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In 2017, we reported the results of an individual patient data (IPD) meta-analysis on the efficacy of vaginal progesterone for the prevention of preterm birth and neonatal morbidity and mortality in asymptomatic women with a twin gestation and a sonographic cervical length (CL) <= 25 mm1. Moreover, vaginal progesterone administration was associated with a significant decrease in the risk of preterm birth < 35, < 34, < 32 and < 30 weeks of gestation, neonatal death, respiratory distress syndrome (RDS), composite neonatal morbidity and mortality, use of mechanical ventilation and birth weight < 1500 g SP 1 sp . We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach14 to assess the quality of evidence for the clinically relevant outcomes of preterm birth < 33 weeks' gestation and composite neonatal morbidity and mortality. [Extracted from the article]

Introduction and hypothesis: To identify preoperative level II/III MRI measures associated with long-term recurrence after native tissue prolapse repair. Methods: Women who previously participated in pelvic floor research involving MRI prior to undergoing primary native tissue prolapse repair were recruited to return for repeat examination and MRI. Recurrence was defined by POP-Q (Ba/Bp > 0 or C > –4), repeat surgery, or pessary use. Preoperative MR images were used to perform five level II/III measurements including a new levator plate (LP) shape analysis at rest and maximal Valsalva. Principal component analysis (PCA) was used to evaluate LP shape variations. Principal component scores calculated for two independent shape variations were noted. Results: Thirty-five women were included with a mean follow-up of 13.2 ± 3.3 years. Nineteen (54%) were in the success group. There were no statistical differences between success versus recurrence groups in demographic, clinical, or surgical characteristics. Women with recurrence had a larger preoperative resting levator hiatus [median 6.4 cm (IQR 5.7, 7.1) vs. 5.8 cm (IQR 5.3, 6.3), p = 0.03]. This measure was associated with increased odds of recurrence (OR 8.2, CI 1.4-48.9, p = 0.02). Using PCA, preoperative LP shape PC1 scores were different between success and recurrence groups (p = 0.02), with a more dorsally oriented LP shape associated with recurrence. Conclusions: Larger preoperative levator hiatus at rest and a more dorsally oriented levator plate shape were associated with prolapse recurrence at long-term follow-up. For every 1 cm increase in preoperative resting levator hiatus, the odds of long-term prolapse recurrence increases 8-fold. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The aims were to review the literature from the last two decades and analyze treatment efficacy and findings of the studies on colpocleisis. Methods: A systematic search was conducted within the MEDLINE/PubMed and ClinicalTrials.gov databases, using the following keywords: pelvic organ prolapse (POP), colpocleisis, obliterative, and LeFort. All English full-text prospective and retrospective observational and interventional studies were included. Anatomical and subjective success, surgical techniques, concomitant procedures, complication rates, anesthesia methods, and decision regret were analyzed. Results: A total of 237 papers were identified and 49 met the inclusion criteria. Mean patient age was 69.0 ± 8.0 to 84 ± 3.1. Over 90.2% of patients undergoing colpocleisis were diagnosed with POP stage ≥ 3. The follow-up ranged from 30 days to a median of 5 years. Anatomical success, defined as POP-Q stage ≤ 1 and no prolapse beyond the hymen, was achieved in 62.5 to 100% and 87.5 to 100% of all patients respectively. Subjective success ranged from 88% to 100%. Regret over the loss of coital ability ranged from 0% in many studies to 12.9%, general decision regret from 0% to 13.8%. After concomitant midurethral sling surgery, 86.8% to 94% of all patients were continent, with a 0–14% sling revision rate due to urinary retention. Urinary tract infection was the most common postoperative complication (4.3 to 9% confirmed with urine culture, 34.7% based on symptom definition). Bowel (0 to 2.7%) and urinary tract (0 to 9.1%) injuries were the consequences of concomitant procedures. The mortality rates were up to 1.3%. Conclusions: Colpocleisis is a heterogeneous procedure, characterized by high subjective and objective success, low coital ability regret, and a low risk of complications. [ABSTRACT FROM AUTHOR]

A 37‐year‐old multiparous woman complained of uterine prolapse at 14 weeks of gestation. A silicone ring‐shaped middle‐size vaginal pessary (# 62 mm) was placed into the vagina to reduce prolapsed uterus. Because the cervical length became shortened at 25 weeks of gestation, we decided to start intramuscular administration of progesterone (250 mg) weekly. At 33 weeks of gestation, she complained of the vaginal pessary spontaneous falling out, so we inserted a vaginal pessary of the same size again. The uterocervical angle became acute, going from 100° to 60° after placing the vaginal pessary into the vagina. We took the vaginal pessary out at 37 weeks of gestation. The patient gave birth at 39 weeks by spontaneous vaginal delivery to a healthy baby. A vaginal pessary may help continue a pregnancy via the same mechanism as a cervical pessary, which sharpens the uterocervical angle. [ABSTRACT FROM AUTHOR]

Background: Doppler-guided hemorrhoidal laser procedure consists of sutureless closure of terminal branches of the superior hemorrhoidal artery by laser energy. Clinical results of patients treated with this procedure were analyzed at the completion of 2-year follow-up. Primary endpoint was resolution of symptoms and secondary endpoints were recurrence rate, type of recurrences, re-operation rate, and potential predictive factors for failure.Methods: Bleeding was assessed on a score from 0 to 4 (none = 0; < 1/month = 1; 1/week = 2; > 1/week = 3; 3-4/week = 4), frequency of hemorrhoid-related symptoms with a score of 0-3 (2/year = 1; 3-5/year = 2; < 5/year = 3). Constipation and fecal incontinence were assessed by means of validated scores. Quality of life and pain at defecation were assessed using a visual analog scale of 0-10 (0 = worst possible-10 = best possible quality of life and 0 = no pain-10 = worst pain imaginable, respectively). Recurrence rate and need for re-operation were reported. Potential predictive factors of failure were analyzed by means of univariate analysis.Results: Two-hundred-eighty-four patients (183 males, 101 females; mean age: 47.5 years) were included in the trial; 8 patients were lost at follow-up. Analysis of 276 patients who completed the 2-year follow-up showed an overall resolution of symptoms in 89.9% (248/276) of patients. Statistically significant improvement of quality of life, pain reduction, bleeding and frequency of acute symptoms were reported. Of 28 patients with persistent or recurrent symptoms, 12 had pain (4.35%), 10 had bleeding (3.6%) and 6 had increasing prolapse at defecation (2.2%). Eleven out of twenty-eight patients required additional surgery. Constipation and III-IV grade hemorrhoids were associated with statistically significant higher failure rates (p = 0.046 and 0.012, respectively). Better results were reported in patients reporting preoperative high-grade pain at evacuation.Conclusions: The Doppler-guided hemorrhoidal laser procedure showed efficacy at long-term follow-up. It can be considered as 'first-line' treatment in patients with low-grade hemorrhoids suffering from bleeding, pain and recurrent acute symptoms in whom conservative treatment failed. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to compare the efficacy of modified transvaginal mesh (TVM) surgery and vaginal pessary in patients with symptomatic pelvic organ prolapse (POP). Methods: We retrospectively analyzed 130 patients with symptomatic POP treated with either modified TVM (n = 62) or vaginal pessary (n = 68). To evaluate the prolapse, lower urinary tract, bowel, and sexual symptoms and prolapse‐related quality of life (QOL) were assessed using the prolapse QOL questionnaire. All questionnaires were completed before treatment and 1 year after the treatment. Results: One year after the treatment, the prolapse and voiding symptoms and all prolapse‐related QOL domains, except for the personal relationships and sleep/energy, were significantly improved in the pessary group. The prolapse, urinary storage, voiding, bowel, and sexual symptoms and all QOL domains significantly improved in the modified‐TVM group. Conclusions: Both the modified TVM surgery and vaginal pessary effectively treated prolapse and voiding symptoms and improved most of the prolapse‐related QOL domains. Modified TVM surgery was more effective in improving urinary storage, bowel, and sexual symptoms than the pessary treatment. Modified TVM seemed to position the organs more correctly to improve bladder, bowel, and sexual function than pessary insertion. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the effectiveness of cervical pessary in preventing preterm birth (PTB) and improving perinatal outcomes among singleton and twin pregnancies.Methods: Electronic databases were systematically searched from their inception until 14 March 2019. Randomized clinical trials comparing the effectiveness of cervical pessary placement with expectant management were included. The primary outcome was the incidence of PTB <34 weeks.Results: Thirteen studies were included, involving eight studies about singleton and six studies about twin pregnancies. For singleton pregnancies with short cervical length, cervical pessary, comparing with expectant treatment, seemed have no effectiveness in preventing PTB <34 weeks (relative risk, 95% confidence interval, 0.73, 0.42-1.28), <37 weeks (0.69, 0.43-1.09), and <28 weeks (0.79, 0.42-1.48); while for twin pregnancies with short cervical length, cervical pessary also did not reduce the risk of PTB <34 weeks (0.81, 0.49-1.35), <37 weeks (0.93, 0.83-1.05), and <28 weeks (0.72, 0.38-1.38). However, cervical pessary seemed have the effectiveness of reducing the risk of spontaneous PTB <28 weeks (0.50, 0.25-0.99) and low birth weight (<1500 g) (0.68, 0.50-0.94) among twin pregnancies with short cervical length. In addition, cervical pessary increased the rate of vaginal discharge and did not improve perinatal outcomes among both singleton and twin pregnancies.Conclusions: Comparing with the expectant treatment, the effectiveness of cervical pessary for reducing the risk of PTB remains uncertain. Additional trials are warranted to further evaluate the effectiveness of cervical pessary. [ABSTRACT FROM AUTHOR]

