Introduction
High body mass index (BMI) is a risk‐factor for stress urinary incontinence (SUI). Mid‐urethral sling (MUS) surgery is an effective treatment of SUI. The aim of this study was to ...investigate if there is an association between BMI at time of MUS‐surgery and the long‐term outcome at 10 years.
Material and Methods
Women who went through MUS surgery in Sweden between 2006 and 2010 and had been registered in the Swedish National Quality Register of Gynecological Surgery were invited to participate in the 10‐year follow‐up. A questionnaire was sent out asking if they were currently suffering from SUI or not and their rated satisfaction, as well as current BMI. SUI at 10 years was correlated to BMI at the time of surgery. SUI at 1 year was assessed by the postoperative questionnaire sent out by the registry. The primary aim of the study was to investigate if there is an association between BMI at surgery and the long‐term outcome, subjective SUI at 10 years after MUS surgery. Our secondary aims were to assess whether BMI at surgery is associated with subjective SUI at 1‐year follow‐up and satisfaction at 10‐year follow‐up.
Results
The subjective cure rate after 10 years was reported by 2108 out of 2157 women. Higher BMI at the time of surgery turned out to be a risk factor for SUI at long‐term follow‐up. Women with BMI <25 reported subjective SUI in 30%, those with BMI 25—<30 in 40%, those with BMI 30—<35 in 47% and those with BMI ≥35 in 59% (p < 0.001). Furthermore, subjective SUI at 1 year was reported higher by women with BMI ≥30, than among women with BMI <30 (33% vs. 20%, p < 0.001). Satisfaction at 10‐year follow‐up was 82% among women with BMI <30 vs 63% if BMI ≥30 (p < 0.001).
Conclusions
We found that higher BMI at the time of MUS surgery is a risk factor for short‐ and long‐term failure compared to normal BMI.
Treating stress urinary incontinence with a mid‐urethral sling seems to be more effective if you have a BMI <30 than if you are obese and have a BMI ≥30.
OBJECTIVE:To evaluate outcomes after pelvic floor muscle therapy, as compared with perineorrhaphy and distal posterior colporrhaphy, in the treatment of women with a poorly healed second-degree ...obstetric injury diagnosed at least 6 months postpartum.
METHODS:We performed a single center, open-label, randomized controlled trial. After informed consent, patients with a poorly healed second-degree perineal tear at minimum 6 months postpartum were randomized to either surgery or physical therapy. The primary outcome was treatment success, as defined by Patient Global Impression of Improvement, at 6 months. Secondary outcomes included the Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the Hospital Anxiety and Depression Scale. Assuming a 60% treatment success in the surgery group and 20% in the physical therapy group, plus anticipating a 20% loss to follow-up, a total of 70 patients needed to be recruited.
RESULTS:From October 2015 to June 2018, 70 of 109 eligible patients were randomized, half into surgery and half into tutored pelvic floor muscle therapy. The median age of the study group was 35 years, and the median duration postpartum at enrollment in the study was 10 months. There were three dropouts in the surgery group postrandomization. In an intention-to-treat analysis, with worst case imputation of missing outcomes, subjective global improvement was reported by 25 of 35 patients (71%) in the surgery group compared with 4 of 35 patients (11%) in the physical therapy group (treatment effect in percentage points 60% 95% CI 42–78%, odds ratio 19 95% CI 5–69). The surgery group was superior to physical therapy regarding all secondary endpoints.
CONCLUSION:Surgical treatment is effective and superior to pelvic floor muscle training in relieving symptoms related to a poorly healed second-degree perineal tear in women presenting at least 6 months postpartum.
CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT02545218.
To assess if women with obesity have increased complication rates compared with women with normal weight undergoing hysterectomy for benign reasons and if the mode of hysterectomy affects the ...outcomes.
Cohort study.
Prospectively collected data from 3 Swedish population-based registers.
Women undergoing a total hysterectomy for benign indications in Sweden between January 1, 2015, and December 31, 2017. The patients were grouped according to the World Health Organization's classification of obesity.
Intraoperative and postoperative data were retrieved from the surgical register up to 1 year after the hysterectomy. Different modes of hysterectomy in patients with obesity were compared, such as open abdominal hysterectomy (AH), traditional laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and robot-assisted laparoscopic hysterectomy (RTLH).
Out of 12,386 women who had a total hysterectomy during the study period, we identified 2787 women with normal weight and 1535 women with obesity (body mass index ≥30). One year after the hysterectomy, the frequency of complications was higher in women with obesity than in women with normal weight (adjusted odds ratio aOR) 1.4; 95% confidence interval CI, 1.1–1.8). In women with obesity, AH was associated with a higher overall complication rate (aOR 1.8; 95% CI, 1.2–2.6) and VH had a slightly higher risk of intraoperative complications (aOR 4.4; 95% CI, 1.2–15.8), both in comparison with RTLH. Women with obesity had a higher rate of conversion to AH with conventional minimally invasive hysterectomy (TLH: aOR 28.2; 95% CI, 6.4–124.7 and VH: 17.1; 95% CI, 3.5–83.8, respectively) compared with RTLH. AH, TLH, and VH were associated with a higher risk of blood loss >500 mL than RTLH (aOR 11.8; 95% CI, 3.4–40.5; aOR 8.5; 95% CI, 2.5–29.5; and aOR 5.8; 95% CI, 1.5–22.8, respectively) in women with obesity.
