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Is there any difference in pelvic floor muscles morphology and function between continent and incontinent athletes?
European Journal of Obstetrics & Gynecology and Reproductive Biology 200 (2016) 128–131
Conclusion: These findings support the use of the KHPQ as a global assessment of pelvic function in post-partum women. http://dx.doi.org/10.1016/j.ejogrb.2016.03.003 Robotic sacrocolpopexy – efficacy in treating vaginal vault prolapse O.E. O’Sullivan 1, S.E. Schraffordt Koops 2, B.A. O’Reilly 1on behalf of the PARSEC group 1
Department of Urogynaecology, Cork University Maternity Hospital, Cork, Ireland 2 Department of Gynaecology and Obstetrics, Meander MEDICAL Center, Amersfoort, The Netherlands Introduction: Sacrocolpopexy remains the gold standard for the treatment of vaginal vault prolapse (VVP). Robotic surgery rates are increasing with few large prospective studies available to assess the benefits. Objective: The primary aim was to assess the efficacy of the procedure. The secondary aims included assessing the safety profile and surgical variables using the robot. Methods: A prospective European multi-centred cohort study was performed from August 2011 to August 2014. There were strict entry criteria: VVP stage 2 (simplified POP-Q point C 2). The primary outcome was anatomical cure at 6 weeks and 1 year using the simplified POP-Q. Secondary outcomes included mesh erosion rates, reoperations rate and intra-peri and post-operative complications. Statistical analysis was performed using student ttest and linear regression where appropriate. Results: 172 women were enrolled, mean age was 64years (range 38–83years), mean parity: 3 (range 0–12), mean BMI: 26.7 (range 20.46–37.1). The prolapse results: Table 1. The conversion rate was 2.9% (5/172). Intraoperative complication rate was 1.1%(2/172). 17% (30/172) had concomitant surgery. The reoperation rate was 9.3% (16/172) none for recurrent VVP. No mesh erosions have been reported. Console time varied from 53 to 141 min with longer console times reported for the more challenging cases.
Point A Point B Point C *
There are few clinical conditions encountered by the Urogynaecologist that causes more clinician frustration as Bladder Pain Syndrome (BPS). There is a trend towards delayed diagnosis. The impact of this chronicity on disease progression is unknown. Despite excellent care, some patients never find relief of their pain, even post cystectomy. Is this a peripheral pathology with pain originating in the bladder, or has the pain become centralized? We aim to study the effect of local anaesthetics on pain and urodynamic parameters in patients with BPS, thus determining those patients with peripheral pain and those with pain centralization. 24 female patients with histories indicative of BPS were recruited. Written consent was given and urodynamic assessment completed. Participants completed a Visual Analogue Scale (VAS) at cystometric capacity. Participants were randomly assigned to ‘lidocaine’ or ‘control’ groups; ‘lidocaine’ participants received 20 ml of 2% alkalinized lidocaine, while the ‘control’ participants received 20 ml normal saline. These solutions were allowed to remain in situ for 10 min and urodynamics repeated. Lidocaine treatment resulted in decreased pain perception, leading to an increase in urodynamic parameters and volumes. There was a lack of analgesic effect in 5 of the 16 patients who received lidocaine, with a corresponding deterioration in their urodynamic parameters, similar to the saline controls. This study allowed the evaluation of BPS from a pain perspective, and can thus facilitate the treatment of BPS by differentiating those patients that are likely to respond to peripheral treatment strategies and those patients for whom the pain has become centralized. http://dx.doi.org/10.1016/j.ejogrb.2016.03.005 Is there any difference in pelvic floor muscles morphology and function between continent and incontinent athletes? Thuane Da Roza 1,2, Sofia Branda˜o 2,3, Teresa Mascarenhas 3, Marco Parente 2, Renato Natal Jorge 2 1
CEFID-UDESC – Biomechanics Laboratory, Floriano´polis, Brazil LAETA, INEGI – Po´lo FEUP, Faculty of Engineering, University of Porto, Portugal 3 Centro Hospitalar de Sa˜o Joa˜o-EPE, Faculty of Medicine, University of Porto, Portugal 2
Table 1 Simplified POP-Q
129
Pre-op 3 2 3
6/52 post op *
0 0* 0*
1 year post-op 1* 1* 1*
p = 0.0001.