Due to its low postoperative complication rate, vaginal surgery is the preferred intervention for pelvic organ prolapse (POP) in elderly patients. We aimed to assess outcomes and perioperative complication rates associated with laparoscopic sacrocolpopexy (LSC) in elderly women. We retrospectively reviewed the medical records of 74 consecutive patients [52 (70.3%) aged <75 years; 22 (29.7%) aged ≥75 years] with POP who underwent LSC between August 2015 and December 2017. We evaluated preoperative risks using the Charlson Comorbidity Index (CCI) and complications, using the Clavien-Dindo grading (CDG). No between-group differences were observed in CCI. CDG indicated fewer perioperative complications in patients aged >75 years. Anatomical success rates at 15 months were 95.5% and 90.4% in patients aged ≥75 and <75 years, respectively. LSC has a high anatomical correction rate and few perioperative complications regardless of age. Thus, the appropriate surgical intervention method would depend on the patient's health and comorbidities. What is already known on this subject? Laparoscopic sacrocolpopexy (LSC) is a superior method to vaginal surgery because of its anatomical and functional outcomes, particularly regarding sexual activity. What do the results of this study add? In this single-center study with a 15-month follow-up, we demonstrated that LSC has a high anatomical correction rate and few perioperative complications regardless of age at the time of surgery. Furthermore, there was no significant difference in the rate of complications between the ≥75 and <75 years groups. Thus, LSC may be considered for women aged >75 years. However, in these elderly patients, the surgical method should be determined according to their health status and medical comorbidities. What the implications are of these findings for clinical practice and/or further research? Age should not be the basis for exclusion from laparoscopic procedures. Moreover, LSC is a suitable and valid option for elderly women with POP. As the study population consisted of a homogenous group of Japanese women, it lacks generalisability. Studies evaluating these outcomes are required in other populations. [ABSTRACT FROM AUTHOR]

Objective: To test the effectiveness of cervical pessary in addition to vaginal progesterone for the prevention of preterm birth in women with midpregnancy short cervixes.Methods: We performed a multicenter, open-label, randomized controlled trial in 17 perinatal centers. Asymptomatic women with singleton or twin pregnancies and cervical lengths of 30 mm or less, measured at 18 0/7-22 6/7 weeks of gestation, were randomized to cervical pessary plus vaginal progesterone (pessary plus progesterone group) or vaginal progesterone only (progesterone-only group) (200 mg/day). Treatments were used from randomization to 36 weeks of gestation or delivery. The primary outcome was a composite of neonatal mortality and morbidity. Secondary outcomes were delivery before 37 weeks and before 34 weeks of gestation. Analysis was performed according to intention to treat.Results: Between July 9, 2015, and March 29, 2019, 8,168 women were screened, of whom 475 were randomized to pessary and 461 to progesterone only. The composite perinatal outcome occurred in 19.2% (89/463) of the women in the pessary group compared with 20.9% (91/436) of the women in the progesterone-only group (adjusted risk ratio [aRR] 0.88, 95% CI 0.69-1.12). Delivery rates before 37 weeks of gestation were 29.1% compared with 31.4% (aRR 0.86, 95% CI 0.72-1.04); delivery rates before 34 weeks were 9.9% compared with 13.9% (aRR 0.66, 95% CI 0.47-0.93). Women in the pessary group had more vaginal discharge (51.6% [245/476] vs 25.4% [117/479] [P<.001]), pain (33.1% [157/476] vs 24.1% [111/479] [P=.002]), and vaginal bleeding (9.7% [46/476] vs 4.8% [22/479] [P=.004]).Conclusion: In asymptomatic women with short cervixes, the combination of pessary and progesterone did not decrease rates of neonatal morbidity or mortality when compared with progesterone only.Clinical Trial Registration: Brazilian Clinical Trial Registry (ReBec), UTN:U1111-1164-2636. [ABSTRACT FROM AUTHOR]

Pelvic organ prolapse (POP) is a problem faced by many elderly women, and the incidence is increasing year by year. The pessary treatment is not only a conservative treatment method but also a first-line treatment method for this disease. However, if it is used improperly, multiple complications may occur during the treatment process, severe cases have to receive surgical intervention, and some may even be life-threatening. At present, there is a lack of unified guidelines for the treatment of pessaries in the world. Non-standard treatment operations and poor patient compliance are closely related to the occurrence of complications. This article focuses on summarizing and categorizing the currently reported pessary -related complications, introduces a grading method for pessary-related complications, and proposes a few ways to the prevention of complications as following. [ABSTRACT FROM AUTHOR]

Objective: To compare the surgical outcomes of laparoscopic sacrocolpopexy for pelvic organ prolapse between a group in which only sutures were used (standard method), and a group in which a combination of tackers and sutures were used (tacker combination method). Methods: A total of 77 patients who underwent laparoscopic sacrocolpopexys from June 2016 to October 2019 were divided into a suture group (36 patients) and a suture + tacker group (41 patients). We retrospectively compared operation time, amount of blood loss, postoperative length of hospital stay, incidence of perioperative complications and anatomical cure rate 1 year after surgery. Lower urinary tract symptoms were evaluated using symptom questionnaires and objective parameters. Results: Operation time in the suture + tacker group was shorter (104.9 ± 27.0 vs 147.5 ± 33.7 min; P < 0.0001). The incidence of perioperative complications in the suture group and the suture + tacker group was 2.8% and 2.4%, respectively (P = 0.9409). Anatomical cure rates at 1 year after surgery were 94.4% and 100%, respectively (P = 0.2153). Both groups showed significant improvement after 1 year for International Prostate Symptom Score total and quality of life score, Overactive Bladder Symptom Score total score, voided volume, maximum urinary flow rate and post‐void residual. [Corrections added on 7 September 2021 after first online publication: the first two P‐values have been updated.] Conclusions: The combined use of sutures and tackers in laparoscopic sacrocolpopexy simplifies the procedure and translates into shorter operation time. Surgical outcomes at 1 year and improvement of lower urinary tract symptoms are similar regardless of the technique. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether locally applied vaginal estrogen affects prolapse‐associated complaints compared with placebo treatment in postmenopausal women prior to surgical prolapse repair. Design: Randomised, double‐masked, placebo‐controlled, multicentre study. Setting: Urogynaecology unit at the Medical University of Vienna and University Hospital of Tulln. Population: Postmenopausal women with symptomatic pelvic organ prolapse and planned surgical prolapse repair. Methods: Women were randomly assigned local estrogen cream or placebo cream 6 weeks preoperatively. Main outcome measures: The primary outcome was differences in subjective prolapse‐associated complaints after 6 weeks of treatment prior to surgery, assessed with the comprehensive German pelvic floor questionnaire. Secondary outcomes included differences in other pelvic floor‐associated complaints (bladder, bowel or sexual function). Results: Out of 120 women randomised, 103 (86%) remained for the final analysis. After 6 weeks of treatment the prolapse domain score did not differ between the estrogen and the placebo groups (4.4 ± 0.19 versus 4.6 ± 0.19; mean difference, −0.21; 95% CI −0.74 to 0.33; P = 0.445). Multivariate analysis, including only women receiving the intervention, showed that none of the confounding factors modified the response to estradiol. Conclusions: These results demonstrate that preoperative locally applied estrogen does not ameliorate prolapse‐associated symptoms in postmenopausal women with symptomatic pelvic organ prolapse. Preoperative local estrogen does not ameliorate prolapse‐associated symptoms in postmenopausal women with pelvic organ prolapse. Preoperative local estrogen does not ameliorate prolapse‐associated symptoms in postmenopausal women with pelvic organ prolapse. [ABSTRACT FROM AUTHOR]

