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The introduction of the tensionfree vaginal tape in 1995 drastically changed the landscape of surgical procedures for stress urinary incontinence (SUI). Because of the uncomplicated technique many urologists and gynecologists embraced the procedure with tripled the number of annual procedures in the beginning of this century. At the same time polypropylene was used for the development of surgical procedures of pelvic organ prolapse (POP). Especially the use of polypropylene for POP has caused many severe clinical complications. This caused a huge reduction of these kind of surgical procedures and it is performed nowadays only under strict conditions. At the same time the use of polypropylene for SUI was scrutinized and questioned. Nowadays, in the Ango-Saxon countries the use of polypropylene tapes for SUI is not recommended. This manuscript explores the role of polypropylene tapes for SUI. Questions that are dealt with are: How dangerous are polypropylene tapes anyway? What are the alternatives? Which factors contribute to a successful outcome of stress incontinence surgery?

OBJECTIVES: To compare translabial three-dimensional (3D) ultrasound with magnetic resonance imaging (MRI) for the measurement of levator hiatus biometry at rest in women with pelvic organ prolapse, and to determine the interobserver reliability between two independent observers for ultrasound and MRI measurements. METHODS: In a multicentre prospective cohort study, women planned for conventional anterior colporrhaphy underwent translabial 3D ultrasound and MRI prior to surgery. Intraclass Correlation Coefficients (ICC) were calculated to estimate the interobserver reliability between two independent observers and to calculate the agreement between ultrasound and MRI measurements. Bland-Altman plots were created to visualize the agreement between ultrasound and MRI measurements. RESULTS: One hundred thirty-nine women were included in 9 hospitals. The interobserver reliability between the assessments on ultrasound at rest, during Valsalva and during contraction and on MRI at rest by two independent observers was good. The agreement between ultrasound and MRI for the measurements of levator hiatus biometry at rest was moderate with an ICC of 0.52 (95% confidence interval (CI) 0.32-0.66) for levator hiatal area, an ICC of 0.44 (95% CI 0.21-0.60) for the anteroposterior diameter and an ICC of 0.44 (95% CI 0.22-0.60) for the transversal diameter. MRI measurements were statistically significantly larger than on translabial 3D ultrasound. CONCLUSIONS: The agreement between translabial 3D ultrasound and MRI for the measurement of the levator hiatus biometry at rest in women with pelvic organ prolapse was only moderate. The results of translabial 3D ultrasound and MRI should therefore not be interchangeably used in daily practice or in clinical research.

This study was aimed to evaluate the effects of hysterectomy on pelvic floor function. We conducted a prospective observational multicenter study with three-year follow-up in thirteen teaching and nonteaching hospitals in the Netherlands. Four-hundred-thirty females who underwent hysterectomy for benign disease other than symptomatic uterine prolapse were included. Validated disease-specific quality-of-life questionnaire were completed before surgery and at 6 months, 12 months and three years after surgery to assess the presence of micturition symptoms, defecation symptoms and sexual problems. Micturition symptoms at three year after surgery were more common following vaginal hysterectomy than following abdominal hysterectomy (OR 2.2, 95% CI 1.3-4.0). Micturition symptoms that more often disappeared following -abdominal hysterectomy included urgency (OR 2.4, 95% CI 1.0-5.5) and obstructive micturition (OR 2.9, 95% CI 1.0-8.2). Constipation had developed in 2% of the patients without constipation before surgery and persisted in 46% of the -patients with constipation before surgery. Sexual pleasure statistically significantly improved in all patients, independently of the performed technique of -hysterectomy. At six months after vaginal, subtotal abdominal hysterectomy and total abdominal hysterectomy, the prevalence of one or more bothersome sexual problems was 43%, 41% and 39% respectively (Chi-square test: p = 0.88). From our prospective study it can be concluded that removal of the cervix during hysterectomy does not worsen pelvic floor function. Abdominal hysterectomy might have benefits over vaginal hysterectomy with respect to micturition. Hysterectomy does not cause constipation. Sexual function following hysterectomy does not depend on the performed technique and is on average better than before surgery.