The use of RTLH may lower the risk of conversion rates and intraoperative bleeding in women who are obese compared with other modes of hysterectomy.
Introduction and hypothesis
The mid-urethral sling (MUS) has been used for more than 30 years to cure stress urinary incontinence. The objective of this study was to assess whether surgical technique ...affects the outcome after more than ten years, regarding dyspareunia and pelvic pain.
Methods
In this longitudinal cohort study we used the Swedish National Quality Register of Gynecological Surgery to identify women who underwent MUS surgery in the period 2006–2010. Out of 4348 eligible women, 2555 (59%) responded to the questionnaire sent out in 2020–2021. The two main surgical techniques, the retropubic and the obturatoric approach, were represented by 1562 and 859 women respectively. The Urogenital Distress Inventory-6 (UDI-6) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), as well as general questions concerning the MUS surgery, were sent out to the study population. Dyspareunia and pelvic pain were defined as primary outcomes. Secondary outcomes included PISQ-12, general satisfaction, and self-reported problems due to sling insertion.
Results
A total of 2421 women were included in the analysis. Among these, 71% responded to questions regarding dyspareunia and 77% responded to questions regarding pelvic pain. In a multivariate logistic regression analysis of the primary outcomes, we found no difference in reported dyspareunia (15% vs 17%, odds ratio (OR) 1.1, 95% CI 0.8–1.5) or in reported pelvic pain (17% vs 18%, OR 1.0, 95% CI 0.8–1.3) between the retropubic and obturatoric techniques among study responders.
Conclusion
Dyspareunia and pelvic pain 10–14 years after insertion of a MUS do not differ with respect to surgical technique.
OBJECTIVE:To assess whether subsequent childbirths affect the outcomes of midurethral sling surgery with regard to stress urinary incontinence (SUI).
METHODS:In this population-based cohort study, we ...used the validated Swedish nationwide health care registers (the Patient Register and the Medical Birth Register) to identify women with a delivery after midurethral sling surgery (n=207, study group). From the same registers we then randomly identified a control group who had no deliveries after their midurethral sling procedure (n=521, control group). The women in the control group were matched to the women in the study group by age and year of surgery. The Urogenital Distress Inventory and the Incontinence Impact Questionnaire were sent out to the study population. Symptomatic SUI was defined as the primary outcome. Secondary outcomes included the total Urogenital Distress Inventory score, Urogenital Distress Inventory subscale scores, and Incontinence Impact Questionnaire scores.
RESULTS:A total of 728 women were eligible for the study. The response rate was 74%; 163 in the study group (64 with vaginal delivery and 95 with cesarean delivery) and 374 women in the control group were included in the analysis. The rate of SUI (primary outcome) was 36 of 163 (22%) in the study group and 63 of 374 (17%) in the control group. In a multivariate regression analysis of the primary outcome, we found no significant difference between the groups (odds ratio OR 1.2, 95% CI 0.7–2.0). Vaginal childbirth after midurethral sling surgery did not increase the risk of SUI compared with cesarean delivery (22% vs 22%, OR 0.6, 95% CI 0.2–1.4). There were no significant differences in Urogenital Distress Inventory and Incontinence Impact Questionnaire scores between any of the groups.
CONCLUSION:Childbirth after a midurethral sling procedure is not associated with an increased risk of patient-reported SUI, and continence status is not affected by the mode of a subsequent delivery.
Introduction and hypothesis
Long-term performance of mid-urethral slings (MUS) and potential differences between the retropubic and the transobturator technique for insertion are scarcely studied. ...This study aims to evaluate the efficacy and safety 10 years after surgery and compare the two main surgical techniques used.
Methods
Women who underwent surgery with a MUS between 2006 and 2010 were identified using the Swedish National Quality Register of Gynecological Surgery and were invited 10 years after the operation to answer questionnaires regarding urinary incontinence and its impact on quality-of-life parameters (UDI-6, IIQ-7) and impression of improvement, as well as questions regarding possible sling-related complications and reoperation.
Results
The subjective cure rate reported by 2421 participating women was 63.3%. Improvement was reported by 79.2% of the participants. Women in the retropubic group reported higher cure rates, lower urgency urinary incontinence rates and lower UDI-6 scores. No difference was shown between the two methods regarding complications, reoperation due to complications or IIQ-7 scores. Persisting sling-related symptoms were reported by 17.7% of the participants, most commonly urinary retention. Mesh exposure was reported by 2.0%, reoperation because of the tape by 5.6% and repeated operation for incontinence by 6.9%, significantly more in the transobturator group (9.1% vs. 5.6%). Preoperative urinary retention was a strong predictor for impaired efficacy and safety at 10 years.