ObjectiveWe aimed to evaluate the effectiveness of cervical pessary for extending twin pregnancy in women with a short cervix.MethodsBetween January 2014 and March 2019, the use of a cervical pessary for twin pregnancy in women with a cervical length of ≤15 mm was investigated between 16 and 28 weeks of gestation. We included women with a shortened cervix after a cerclage procedure and visible fetal membranes and cervical dilatation. Thirteen patients underwent pessary insertion and were matched with a control group of 15 patients. Pregnancy and neonatal outcomes were compared between the groups. We excluded women with major fetal anomalies discovered before or after birth and known placenta previa.ResultsWomen who underwent pessary insertion were diagnosed with a short cervix (0.65±0.47 vs. 0.66±0.51 cm in the pessary and control groups, respectively; P=0.957) at a gestational age similar to that of the controls (23.29 vs. 25.14 weeks, P=0.294). There was no significant difference in gestational age at delivery between them (33.29 vs. 27.29 weeks in the pessary and control groups, respectively, P=0.058). The pessary group had a longer interval between the diagnosis and delivery than the control group (60.7±28.3 vs. 22.6±24.5 days, P=0.001). The number of adverse neonatal outcomes was significantly lower in the pessary group (n=7; 28.0%) than in the control group (n=14; 58.3%; P=0.032).ConclusionThe use of a cervical pessary may prolong gestation in twin pregnancies in women with an extremely short cervix until viable gestational age.

Introduction and Hypothesis: Pessary self-management offers benefits to women with no increased risk of complications. However, many are unwilling to self-manage, preferring clinician-led care. This study is aimed at exploring factors associated with willingness to self-manage a pessary., Methods: Women attending pessary clinic at a UK hospital were asked to complete a questionnaire providing responses on pessary use, comorbidities, female genital self-image, self-management experience and willingness (or not) to learn self-management. Based upon statistical advice we aimed to recruit 90 women. Data were analysed using the non-parametric Kruskal-Wallis test and Chi-squared test. Free text data were analysed thematically., Results: A total of 89 women completed the questionnaire. Thirty-three women (38%) had previously been taught pessary self-management. Of the remaining women, 12 (21%) were willing to learn, 28 (50%) were not willing and 16 (29%) were unsure. There was no correlation between female genital self-image and willingness to self-manage a pessary. Younger women were more willing to learn self-management (p =  < 0.001). Willing women were motivated by reduced follow-up visits. Self-managing women reported benefits including increased autonomy, cleanliness and giving their body "a break". Reasons discouraging women from self-managing were a lack of confidence; feeling physically unable; wanting clinician-led care; fear of problems or previous problems with their pessary., Conclusions: Most women were either unsure about pessary self-management or unwilling to self-manage. Age was the only factor we found that had a significant relationship with willingness to self-manage a pessary. With robust self-management teaching, support and follow-up, it is likely that many of the barriers women report can be overcome., (© 2024. The Author(s).)

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Background: Pessaries are an effective treatment for pelvic organ prolapse, yet currently available pessaries can cause discomfort during removal and insertion. An early feasibility trial of an investigational, collapsible pessary previously demonstrated mechanical feasibility during a brief 15-minute office trial. Longer-term, patient-centered safety and efficacy data are needed., Objective: This study aimed to assess the effectiveness and safety of the investigational vaginal pessary for pelvic organ prolapse at 3 months., Study Design: This was a prospective, 7-center, open-label equivalence study with participants serving as their own controls. Subjects were current users of a Gellhorn or ring pessary with ≥stage 2 prolapse. Subjective and objective data were collected at baseline for 1 month while subjects used their current pessary. Data were then collected throughout a 3-month treatment phase with the study pessary. The primary outcome was change in Pelvic Floor Distress Inventory-20 score. Secondary outcome measures included objective assessment of prolapse support, changes in the Pelvic Floor Impact Questionnaire-7, and pain with insertion and removal, measured using a visual analog scale. Data from subjects fitted with the study pessary were analyzed using an intention-to-treat approach, and those who dropped out were assigned scores at the upper limit of the predefined equivalence limits. Secondary per protocol analyses included subjects who completed treatment. The study was powered to 80% with a minimal important change equivalence limit of 18.3 points on the Pelvic Floor Distress Inventory-20 scale. Square root transformations were used for nonparametric data, and P values were adjusted for multiple comparisons., Results: A total of 78 subjects were enrolled, however, 16 withdrew before study pessary placement. The study pessary was fitted in 62 subjects (50 ring and 12 Gellhorn pessary users), and 48 (62%) completed the 3-month intervention. The change in Pelvic Floor Distress Inventory-20 scores at 3 months demonstrated equivalence when compared with the subjects' baseline scores (mean difference, -3.96 [improvement]; 90% confidence interval, -11.99 to 4.08; P=.002). Among those completing study, the Pelvic Floor Distress Inventory-20 scores, equivalence was not demonstrated and scores favored the study pessary (mean difference, -10.45; 90% confidence interval, -20.35 to 0.54; P=.095). Secondary outcomes included objective measures of support, which were similar (mean difference: Ba, 0.54 cm; Bp, 0.04 cm, favoring study pessary; improvement in mean Pelvic Floor Impact Questionnaire-7 scores for those who completed the trial: before, 32.23; after, 16.86; P=.019), and pain with insertion and removal, which was lower with the study pessary than with the subject's own pessary (mean difference visual analog scale score insertion, 9.91 mm; P=.019; removal, 11.23 mm; P=.019). No serious adverse events related to the pessary were reported., Conclusion: Equivalence was demonstrated in the primary outcome of the study pessary when compared with current, noncollapsible pessaries in terms of change in severity and bother of pelvic floor symptoms. Among participants who completed the trial, the Pelvic Floor Impact Questionnaire-7 improved with study pessary use and change in Pelvic Floor Distress Inventory-20 scores were nonequivalent, favoring the study pessary. Subjects reported significantly lower pain scores with both pessary insertion and removal with the novel collapsible pessary when compared with their standard pessary., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Most deliveries before 34 weeks of gestation occur in individuals with no previous history of preterm birth. Midtrimester cervical length assessment using transvaginal ultrasound is one of the best clinical predictors of spontaneous preterm birth. This Consult provides guidance for the diagnosis and management of a short cervix in an individual without a history of preterm birth. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend that all cervical length measurements used to guide therapeutic recommendations be performed using a transvaginal approach and in accordance with standardized procedures as described by organizations such as the Perinatal Quality Foundation or the Fetal Medicine Foundation (GRADE 1C); (2) we recommend using a midtrimester cervical length of ≤25 mm to diagnose a short cervix in individuals with a singleton gestation and no previous history of spontaneous preterm birth (GRADE 1C); (3) we recommend that asymptomatic individuals with a singleton gestation and a transvaginal cervical length of ≤20 mm diagnosed before 24 weeks of gestation be prescribed vaginal progesterone to reduce the risk of preterm birth (GRADE 1A); (4) we recommend that treatment with vaginal progesterone be considered at a cervical length of 21 to 25 mm based on shared decision-making (GRADE 1B); (5) we recommend that 17-alpha hydroxyprogesterone caproate, including compounded formulations, not be prescribed for the treatment of a short cervix (GRADE 1B); (6) in individuals without a history of preterm birth who have a sonographic short cervix (10-25 mm), we recommend against cerclage placement in the absence of cervical dilation (GRADE 1B); (7) we recommend that cervical pessary not be placed for the prevention of preterm birth in individuals with a singleton gestation and a short cervix (GRADE 1B); and (8) we recommend against routine use of progesterone, pessary, or cerclage for the treatment of cervical shortening in twin gestations outside the context of a clinical trial (GRADE 1B)., (Copyright © 2024. Published by Elsevier Inc.)