Vascularisation of the vagina is necessary for optimal function and support of the surrounding organs. We evaluated whether vaginal microcirculation, as representative of vascularisation, differs between women with and without pelvic organ prolapse (POP). In 17 women with POP-Q stage ≥2 and 10 women without POP measurements were performed using sidestream dark-field imaging (groups were not matched). POP and non-POP sites were compared in women with a single compartment prolapse (n = 7). Morphology of the microvessels was scored using the microcirculatory architecture and capillary tortuosity scores at four regions of the vaginal wall. Capillary density measurements were performed and microvascular flow was assessed according to the microvascular flow index (MFI) score. Architecture and tortuosity scores were similar for each anatomical region between women with and without POP and between the POP and non-POP site. A statistically significant difference in capillary density in the left vaginal wall between women with and without POP was observed (25.8 vs. 34.0, P = 0.049). No significant differences in capillary density were observed between the POP and non-POP site. Average MFI scores revealed a continuous flow for all four regions in patients with and without POP. Vaginal microcirculatory architecture, capillary density, and microvascular flow are similar in women with and without POP. Our method to assess the microcirculation of the vaginal wall is consistent in women with POP, which generates an opportunity to assess vaginal microcirculation in the (surgical) treatments of POP. Neurourol. Urodynam. 35:764-770, 2016. © 2015 Wiley Periodicals, Inc

OBJECTIVE: To compare transvaginal prolapse repair combined with midurethral sling (MUS) versus prolapse repair only. DESIGN: Multi-centre randomised trial. SETTING: Fourteen teaching hospitals in the Netherlands. POPULATION: Women with symptomatic stage two or greater pelvic organ prolapse (POP), and subjective or objective stress urinary incontinence (SUI) without prolapse reduction. METHODS: Women were randomly assigned to undergo vaginal prolapse repair with or without MUS. Analysis was according to intention to treat. MAIN OUTCOME MEASURES: The primary outcome at 12 months' follow-up was the absence of urinary incontinence (UI) assessed with the Urogenital Distress Inventory and treatment for SUI or overactive bladder. Secondary outcomes included complications. RESULTS: One hundred and thirty-four women were analysed at 12 months' follow-up (63 in MUS and 71 in control group). More women in the MUS group reported the absence of UI and SUI; respectively 62% versus 30% UI (relative risk [RR] 2.09; 95% confidence interval [CI] 1.39-3.15) and 78% versus 39% SUI (RR 1.97; 95% CI 1.44-2.71). Fewer women underwent treatment for postoperative SUI in the MUS group (10% versus 37%; RR 0.26; 95% CI 0.11-0.59). In the control group, 12 women (17%) underwent MUS after prolapse surgery versus none in the MUS group. Severe complications were more common in the MUS group, but the difference was not statistically significant (16% versus 6%; RR 2.82; 95% CI 0.93-8.54). CONCLUSIONS: Women with prolapse and co-existing SUI are less likely to have SUI after transvaginal prolapse repair with MUS compared with prolapse repair only. However, only 17% of the women undergoing POP surgery needed additional MUS. A well-informed decision balancing risks and benefits of both strategies should be tailored to individual women.