Conclusions
Mid-urethral slings demonstrate good results for the treatment of stress urinary incontinence and tolerable complication profiles in a 10-year perspective. The retropubic approach displays higher efficacy than the transobturator, with no difference regarding safety.
Introduction and hypothesis
Surgical management of uterine prolapse varies greatly and recently uterus-preserving techniques have been gaining popularity. The aim of this study was to compare ...patient-reported outcomes after cervical amputation versus vaginal hysterectomy, with or without concomitant anterior colporrhaphy, in women suffering from pelvic organ prolapse.
Method
We carried out a population-based longitudinal cohort study with data from the Swedish National Quality Register for Gynecological Surgery. Between 2006 and 2013, a total of 3,174 patients with uterine prolapse were identified, who had undergone primary surgery with either cervical amputation or vaginal hysterectomy, with or without concomitant anterior colporrhaphy. Pre- and postoperative prolapse-related symptoms and patient satisfaction were assessed, in addition to complications and adverse events. Between-group comparisons were performed using univariate and multivariate logistic regression.
Results
There were no differences between the two groups in neither symptom relief nor patient satisfaction. In both groups a total of 81 % of the women reported the absence of vaginal bulging 1 year after surgery and a total of 89 % were satisfied with the result of the operation. The vaginal hysterectomy group had a higher rate of severe complications than the cervical amputation group, 1.9 % vs 0.2 % (
p
< 0.001). The vaginal hysterectomy group also had a longer duration of surgery and greater perioperative blood loss, in addition to longer hospitalization.
Conclusions
Cervical amputation seems to perform equally well in comparison to vaginal hysterectomy in the treatment of uterine prolapse, but with less morbidity and a lower rate of severe complications.
(Abstracted from Obstet Gynecol 2020;135:341–351)Perineal trauma and tears during vaginal childbirth is common in primiparous women. Reported rates of perineal tears range from 47% to 78%.
Introduction and hypothesis
The optimal suture material in traditional prolapse surgery is still controversial. Our aim was to investigate the effect of using sutures with rapid (RA) or slow (SA) ...absorption, on symptomatic recurrence after anterior and posterior colporrhaphy.
Methods
A population-based longitudinal cohort study with data from the Swedish National Quality Register for Gynecological Surgery. A total of 1,107 women who underwent primary anterior colporrhaphy and 577 women who underwent primary posterior colporrhaphy between September 2012 and September 2013 were included. Two groups in each cohort were created based on which suture material was used. Pre- and postoperative prolapse-related symptoms and patient satisfaction were assessed.
Results
We found a significantly lower rate of symptomatic recurrence 1 year after anterior colporrhaphy in the SA suture group compared with the RA suture group, 50 out of 230 (22 %) vs 152 out of 501 (30 %), odds ratio 1.6 (CI 1.1–2.3;
p
= 0.01). The SA group also had a significantly higher patient satisfaction rate, 83 % vs 75 %, odds ratio 1.6 (CI 1.04–2.4), (
p
= 0.03). Urgency improved significantly more in the RA suture group (
p
< 0.001). In the posterior colporrhaphy cohort there was no significant difference between the suture materials.
Conclusions
This study indicates that the use of slowly absorbable sutures decreases the odds of having a symptomatic recurrence after an anterior colporrhaphy compared with the use of rapidly absorbable sutures. However, the use of RA sutures may result in less urgency 1 year postoperatively. In posterior colporrhaphy the choice of suture material does not affect postoperative symptoms.
Few studies are performed on the sustainability of the pelvic floor extracellular matrix important for preventing development of pelvic organ prolapse (POP). Collagens I and III, the ...elastin-associated proteins fibrillin-1 and fibulin-5 and the small leucine-rich repeat proteoglycans (SLRPs) decorin, lumican and fibromodulin are involved in giving the tissue its mechanical properties. Para-urethral biopsies were obtained from 15 women, 6 pre- and 9 post-menopausal, with POP. Real-time reverse transcription–polymerase chain reaction and immunohistochemistry for collagen I, collagen III, fibrillin-1, fibulin-5, decorin, lumican and fibromodulin were performed and compared with 14 controls, 8 pre- and 6 post-menopausal. Statistical comparisons controlled for age changes in gene expressions. A 16-fold decrease in decorin mRNA expression, P = 0.0001, and 8-fold in lumican mRNA expression, P = 0.001, were discovered in premenopausal POP compared with matched controls. In all women with POP, there were lower gene expressions of fibromodulin, P = 0.004, and fibulin-5, P = 0.001, compared with all controls. All proteins were detectable by immunohistochemistry, showing a weaker staining for decorin in premenopausal POP. For the first time, we show substantially decreased gene signal for production of SLRPs, regulators of collagen fiber assembly and impairment in elastic fiber assembly by down-regulation of fibulin-5 in POP.
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