Background: Miscarriage and preterm birth are leading causes of loss and disability in monochorionic twins after laser treatment of twin-twin transfusion syndrome., Objective: This study aimed to investigate the use of cervical pessary to reduce preterm birth before 32 weeks of gestation in monochorionic diamniotic twin pregnancies after fetal surgery for twin-twin transfusion syndrome., Study Design: In this open-label multicenter randomized trial, pregnant women carrying monochorionic diamniotic twins requiring fetoscopic laser coagulation for twin-twin transfusion syndrome were randomly assigned in a 1:1 ratio to pessary placement or conservative management. The primary outcome was birth before 32 weeks of gestation. The secondary outcomes were birth before 28, 30, 34, or 37 weeks of gestation; preterm premature rupture of membranes; fetal and neonatal survival; and a composite of maternal and neonatal complications. The estimated sample size was 364 patients, with 182 cases in each arm of the study. The analysis was performed according to the intention-to-treat principle. Moreover, 2 interim analyses were planned., Results: The trial was stopped prematurely after the first planned interim analysis for futility. Overall, 137 women were included in the analysis, 67 in the pessary group and 70 in the conservative management group. Preterm birth before 32 weeks of gestation occurred in 27 of 67 women (40.3%) in the pessary group and in 25 of 70 women (35.7%) in the conservative management group (adjusted odds ratio, 1.19; 95% confidence interval, 0.58-2.47; P=.63). No differences between groups were observed in the rate of deliveries before 28, 30, 34, and 37 weeks of gestation. Overall survival to delivery was 91.2% (125/137) for at least 1 twin, and 70.8% (97/137) for both twins, with no difference between groups. Neonatal survival at 30 days was 76.5% (208/272). There was no difference between the groups in maternal or neonatal morbidity., Conclusion: In monochorionic diamniotic twin pregnancies requiring fetal therapy for twin-twin transfusion syndrome, routine use of cervical pessary did not reduce the rate of preterm birth before 32 weeks of gestation., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To study and compare the clinical effects of cervical pessary and progesterone for preventing preterm birth in singleton pregnant women with a short cervical length (CL)., Methods: This study was a prospective cohort study. A total of 148 pregnant women with CL≤25 mm, as determined by ultrasound examination performed before 28 weeks of pregnancy, were included in the study. All subjects were admitted to West China Second Hospital, Sichuan University between August 2020 and December 2022. According to their treatment plans, the pregnant women were divided into a cervical pessary group ( n =55) and a progesterone group ( n =93). Spontaneous preterm birth before 37 weeks of pregnancy was defined as the main outcome index. Preterm birth (abortion) or spontaneous preterm birth (abortion) before 37, 34, 32, 30, and 28 weeks of pregnancy, mean extended gestational age, neonatal morbidity, and neonatal mortality were the secondary outcome indicators. The pregnancy outcomes and the neonatal outcomes of the two groups were compared and statistically analyzed., Results: There was no statistically significant difference in the incidence of preterm birth (including iatrogenic preterm birth, spontaneous preterm birth, and abortion) before 37, 34, 32, 30, and 28 weeks between the cervical pessary group and the progesterone group. When iatrogenic preterm birth was excluded, the incidence of spontaneous preterm birth before 37 weeks was lower in the cervical pessary group (23.6%) than that in the progesterone group (41.9%), with the difference between the two groups being statistically significant ( P =0.024). There was no statistically significant difference in the incidence of spontaneous preterm birth (including miscarriage) before 34, 32, 30, and 28 weeks. There was no statistically significant difference in the incidence of neonatal morbidity, the rate of transfer to the neonatal care unit after birth, and the neonatal mortality rate between the two groups. Multivariate logistic analysis showed that treatment with cervical pessary was a protective factor for spontaneous preterm birth before 37 weeks compared to progesterone therapy., Conclusion: Using cervical pessary to prevent spontaneous preterm birth in singleton pregnant women with a short cervical length in the second trimester can significantly reduce the incidence of spontaneous preterm birth before 37 weeks., Competing Interests: 利益冲突　所有作者均声明不存在利益冲突, (© 2024《四川大学学报（医学版）》编辑部 版权所有Copyright ©2024 Editorial Office of Journal of Sichuan University (Medical Sciences).)

Background: Cervical cerclage, cervical pessary, and vaginal progesterone have each been shown to reduce preterm birth (PTB) in high-risk women, but to our knowledge, there has been no randomised comparison of the 3 interventions. The SuPPoRT "Stitch, Pessary, or Progesterone Randomised Trial" was designed to compare the rate of PTB <37 weeks between each intervention in women who develop a short cervix in pregnancy., Methods and Findings: SuPPoRT was a multicentre, open label 3-arm randomised controlled trial designed to demonstrate equivalence (equivalence margin 20%) conducted from 1 July 2015 to 1 July 2021 in 19 obstetric units in the United Kingdom. Asymptomatic women with singleton pregnancies with transvaginal ultrasound cervical lengths measuring <25 mm between 14+0 and 23+6 weeks' gestation were eligible for randomisation (1:1:1) to receive either vaginal cervical cerclage (n = 128), cervical pessary (n = 126), or vaginal progesterone (n = 132). Minimisation variables were gestation at recruitment, body mass index (BMI), and risk factor for PTB. The primary outcome was PTB <37 weeks' gestation. Secondary outcomes included PTB <34 weeks', <30 weeks', and adverse perinatal outcome. Analysis was by intention to treat. A total of 386 pregnant women between 14+0 and 23+6 weeks' gestation with a cervical length <25 mm were randomised to one of the 3 interventions. Of these women, 67% were of white ethnicity, 18% black ethnicity, and 7.5% Asian ethnicity. Mean BMI was 25.6. Over 85% of women had prior risk factors for PTB; 39.1% had experienced a spontaneous PTB or midtrimester loss (>14 weeks gestation); and 45.8% had prior cervical surgery. Data from 381 women were available for outcome analysis. Using binary regression, randomised therapies (cerclage versus pessary versus vaginal progesterone) were found to have similar effects on the primary outcome PTB <37 weeks (39/127 versus 38/122 versus 32/132, p = 0.4, cerclage versus pessary risk difference (RD) -0.7% [-12.1 to 10.7], cerclage versus progesterone RD 6.2% [-5.0 to 17.0], and progesterone versus pessary RD -6.9% [-17.9 to 4.1]). Similarly, no difference was seen for PTB <34 and 30 weeks, nor adverse perinatal outcome. There were some differences in the mild side effect profile between interventions (vaginal discharge and bleeding) and women randomised to progesterone reported more severe abdominal pain. A small proportion of women did not receive the intervention as per protocol; however, per-protocol and as-treated analyses showed similar results. The main study limitation was that the trial was underpowered for neonatal outcomes and was stopped early due to the COVID-19 pandemic., Conclusions: In this study, we found that for women who develop a short cervix, cerclage, pessary, and vaginal progesterone were equally efficacious at preventing PTB, as judged with a 20% equivalence margin. Commencing with any of the therapies would be reasonable clinical management. These results can be used as a counselling tool for clinicians when managing women with a short cervix., Trial Registration: EU Clinical Trials register. EudraCT Number: 2015-000456-15, clinicaltrialsregister.eu., ISRCTN Registry: ISRCTN13364447, isrctn.com., Competing Interests: AS is a member of PLOS Medicine’s editorial board. The authors have declared that no other competing interests exist., (Copyright: © 2024 Hezelgrave et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: The efficacy and tolerability of a non-hormonal pessary (that forms an oil-in-water emollient with the vaginal fluid) were assessed for the treatment of symptoms of vaginal dryness associated with menopause., Study Design: Seventy-nine postmenopausal women (mean age 60.8 ± 6.5 years) with mild to moderate symptoms of vaginal dryness (including dyspareunia) were enrolled in this open-label, prospective, post-market clinical follow-up trial, conducted in 2022 by one research center in Germany. The investigational pessary was applied for the first 7 days once daily and the subsequent 31 days twice a week, at bedtime. A treatment-free period of 6 days completed the trial., Main Outcome Measures: During the trial, participants filled out questionnaires that enabled the calculation of a total severity score for subjective symptoms of atrophy-related vaginal dryness and impairment of daily as well as sexual life. Furthermore, vaginal health index and safety were studied., Results: A rapid and significant reduction in the severity scores for symptoms was observed over the 38-day course of treatment and beyond. Quality of life assessed by DIVA (day-to-day impact of vaginal aging) questionnaire, dyspareunia and vaginal health index also clearly improved. The tolerability was mainly rated as "good to very good" by the investigator and 94.9 % of participants. The vast majority were very satisfied with the simple and pleasant handling. No serious adverse events occurred., Conclusion: Overall, the presented data suggest that the investigated non-hormonal pessary is an effective and well tolerated treatment option for vaginal symptoms associated with dryness, thus improving quality of life for women, even those who are sexually active., Clinicaltrials: gov identifier NCT05211505., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: all authors are employees of Dr. August Wolff GmbH & Co. KG Arzneimittel, 33611 Bielefeld, Germany., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: There is no evidence about the efficacy of self-care of vaginal pessary in women with symptomatic pelvic organ prolapse (POP). The aim of this systematic review and meta-analysis is to assess the adherence to pessary treatment among women who engage in self-management of their pessary., Methods: We performed a systematic review and meta-analysis, according to PRISMA 2020 guidelines, and selected seven publications for inclusion in the analysis., Results: Pooled continuation rate of self-cared vaginal pessary was the 76% (95%CI: 66-85%) with a I 2 -test of 93.3% (p < 0.001). Pooled conversion to POP surgery was the 12% (95%CI: 1-23%) with a I 2 -test of 96% (p < 0.001). Continuation rate was not statistically different between women who were treated by self-care and non-self-care management of vaginal pessary (RR 1.11, 95%CI 0.96-1.27; p = 0.15), with a related I 2 -test of 37% (p = 0.21)., Conclusion: Self-care vaginal pessary management presented a high continuation rate in women affected by pelvic organ prolapse at a long follow-up. The rate of conversion to surgical management of POP was low. No significant difference in continuation rate were highlighted between women who adopted the self-care or the clinical-based management of pessary., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