Please cite this paper as: Lakeman M, The S, Schellart R, Dietz V, ter Haar J, Thurkow A, Scholten P, Dijkgraaf M, Roovers J. Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for vaginal hysterectomy: a randomised controlled trial. BJOG 2012;119:14731482. Objective To compare the effects of electrical bipolar vessel sealing and conventional suturing on postoperative pain, recovery, costs and micturition symptoms in women undergoing vaginal hysterectomy. Design Randomised controlled trial. Setting Eight teaching hospitals in the Netherlands. Population One hundred women scheduled to undergo vaginal hysterectomy for benign conditions excluding pelvic organ prolapse. Methods Women were randomised to vessel sealing or conventional surgery. The quality of life related to pelvic floor function was assessed using validated questionnaires before surgery and 6 months after surgery. Pain scores and recovery were assessed using a diary, including daily visual analogue scale scores, starting from the day before surgery until 6 weeks after surgery. Main outcome measures Visual analogue scale pain scores, surgery time, blood loss, complications, quality of life related to pelvic floor function and costs. Results The evening after surgery, women in the vessel-sealing group reported significantly less pain (5.7 versus 4.5 on a scale of 010, P = 0.03), but after that pain scores were similar. Operation duration was shorter for vessel sealing (60 versus 71 minutes, P = 0.05). Blood loss and hospital stay did not differ. We observed no major difference in costs between the two interventions (2903 versus 3102 pound, P = 0.26). Changes in micturition and defecation symptoms were not affected by the surgical technique used. Conclusion Using vessel sealing during vaginal hysterectomy resulted in less pain on the first postoperative day, shorter operating time, similar morbidity and similar pelvic floor function. No major differences in costs were found between the two interventions

We compared micturition and defecation symptoms with the route of hysterectomy over a period of 10 years. Prospective multicentre observational study. Thirteen teaching hospitals in the Netherlands. A total of 430 women who underwent vaginal or abdominal hysterectomy for benign conditions (pelvic organ prolapse excluded). The presence and discomfort experienced as a result of micturition and defecation symptoms were assessed using validated questionnaires before surgery, and at 6 weeks, 6 months, 1 year, 3 years and 10 years after surgery. Statistically significant differences in symptoms between vaginal and abdominal hysterectomy were adjusted for pre-operative differences in uterine descent, uterine size, parity and indication for hysterectomy. Presence of bothersome micturition and defecation symptoms, as assessed by the Urogenital Distress Inventory (UDI) and Defecation Distress Inventory (DDI). Ten years after hysterectomy the response rate was 73%. Preoperatively, no differences were observed in the prevalence of micturition symptoms between patients who underwent vaginal and abdominal hysterectomy. However, 10 years after vaginal hysterectomy, significantly more women had been treated for micturition symptoms (18 versus 8%; P = 0.02; adjusted OR 3.8, 95% CI 1.2-11.6). Defecation symptoms also seemed more common after vaginal hysterectomy (58 versus 46%; P = 0.08). After adjustment, no statistically significant differences in defecation symptoms were found. Despite the same incidence of micturition symptoms before surgery, patients undergoing vaginal hysterectomy are more likely to seek medical help for micturition symptoms. Defecation symptoms were also more common after vaginal hysterectomy; however, this difference was not statistically significant

OBJECTIVE: (1) To explore the reasons for not seeking help for severe pelvic floor symptoms after gynaecological cancer treatment. (2) To determine the willingness to undergo treatment for these symptoms. (3) To invite suggestions to improve outpatient care. DESIGN: Qualitative study using semistructured interviews. SETTING: Vulvar, endometrial or cervical cancer survivors treated in the Academic Medical Centre, Amsterdam, the Netherlands between 1997 and 2007. POPULATION: Purposively selected sample from 138 eligible respondents to pelvic floor-related questionnaires, who were severely bothered by their symptoms (>75th percentile of domain sum score of questionnaires) and had not sought medical help. METHODS: After each semistructured interview, a checklist with reasons for not seeking help was complemented with newly mentioned reasons. The interviews were stopped when data saturation was accomplished, i.e. three consecutive interviewees had not revealed new reasons. The interviews were analysed by two researchers independently. MAIN OUTCOME MEASURE: Help-seeking behaviour for bothersome pelvic floor symptoms. RESULTS: Fifteen interviews were conducted. Most reported reasons for not seeking help were that women found their symptoms bearable in the light of their cancer diagnosis and lacked knowledge about possible treatments. Seven women were willing to undergo treatment. Eleven women stated that care should be improved, specifically by timely referral to pelvic floor specialists and additional care by oncology nurses. CONCLUSIONS: There is a need for standardised attention to adverse effects on pelvic floor function after cancer treatment. This could be realised by quantifying symptoms using questionnaires, standardised attention for such symptoms by gynaecological oncologists or oncology nurses, and timely referral to pelvic floor specialists of women with bothersome pelvic floor symptoms

