done on patients who had uterus preserved compared with those with vaginal hysterectomy., Results: Postoperative data were available for 146 patients: 120 in the hysterectomy group and 26 in the hysteropexy group. Mean age, parity, postmenopausal status and mean operating time in the hysterectomy group were significantly higher than in the hysteropexy group. At median follow-up of 86 months, objective cure at overall compartments for all patients was 67.8%, and for subjective cure, this was 64.4%. There was no difference in the adjusted odds ratio for objective and subjective cure rates in both groups, but the hysterectomy group had a significantly lower mean total POPDI-6 score., Conclusion: SSF plus AC and PC have a low reoperation rate despite a moderate success rate at 7-year follow-up. There was no difference in the adjusted objective, subjective success rates and sexual function between sacrospinous hysteropexy and hysterectomy. The hysterectomy group, however, had fewer bothersome prolapse symptoms., (© 2015 The Authors. Journal of Obstetrics and Gynaecology Research © 2015 Japan Society of Obstetrics and Gynecology.)

Intravesical mesh erosion and extrusion have been reported as devastating late complications of synthetic suburethral sling placement for the treatment of stress urinary incontinence. We report a case of a female patient with intravesical mesh erosion from a sling suspension that developed 4 years after primary prolapse surgery with mesh reinforcement. Intravesical mesh erosion was observed ultrasonographically and confirmed through cystoscopy. We excised the mesh via a vaginal approach and repaired both bladder mucosa and vaginal wall. As of this writing, the patient has been symptom-free for the past year post-surgery. Long-term follow-up is recommended in such cases. Anti-incontinence surgery followed by primary prolapse surgery could potentially jeopardize the former. Complications may arise several years later so long-term follow-up is essential. Ultrasonography is an effective tool in evaluating mesh morphology and detecting intravesical mesh erosion.

Abdominal sacrocolpopexy is a well-established procedure for the reconstruction of apical support in pelvic organ prolapse. Its long-term efficacy is well known; however, it is also associated with higher perioperative morbidity when compared with the less invasive transvaginal approach. Long-term risk of bowel-related complication from abdominal sacrocolpopexy is rare, but can be significant as it is often serious and requires major surgical intervention. Here we highlight an unusual case of strangulated small bowel (in this instance complicated with sepsis secondary to peritonitis), 14 years after an abdominal sacrocolpopexy procedure. This example amplifies the need for proper preoperative counseling; also, life-long follow-up is necessary for patients undergoing this procedure., (© 2013 The Authors. Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology.)

Anterior intravaginal slingplasty (IVS), which utilizes multifilament polypropylene mesh is associated with significant risk of mesh erosion and infection. A case of mesh erosion occurred at 6 months following retropubic suburethral IVS sling was referred to our clinic. Complete removal of the protruded tape with primary closure of the vaginal defect was performed. However, repeat vaginal erosion was observed 2 years later. The undermined remaining tape further developed a retropubic purulent abscess. Thereafter, complete mesh removal and debridement in the retropubic space was carried out. The retropubic abscess resulted from the remains of the IVS tape. We emphasize that complicated sequel can develop after incomplete removal of IVS tape when tape erosion is encountered., (© 2011 The Authors. Journal of Obstetrics and Gynaecology Research © 2011 Japan Society of Obstetrics and Gynecology.)

Objective: To evaluate the influence of intracervical saline injection on inexperienced operators and on laparoscopically assisted vaginal hysterectomy (LAVH)., Study Design: This retrospective study included 273 women undergoing LAVH. From July 1997 to June 2002, 138 LAVHs were performed with laparoscopically approached colpotomies and bladder mobilization. Among 135 LAVHs with a vaginal approach, colpotomies/bladder mobilization was done directly in 62 and in the other 73 after a circumferential intracervical saline injection. All operations were performed by inexperienced operators under the supervision of senior surgeons. Blood loss, operative time and complications were analyzed., Results: The average follow-up period was 41.2 +/- 17.4 months (range, 12-72). No statistically significant differences were observed in age, hemoglobin levels or length of postoperative hospital stay. The incidence of postoperative infection, hematoma and bowel injury was not significantly different. LAVH with vaginal colpotomies/bladder mobilization and intracervical saline injection was associated with the smallest estimated blood loss (p = 0.002) and operative time (p < 0.001). LAVH with laparoscopic colpotomies and bladder mobilization had the longest operative time (p<0.001) and the highest bladder injury rate (p= 0.004)., Conclusion: A circumferential injection of normal saline at the cervicovaginal junction is a good option for inexperienced operators.

Objective: We sought to demonstrate that a positive pessary test could predict postsurgical stress urinary incontinence in women with severe pelvic organ prolapse and that performing tension-free vaginal taping (TVT) could effectively prevent its occurrence., Methods: Among the 79 patients evaluated for severe pelvic organ prolapse without symptoms of stress urinary incontinence, all underwent meticulous urogynecologic evaluations and pessary testing. In group 1, 32 patients had positive pessary tests and underwent vaginal hysterectomy, anterior and posterior colporrhaphy, and TVT. In group 2, 47 patients (17 of whom had positive pessary tests and 30 of whom had negative pessary tests) underwent vaginal hysterectomy and anterior and posterior colporrhaphy alone. A comparison in terms of surgical outcome and clinical manifestations was made between these 2 groups of patients., Results: After surgery, a small proportion of patients had de novo idiopathic detrusor overactivity (7.6%, n = 6), urinary tract infections (7.6%, n = 6), mild recurrent prolapse (5.1%, n = 4), and urinary retention (3.8%, n = 3). Eleven (64.7%) of 17 patients with positive pessary tests who did not undergo TVT had urine leakage after their hysterectomies in contrast with the 30 patients who had negative pessary test, none of whom developed symptomatic stress urinary incontinence after vaginal hysterectomy. Among the 32 patients with positive pessary tests who had TVT with their hysterectomies, 3 developed urine leakage later; the cure rate was 90.6%., Conclusion: Continent patients suffering from severe pelvic organ prolapse but with a positive pessary test are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence. Among the patients in our medium-range study, TVT effectively prevented postsurgical urinary incontinence., Level of Evidence: II-1