A pessary is a medical device that is inserted into the vagina to provide structural support to one or more of the descending vaginal compartments in women with pelvic organ prolapse. It is a common management option offered to women in the short and long term. This article will discuss the current use of vaginal pessaries for POP, the current challenges with their use and common complications seen in practise. It will also discuss the unmet needs in the current products available on the market and suggest ideas for product design, materials and considerations for future development., Competing Interests: Declaration of conflicting interestsThe author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction and Hypothesis: Continuation of using a pessary for the treatment of pelvic organ prolapse (POP) is important for improving symptoms but the data on long-term compliance is very limited. Therefore, we conducted this study aimed at evaluating the compliance of patients in the long-term use of a pessary., Methods: The medical records of women with symptomatic POP were retrospectively reviewed to recruit cases opting for pessary use. The inclusion criteria were women who had a successful pessary fitting and completed at least 5 years of follow-up. Exclusion criteria were pregnancy, death during the follow-up period, and loss to follow-up. Demographic data, pelvic organ prolapse stage, associated symptoms, type and size of pessary, and reason for discontinuation were reviewed., Results: A total of 261 patients opted for pessary use. Of them, 88.9% (231 out of 261) were successful in initial pessary fitting and 54 were excluded for various reasons. The remaining 178 patients were available for analysis. The continuation rate of self-care pessary at the 5-year follow-up was 53.93% (96). The discontinuation rate was 46.07% (82). The main reasons for discontinuation were desire for surgery (39.1%) and discomfort (31.7%). The highest rate of discontinuation (46.63%) was found in the 1st year of follow-up. The significant risk factors of discontinuation included digitation symptoms on univariate analysis and prior hysterectomy on multivariate analysis, with an odds ratio (95% CI) of 5.98 (1.56-22.88)., Conclusions: Among Thai women, the adherence to self-care pessary in symptomatic pelvic organ prolapse at the 5-year follow-up was 53.93%. The main reason for discontinuation was a prior hysterectomy., (© 2024. The International Urogynecological Association.)

Background: To evaluate the use and effect of cervical stitch cerclage, pessary, and progesterone on pregnancy outcome in mothers of very low birth weight infants (VLBWI) born<32 weeks of gestation in the German Neonatal Network (GNN)., Methods: The GNN is a population-based cohort study enrolling VLBWI since 2009. We included 575 neonates from 424 mothers into our analysis, who were born between 2015 and 2019, after prenatal intervention with cerclage, pessary, progesterone or a combination between 20/0 to 25/0 weeks of gestation to prevent preterm birth. Median intervention-to-birth interval was the primary endpoint., Results: 231 of 424 pregnant women had a cerclage only (54.5%), 76 women a pessary only (17.9%), and 27 were prescribed progesterone only (15.3%). The most common combination treatment (>1 intervention group) was cerclage plus progesterone (n=27), followed by cerclage plus pessary (n=13). The median intervention-to-birth interval for the whole cohort was 24 days (IQR 19.0 days). The earlier the intervention was started, the longer the intervention-to-birth interval lasted: When started at 20 weeks, the interval was 34 days in contrast to 11.5 days, when started at 25 weeks. The >1 group was born at a significantly higher median GA with 27.0 weeks (IQR 2.9 weeks) and a higher median birth weight of 980 g (IQR 394 g) accordingly., Conclusion: We propose that the earliest possible start of intervention leads to the most efficient pregnancy prolongation., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

In 2019 and 2020, an annual vaginal prolapse incidence of 13% was recorded among hoggets in a dairy sheep farm in Greece, whereas in mature ewes the annual incidence was 0.7%. During our farm visit, we noticed that the feeders were particularly elevated both in hoggets and mature ewes barn, which forced the animals to take a highly inclined position to reach their feed. We identified the feeders' elevation as a possible cause of vaginal prolapse and advised their replacement. In December 2020, in the hoggets' barn, the raised feeders were replaced with lower ones, resolving the problem. These findings provide strong circumstantial evidence that hoggets are particularly prone to vaginal prolapse when forced to maintain an inclined position for long periods, whereas mature ewes appear less susceptible. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The current study was aimed at investigating the safety, efficiency, and durability of transvaginal sacrospinous ligament suture rectopexy in women with obstructed defecation symptoms (ODS) and significant rectal hypermobility/folding. Methods: This was a prospective case series study performed during December 2018 to July 2020. Women presenting to our center with pelvic organ prolapse electing for surgical treatment were screened for ODS utilizing the PFDI-20 questionnaire. Patients were eligible for inclusion if they reported OD symptoms accompanying >50% of bowel movements (BMs), BM frequency ≥3 per week, stool type 3 or 4 based on the Bristol stool chart, absence of dyssynergic Valsalva, and dynamic ultrasound indicating a rectal compression ratio >25%. Patients underwent transvaginal sacrospinous ligament rectopexy and were followed up at 2 and 12 months postoperatively. Results: A total of 20 patients underwent the procedure and completed the follow-up. Statistically significant improvements were observed in all OD symptoms and subjective improvement (94.7% ± 13.4 and 90.6% ± 18) at 2 and 12 months after the surgery respectively. Mean rectal compression ratio, detected via ultrasound, improved from 45.5% ± 18.4 preoperatively to 9.2% ± 13.7 at 2 months (p < 0.0001) and 19.6% ± 14.4 at 12 months (p < 0.0012). Surgical failure, defined as combined subjective (ODS >50% of bowel movements) and anatomical failure (rectal compression ratio >25%), occurred in 2 patients. Conclusion: Transvaginal sacrospinous ligament suture rectopexy was safe, feasible, and effectively treated ODS within this cohort of women undergoing POP surgery with rectal hypermobility confirmed by dynamic ultrasound. [ABSTRACT FROM AUTHOR]