Vaginal surgery may affect sexual function both positively and negatively. Possibly, negative consequences of surgical interventions on sexuality may be caused by reduced sensibility of the vaginal wall. To develop a new method to measure vaginal sensibility. We developed a technique to measure the sensibility of the vaginal wall consisting of a St Marks electrode on a gloved index finger, with a stimulating electrode mounted at the tip. Measurements were performed in four different target areas (caudal and cranial, posterior and anterior) by two independent female researchers in a random order. Subjects were 12 healthy women. The intra-observer reproducibility of both researchers was almost perfect (Pearsons-Rho correlation coefficient 0.77-0.96 < 0.001). The inter-observer reproducibility was moderate (Pearsons-Rho correlation coefficient 0.39-0.49). Both researchers measured increased sensibility in the cranial posterior vaginal wall relative to the cranial anterior vaginal wall, but for all measurements, researcher 2 obtained higher sensibility ratings than researcher 1. In addition, researcher 2 found a decreased sensibility in the cranial anterior vaginal wall for women not using oral contraceptives. Phase of the menstrual cycle did not influence vaginal sensibility. We developed a new instrument to measure vaginal sensibility. The instrument has excellent intra-observer reproducibility. This method is sufficiently sensitive so as to differentiate between anterior and posterior cranial vaginal wall sensibility, but outcome differs as a function of researcher. Further evaluation of the clinical use of this method is needed, provided that measurements are performed by the same researcher

Three women, aged 21, 28 and 37 years, respectively, were diagnosed with interstitial pregnancies. The first patient presented with lateral abdominal pain, the second patient was asymptomatic and consulted the physician for a routine first trimester scan and the third patient had painless vaginal bleeding in the first trimester. Each was treated with systemic methotrexate in a multiple dose regimen, which was successful in the latter two patients. The first patient was discharged in good condition after her last methotrexate injection, but developed severe abdominal pain and collapsed at home after the interstitial pregnancy had ruptured. She underwent surgery and recovered. Today, the incidence of ectopic pregnancy in the Netherlands is around 8 per 1000 live births. Interstitial pregnancies, which nidate in the portion of the fallopian tube embedded in the uterine wall, account for 2-3% of all ectopic pregnancies. A urinary pregnancy test should be performed for any fertile woman with abdominal pain or abnormal vaginal bleeding. If the result is positive, the patient should be referred to a gynaecologist for transvaginal ultrasound to exclude ectopic pregnancy. In case of a pregnancy of unknown location, one should search for specific ultrasound markers of non-tubal ectopic pregnancy and assess serum human chorionic gonadotropin (HCG). Interstitial ectopic pregnancy should be considered if the serum HCG level is above 2000 U/l

OBJECTIVE: To determine the frequency of defecation symptoms after hysterectomy. DESIGN: Prospective multicentre study, 3 year follow-up. METHODS: 404 patients from 13 teaching or non-teaching hospitals in The Netherlands, who underwent hysterectomy for benign disease other than symptomatic uterine prolapse or known endometriosis, were asked to complete the defecation distress inventory before and 3 years after surgery. The defecation distress inventory is a validated disease specific quality of life questionnaire for assessment of the presence and experienced inconvenience of defecation symptoms. RESULTS: A response rate of 328/372 (88%) of 404 patients whose address could be recovered after 3 years was found. De novo constipation occurred in 2% of the patients following hysterectomy. Sensation of anal blockage and incomplete defecation occurred in more than 15% of the patients. Defecation symptoms reported before surgery had persisted in about half of the patients at 3 years after hysterectomy. A feeling of incomplete defecation at 3 years after hysterectomy was more common after subtotal hysterectomy than after total or vaginal hysterectomy (adjusted odds ratio: 2.1 (95% CI: 1.1-3.8) and 1.4 (95% CI: 0.7-2.7), respectively). CONCLUSION: Defecation symptoms seldom developed after hysterectomy for benign disease. The type of operation did not play a role