Pelvic organ prolapse and stress urinary incontinence are common female conditions that affect quality of life. Vaginal pessaries are an inexpensive and effective approach to manage these challenges. This article discusses the fitting and management of vaginal pessaries in the outpatient setting. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to develop and test the feasibility of a magnetic resonance imaging (MRI)‐based measurement strategy to evaluate the effectiveness of surgical procedures in restoring normal anatomy in all three systems of pelvic floor support and quantify the structural changes induced by prolapse surgery. Methods: Patients underwent clinical examination and stress MRI preoperatively and again 3 months postoperatively. Preoperative and postoperative measures of three MRI‐based structural support systems were made: (1) vaginal wall, (2) apical and paravaginal support, and (3) hiatal closure system. Preoperative to postoperative structural changes were calculated and compared to normal values, and bivariate associations were determined. Results: The three structural support systems were successfully quantified for both preoperative and postoperative MRIs regardless of operative approaches in all 15 women in the pilot group. Apical support was restored to normal in 11 of 12 patients who underwent an apical suspension procedure and 9 of 14 patients with a posterior repair had normalization of genital hiatus size. Mid‐vaginal paravaginal location was elevated an average of 2.5 ± 2.0 cm despite no paravaginal repairs being performed. Paravaginal location improvements were also significantly correlated with apical elevation (r values 0.99–0.87, p < 0.001). Conclusions: A strategy that quantifies structural‐specific preoperative impairments and improvements after prolapse surgery was successfully developed. Early findings reveal that prolapse surgery is more successful in restoring normal anatomy at Level I than Level III. Improvement in paravaginal location is significantly correlated with apical elevation. [ABSTRACT FROM AUTHOR]

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

Objective: The purpose of this study was to explore the factors influencing the sexual quality of life of patients with cervical cancer who underwent radical hysterectomy. Methods: This multicenter retrospective cohort study was conducted from June 2013 to June 2018 at nine hospitals in China. In total, 204 women diagnosed with stage IA to stage IIB cervical cancer who underwent radical hysterectomy completed the questionnaire. Sexual function was measured with the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). All analyses were performed with R version 3.4.3 statistical software packages. A two-sided significance level of 0.05 was used to evaluate the statistical significance. Results: The mean sexual quality of life score was 37.21 ± 17.28, where a higher PISQ score indicates a better sexual quality of life, and we identified the factors associated with sexual dysfunction. The average follow-up time was 29.0 ± 16.0 months. In addition to radical hysterectomy, 182 (89.2%) patients underwent ovarian suspension, 93 (45.6%) underwent chemotherapy, and 74 (36.3%) underwent concurrent radiotherapy. The univariate analysis confirmed that age represents a protective factor for sexual function (odds ratio (OR) 6.0, 95% confidence interval (CI) 1.1–10.8, p = 0.017). The patients who underwent ovarian suspension were more likely to experience a good sexual quality of life (OR − 7.2, 95% CI [− 14.8, − 0.4], p = 0.035) compared to those who did not undergo ovarian suspension. A significant negative association was observed between radiotherapy and the behavioral-emotive, physical and partner-related domains of the PISQ (behavioral-emotive, OR − 1.5, 95% CI [− 2.6, − 0.4], p = 0.011; physical, OR − 0.9, 95% CI [− 1.5, − 0.3], p = 0.006; partner-related, OR − 0.7, 95% CI [− 1.3, 0.0], p = 0.043). Chemotherapy and radiotherapy were common risk factors for sexual dysfunction, and radiotherapy exerted a stronger effect than chemotherapy. Conclusions: This study shows that the sexual function of cervical cancer patients tends to be related to age, radiotherapy, and chemotherapy. However, across these factors, patients with preserved ovaries tend to return to a satisfactory sexual quality of life after recovering from surgery. [ABSTRACT FROM AUTHOR]

Objectives: To summarize the published literature regarding pelvic organ prolapse, dehiscence or evisceration, vaginal fistula, and dyspareunia after radical cystectomy and to describe the management approaches used to treat these conditions.Methods: Ovid MEDLINE, Ovid EMBASE, and Web of Science were systematically searched from January 1, 2001 to January 25, 2021 using a combination of search terms for bladder cancer and radical cystectomy with terms for four categories of vaginal complications (prolapse, fistula, evisceration/dehiscence, and dyspareunia). A total of 229 publications were identified, the final review included 28 publications.Results: Neobladder vaginal fistula was evaluated in 17 publications, with an incidence rate of 3 - 6% at higher volume centers, often along the anterior vaginal wall at the location of the neobladder-urethral anastomosis. Sexual function was evaluated in 10 studies, 7 of which utilized validated instruments. Maintaining the anterior vaginal wall and the distal urethra appeared to be associated with improved sexual function. Pelvic organ prolapse was assessed in 5 studies, only 1 used a validated questionnaire and none included a validated objective measure of pelvic organ support.Conclusion: There is a need for more prospective studies, using standardized instruments and subjective outcome measures to better define the incidence of vaginal complications after radical cystectomy for bladder cancer, and to understand their impact on quality of life measures. [ABSTRACT FROM AUTHOR]

Objectives: Laparoscopic sacrocolpopexy is often performed to treat pelvic organ prolapse. Preoperative stress urinary incontinence (SUI) can improve after laparoscopic sacrocolpopexy. In contrast, some patients without incontinence preoperatively develop SUI after pelvic organ prolapse repair (ie, de novo SUI). This study aimed to identify the preoperative predictive factors of de novo SUI after laparoscopic sacrocolpopexy. Methods: A total of 858 patients underwent laparoscopic sacrocolpopexy between January 2013 and November 2017 at Kameda Medical Center. Urodynamic studies were performed pre‐ and postoperatively on 75 patients. This retrospective study included 43 of 75 patients who did not have SUI preoperatively. We assessed urethral function according to functional profile length and maximum urethral closure pressure. We evaluated voiding function in terms of maximum flow rate, detrusor pressure at maximum flow rate, and postvoid residual volume. Furthermore, each factor was compared between de novo SUI‐positive and SUI‐negative groups. Results: After laparoscopic sacrocolpopexy, 30 (69.8%) patients presented with SUI. The preoperative maximum urethral closure pressure was significantly lower in the de novo SUI‐positive group (36.0 cmH2O) than in the de novo SUI‐negative group (50.5 cmH2O, P =.020). More patients with maximum urethral closure pressure <40 cmH2O had de novo SUI than patients with maximum urethral closure pressure ≥40 cmH2O (P =.004). There were no significant differences between preoperative maximum urethral closure pressure and postoperative maximum urethral closure pressure in either group. Conclusions: Low preoperative maximum urethral closure pressure, particularly maximum urethral closure pressure <40 cmH2O, is a predictor of de novo SUI after laparoscopic sacrocolpopexy. [ABSTRACT FROM AUTHOR]

Each type of CAD is coupled to a specific anatomical presentation (see the images just below each CAD type). a Three-window dilator. b Two-window dilator. c Big C dilator Graph: Fig. This innovative shape allows selective rectal resection in which the purse-string suture passes through the redundant tissue that protrudes through the windows[[1]] (Fig. 2 Surgical procedure performed using the three-window dilator. a Evaluation of the prolapse after circular anal dilator placement. b Purse- string using 2/0 monofilament wire. c Firing using TST-33 Mega Window (Touchstone International Medical Science Co, Ltd, Suzhou, China). d Suture bridge between the staple line which needs to be cut. e Stitching the dog ear edges of the staple lines. f Specimen of the partial triple prolapsectomy Declarations Conflict of interest The authors declare that they have no conflict of interest. [Extracted from the article]

Objective: Vaginal progesterone and cervical pessary are both shown to be effective in preventing preterm. We conducted a meta-analysis to evaluate whether the combination of these two interventions has any additional benefit in preventing preterm birth and improving perinatal outcomes in asymptomatic women with a singleton gestation who had a midtrimester sonographic short cervix compared with vaginal progesterone alone.Methods: Five databases were searched from their inception to 21 February 2019. We estimated relative risk (RR) and 95% confidence intervals (CIs) for dichotomous outcomes. The primary outcome was preterm birth <34 weeks, and second outcomes included low birth weight (LBW) delivery, perinatal death, and neonatal intensive care unit (NICU) admission.Results: Three RCTs with a total of 820 participants were identified. Cervical pessary had no significant prevention effect of preterm birth when combined with vaginal progesterone compared to the control group with vaginal progesterone alone (RR = 0.91; 95% CI, 0.47-1.77). No significant difference has been revealed between groups in LBW delivery (RR = 1.13; 95% CI, 0.86-1.48), perinatal death (RR = 1.27; 95% CI, 0.58-2.78) and NICU admission (RR = 1.24; 95% CI, 0.84-1.85).Conclusions: Comparing with vaginal progesterone alone, cervical pessary plus vaginal progesterone did not reduce the rates of preterm birth at <34 weeks of gestation. There was no difference in LBW delivery, perinatal death, and NICU admission. We need more evidence to balance the benefit and side effects on the combination of vaginal progesterone and cervical pessary for preventing preterm birth. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: While 2017 guidelines from The American College of Obstetricians & Gynecologists called for pessary replacement every 3 to 4 months, a recent study in Obstetrics and Gynecology suggested that uninterrupted pessary use up to 6 months is not an independent risk factor for development of pessary-related complications. Methods: Our recent experience throughout the Covid-19 pandemic highlights the potential ramifications of delayed clinical follow-up. Results: During the Covid-19 pandemic, 3 of our patients developed rectovaginal fistulae secondary to Gellhorn pessary erosion in the context of delayed clinical follow-up. Our patients had previously attended routine appointments every 3 months without complications until missed appointments secondary to the pandemic led to fistulae formation. Conclusion: We believe that delayed clinical follow-up of pessary management beyond 3 months due to the Covid-19 pandemic may lead to fistula complications in elderly women with Gellhorn pessaries. [ABSTRACT FROM AUTHOR]

Objectives: To present a flexible protocol of vaginal pessaries for older women with significant pelvic organ prolapse (POP). Design A prospective cohort study of 140 consecutive older women (aged ≥65 years) with significant POP treated with individually fitted vaginal pessaries. After initial insertion, each patient was invited for a first evaluation after 1 month and subsequent follow‐ups at increasing intervals of 1 month. During each examination, the pessary was removed and the vagina was inspected for infection, bleeding, or erosions. All patients were advised to use a vaginal estrogen cream twice a week. Setting: The study was conducted during 2020 in the urogynecology clinic of a tertiary medical center. Participants: The study cohort included 140 consecutive older women with significant and symptomatic POP treated with vaginal pessaries. Main outcome: Primary outcomes included time intervals between follow‐up visits, pessary‐associated complications, need to change the pessary, need to remove the pessary temporarily, and whether the patients eventually underwent POP surgery. Results: The mean age of the patients at the time of pessary fitting was 76.7 ± 9.2 years (range 65–100 years). Mean interval between follow‐up examinations was 3.3 ± 1.1 months (range 1–6 months). Most patients (83.6%) used a ring pessary with support, but only a small number of patients were able to maintain the pessary by themselves. Of the 140 patients, five (3.6%) patients only eventually underwent POP surgery, and in 11 (7.9%) patients, the vaginal pessary had to be removed for 2–4 weeks because of significant vaginal discharge or superficial erosions. Additionally, 12 (8.6%) patients developed stress urinary incontinence following pessary insertion. Conclusions: Customized management with vaginal pessary for symptomatic POP in older women is effective and safe, and is a suitable therapeutic alternative for older women who are unable or unwilling to undergo reconstructive pelvic surgery. [ABSTRACT FROM AUTHOR]

Objective: To systematically evaluate the content and quality of national and international guidelines on vaginal mesh procedures for pelvic organ prolapse (POP). Methods: We searched PubMed, Medline, Web of Science, and ScienceDirect from inception to March 2020 and organizations' websites. The quality of the guidelines was assessed independently by six appraisers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. Results: Five guidelines were included. Most guidelines recommended individualized treatments, clinical observation, and conservative treatment for asymptomatic women discouraging the use of mesh. Vaginal pessary and pelvic floor muscle training are unanimously considered effective treatments. Only two guidelines recommended weight loss. Each guideline recommended patient counseling supported by data on success rates and complications. Most guidelines highlighted the importance of a specialist experienced surgeon, multidisciplinary teams, and national/international registries. All guidelines highlighted potential benefits of the use of mesh and reported possible complications. The overall quality rating ranged between 4.2 and 6.3, suggestive of moderate to high quality. The highest mean score (92.5%) pertained to "Scope and Purpose" and "Clarity of Presentation", and the lowest to "Editorial Independence" (18%). Three out of five guidelines were "strongly recommended" by the appraisers. Conclusion: Although most guidelines were of moderate to high quality, methodological applicability, stakeholder involvement, and editorial independence were domains with low scores. Synopsis: This study systematically reviewed and evaluated national and international guidelines on the management of pelvic organ prolapse with surgical mesh using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. [ABSTRACT FROM AUTHOR]

Background: Abdominal lateral suspension with mesh represents an alternative treatment to suspend the vaginal apex.Objectives: The aim of this study was to summarize literature data regarding the anatomical and functional outcomes, and intra- and postoperative complications of this technique with minimally invasive approach (laparoscopic/robotic).Search Strategy: Systematic literature search using MEDLINE/PubMed, SCOPUS, Web of Science.Data Collection and Analysis: Two authors extracted data on baseline characteristics (age, BMI, prior pelvic reconstructive surgery, preoperative POP stage), perioperative outcomes (operative time, estimated blood loss, intraoperative and postoperative complications, admission time), objective and subjective success rate, surgical failure, time of follow-up. Data were presented descriptively.Main Results: Thirteen studies were included in the review. The overall number of patients for our analysis was 1066. Patients referred for laparoscopic/robotic lateral suspension were most frequently postmenopausal, aged 50 to 65 years, BMI ≥ 25 kg/m2; 22.2% were already hysterectomized, while 17% had already a previous POP surgery. Operative time ranged from 78.4 ± 29.7 to 254 ± 45 min. The overall anatomic success was more than 90% in the apical compartment and more than 88% in the anterior compartment. Subjective cure rate varies from 78.4% to 100% in medium-term follow-up. Post-operative complication grade >= 3 according to Claiven-Dindo Scale was 1.03%. Mesh erosion rate varied between 0% and 13%.Conclusions: Results coming from our systematic review suggest safety, efficacy and feasibility of minimally invasive lateral suspension with optimal anatomical and functional outcomes. Well-designed, randomized, controlled trials are required to confirm this data. [ABSTRACT FROM AUTHOR]

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Aims: Although abdominal sacrocolpopexy (ASC) is considered the gold standard for surgical repair of vaginal vault prolapse, the open surgical approach has significant morbidity. We aim to compare anatomic and functional outcomes in women receiving either robotic‐assisted sacral colpopexy (RSC) or ASC for post‐hysterectomy prolapse. Methods: We present a retrospective chart review of all women who underwent ASC and RSC at our institution and had 12‐month follow‐up (FU). Pelvic organ prolapse quantification (POP‐Q) staging was assessed both preoperatively and postoperatively. Perioperative and demographic details were collected from the medical records. Results: One hundred twenty four women underwent RSC (mean age 63, median FU 16 months). Those in the ASC group (n = 144) were statistically younger (mean age 60) and had longer FU (median 60 months). Both median day of successful voiding trial and discharge day significantly favored RSC. There were no Clavien Grade IV/V complications for either procedure and three RSC procedures were converted to ASC. Both approaches were associated with a significant improvement in POP‐Q stage at FU, with few women requiring additional surgery. Overall, 76% of women in each group were dry from stress urinary incontinence. Improvement in storage and emptying indices, dyspareunia, and quality of life measures was observed after both approaches. Conclusion: RSC demonstrates good support of significant vaginal vault prolapse at medium term FU, with shorter hospital stays and low complication rates. Close FU after RSC over a longer period will be needed to fully assess durability of both functional and anatomic outcomes. [ABSTRACT FROM AUTHOR]

ObjectiveHealth care providers are increasingly being evaluated by the quality of care they provide. Our aim was to assess the feasibility of recently developed quality indicators (QIs) for pelvic organ prolapse (POP) and identify possible deficits in care.Study designA panel ranked 14 QIs based on the RAND appropriateness method assessing screening and diagnosis, pessary management, and surgery for POP. Retrospective chart abstraction was performed after identifying patients with a diagnosis of POP evaluated within a hospital-based multispecialty group using International Classification of Diseases, ninth edition, diagnosis codes.ResultsOf 283 patients identified, 98% of those with a new complaint of vaginal bulge had a pelvic examination. The POP was described but not staged in 6% and not documented at all in 25.1%. Among those managed with pessaries, 98% had vaginal examinations at least every 6 months. Forty-nine percent of the patients who had surgery had complete preoperative POP staging. Only 20% of women undergoing apical surgery had documentation of counseling regarding different surgical options, and of the women who underwent a hysterectomy for POP, only 48% had a concomitant vault suspension. Although 71% had documentation about the risk of postoperative stress incontinence, only 14.5% had documented counseling regarding risks of mesh. Only 37% of patients implanted with mesh for POP had documented follow-up at 1 year. An intraoperative cystoscopy was performed in 86% undergoing cystocele repair or apical surgery.ConclusionThe quality of care for women with POP can be feasibly measured with QIs. Processes of care were deficient in many areas, and our findings can serve as a basis for quality improvement interventions.

Introduction and hypothesis: This study aimed to investigate the evaluation and management of complications after pelvic floor reconstructive surgery for pelvic organ prolapse in China. Methods: Complications of pelvic floor reconstructive surgery for pelvic organ prolapses from 27 institutions were reported from November 2017 to October 2019. All complications were coded according to the category-time-site system proposed by the International Urogynecological Association (IUGA) and the International Continence Society (ICS). The severity of the complications was graded by the Clavien-Dindo grading system. Four scales were used to evaluate patient satisfaction and quality of life after management of the complications: the Patient Global Impression of Improvement (PGI-I), the Pelvic Floor Impact Questionnaire Short Form (PFIQ-7), the Pelvic Organ Prolapse Symptom Score (POP-SS), and a 5-point Likert-type scale that evaluated the patient's choice of surgery. Results: Totally, 256 cases were reported. The occurrence of complications related to transvaginal mesh (TVM) and laparoscopic sacrocolpopexy (LSC) had a significantly longer post-surgery delay than those of native tissue repair surgery (p < 0.001 and p = 0.010, respectively). Both PFIQ-7 and POP-SS score were lower after management of complications (p < 0.001). Most respondents (81.67%) selected very much better, much better, or a little better on the PGI-I scale. Only 13.3% respondents selected unlikely or highly unlikely on the 5-point Likert-type scale. Conclusions: The occurrence of complications related to TVM surgery and LSC had a longer post-surgery delay than native tissue repair surgery. Long-term regular follow-up was vital in complication management. Patient satisfaction with the management of TVM complications was acceptable. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: The objective was to determine the relationship between the preoperative D-point and apical outcomes at 24 months, using the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) dataset. Methods: This was a secondary analysis of the OPTIMAL trial, a randomized multi-centered study comparing outcomes of sacrospinous ligament fixation and transvaginal uterosacral ligament suspension (USLS). The 2-year dataset utilized included women undergoing USLS with concomitant hysterectomy. The primary outcome was the relationship between preoperative D-point and apical outcomes at 24 months. Secondary objectives were to determine the relationship between preoperative D-point and anatomical, composite and subjective outcomes, and to determine a D-point cut-off that could be used to predict success in each of these categories. Results: Of the 186 women in the USLS arm, 120 were available for analysis of anatomical failure at 24 months. A higher preoperative D-point correlated with improved apical outcome (C-point) at 24 months (r = 0.34; p value = 0.0002). Using ROC curves, a moderate association was found between the preoperative D-point and apical and anatomical success, (AUC 0.689 and 0.662). There was no relationship between preoperative D-point and composite or subjective success (AUC 0.577 and 0.458). Based on the ROC curves, a "cut-off" D-point value of −4.25 cm (sensitivity = 0.58, specificity = 0.67) was determined to be a predictor of postoperative anatomical success at 2 years. Conclusions: Preoperative D-point correlates with postoperative anatomical and apical support, but is less successful at predicting subjective outcomes. The strongest predictive D-point cut-off for anatomical and apical success at 24 months was −4.25 cm. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: There has been a trend toward the use of ultra-lightweight mesh types for minimally invasive sacrocolpopexy. We hypothesized that ultra-lightweight mesh would have a greater proportion of composite anatomical pelvic organ prolapse recurrence than lightweight mesh. Methods: Retrospective cohort study of minimally invasive sacrocolpopexies at two academic institutions from 2009 to 2016. Our primary outcome was composite anatomical prolapse recurrence, defined as prolapse beyond the hymen or retreatment with pessary or surgery, compared between ultra-lightweight (≤21 g/m2 [range 19–21]) and lightweight (>21 g/m2 [range 35–50]) mesh types. We assessed time to prolapse recurrence using Kaplan–Meier and Cox regression. Results: The cohort consisted of 1,272 laparoscopic (n = 530, 41.7%) and robotic-assisted sacrocolpopexies (n = 742, 58.4%). Lightweight mesh was used in 745 procedures (58.6%) and ultra-lightweight mesh in 527 (41.4%). The lightweight mesh had longer median follow-up than the ultra-lightweight group (344 [IQR 50–670] vs 143 days [IQR 44–379], p < 0.01). There was no difference in composite anatomical prolapse recurrence between lightweight and ultra-lightweight mesh (54 [7.2%] vs 35 [6.6%], p = 0.68). Ultra-lightweight mesh demonstrated a shorter time to prolapse recurrence (p < 0.01), which remained significant on multivariate Cox regression (HR 2.38 [95% CI 1.47–3.87]). The lightweight mesh had significantly more mesh complications (43 [5.8%] vs 7 [1.3%], p < 0.01). Conclusions: Ultra-lightweight mesh for minimally invasive sacrocolpopexy was not associated with a higher proportion of composite anatomical prolapse recurrence; however, it was associated with a shorter time to recurrence. Longer follow-up is needed to assess the clinical importance of this finding, particularly given the trade-off of more complications with lightweight mesh. [ABSTRACT FROM AUTHOR]

Introduction: Ventral mesh rectopexy is frequently performed as a means of improving the quality of life for sufferers of rectal prolapse. The minimally invasive approach is highly desirable but can be technically difficult to achieve in the narrow confines of the pelvis. The robotic platform is becoming a more common means of overcoming these difficulties, but evidence of an objective benefit over standard laparoscopy is scarce. This study seeks to review and analyse the data comparing outcomes after robotic and laparoscopic ventral mesh rectopexy. Method: We searched MEDLINE, EMBASE and the Cochrane database for papers comparing robotic to laparoscopic ventral mesh rectopexy. Comparable data was pooled for meta-analysis. Results: Six studies compared outcomes between robotic and laparoscopic ventral mesh rectopexy. Sample sizes were relatively small, and only two of the studies were randomised. Pooled analysis was possible for data on operating time, complication rates, conversion rates and length of stay in hospital. This showed a non-significant trend towards longer operating times and a statistically significant reduction in length of stay after robotic procedures. There was no significant difference in complication and conversion rates. Conclusion: The frequent finding of longer operating time for robotic surgery was not confirmed in this study. Shorter length of stay in hospital was seen, with other post-operative outcomes showing no significant difference. More data is needed with cost-benefit analyses to show whether the robotic platform is justified. [ABSTRACT FROM AUTHOR]