Discussion: Robot-assisted sacrocolpopexy has good anatomical outcomes at one year. It is safe and effective in managing VVP. Surgeons must be cognizant of the need to treat residual anterior/ posterior compartment prolapse that is not cured with the sacrocolpopexy. http://dx.doi.org/10.1016/j.ejogrb.2016.03.004
Understanding stress urinary incontinence (SUI), and the attempt to prevent urine leakage [1] includes different biomechanical aspects – anatomy, strength and correct contraction of the pelvic floor muscles (PFM) [2]. In this context, this study aims to assess if structural and biomechanical characteristics of the PFM may lead to urine leakage in nulliparous athletes. For this purpose, the participants took a questionnaire to collect demographic and clinical data, and took pelvic Magnetic Resonance examination, from which the computational models were built (Fig. 1). Twelve athletes (7 continent and 5 incontinent ones)
The effect of lidocaine on urodynamic parameters in the Bladder Pain Syndrome Ifeoma Offiah 1,2, Elaine Dilloughery 1, Stephen McMahon 2, Barry O’Reilly 1 1
Department of Urogynaecology, Cork University Maternity Hospital, University College Cork, Co., Cork, Ireland 2 Neurorestoration Group, Wolfson CARD, King’s College London, London SE1 1UL, United Kingdom
Fig. 1. Manual segmentation (a) of the pubovisceral muscle to create a 3D model (b).
130
European Journal of Obstetrics & Gynecology and Reproductive Biology 200 (2016) 128–131
were included. Mean age and BMI were 25.1 6.0 years and 21.9 2.2 kg/m2, respectively. The results showed that there were no differences either in the Oxford Scale (strength) or in the displacement of the PFM (function) during biomechanical simulation in between the groups. However, the morphological measurements showed that incontinent women had thicker muscles at the level of midvagina when compared to the continent ones (p = 0.028 in the left and p = 0.019 in the right sides). This suggests that, among athletes, urine leakage may be related to alterations in the intrafusal fibers than just the result of thicker or stronger muscles. Additionally, the results from the numerical simulations evidenced a low percent error (1.47–17.20%), with values of displacement similar from that of the dynamic images acquired at maximal contraction (6.42 0.36 mm vs. 6.10 0.47 mm; p = 0.130). The models were able to replicate PFM maximal contraction. Perhaps, incontinent athletes need different PFM training protocols to be effective in the treatment of SUI.
Image 1. Introital ultrasound, midsaggital plane, recurrent cystocele due to apical mesh dislocation, missing mesh along the vaginal apex and shrunken mesh level II.
References [1] Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010;21(1):5–26. [2] Bø K, Kvarstein B, Hagen RR, Larsen S. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: II. Validity of vaginal pressure measurements of pelvic floor muscle strength and the necessity of supplementary methods for control of correct contraction. Neurourol Urodyn 1990;9(5):479–87. http://dx.doi.org/10.1016/j.ejogrb.2016.03.006 Minimally invasive mesh preserving surgical technique to treat recurrent cystocele after transvaginal mesh interposition J. Marschke, K. Beilecke, R. Tunn Deutsches Beckenbodenzentrum, Fachbereich Urogyna¨kologie, St. Hedwig Kliniken Berlin, Berlin Introduction: Single-incision transvaginal repair using Elevate anterior1 mesh to treat recurrent or advanced cystocele provides anatomical cure rates superior to native tissue repair, nonetheless failure with recurrence can occur. Objective: In cystocele after transvaginal mesh reconstruction our examination includes ultrasound. Mesh failure can be discriminated between apical (Level I) and distal (Level II) defects. In apical failure (Image 1) we perform colposacropexy. Presuming correct positioning of mesh arms two factors can cause Level II mesh failure: mesh deviation in bladder neck region or an oversize of the preshaped mesh (Image 2). Methods: We demonstrate a transvaginal approach to reconstruct a symptomatic recurrence of cystocele in Level II mesh failure due to an oversized mesh. Midline colpotomy is performed cutting all layers of vaginal wall including the mesh. The mesh is separated from vaginal wall and subvesical endopelvin connective tissue thus creating a separate layer. Native tissue reconstruction is performed to reduce pressure on the mesh and colpotomy. Trimming of mesh edges is followed by tension-free readaptation using non-resorbable single stitch suture. A running suture closes the colpotomy. Discussion: Discussion about transvaginal meshes has led to a restricted reaction to complications regardless their type: anatomical failure, dyspareunia, erosion/exposure. Choice of treatment
Image 2. Introital ultrasound, midsaggital plane, recurrent cystocele due to central mesh dislocation level II, correctly placed mesh along the bladder neck and vaginal cuff.
is usually limited to subtotal mesh removal, which implies invasive surgery and leads to recurrence of prolapse. We emphasise the use of sonomorphological description to diagnose reasons for mesh failure and to indicate appropriate treatment. Furthermore we present a method to treat anatomical mesh failure in a minimally invasive route. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ejogrb.2016. 03.049. http://dx.doi.org/10.1016/j.ejogrb.2016.03.049 The diverging role of Robotics in complex Urogynaecology O.E. O’Sullivan, M. Wilkinson, B.A. O’Reilly Department of Urogynaecology, Cork University Maternity Hospital, Cork Introduction: Challenging cases in Urogynaecology can now be performed through minimally invasive surgery for which robotics are proving to be essential.
Conclusion: These findings support the use of the KHPQ as a global assessment of pelvic function in post-partum women. http://dx.doi.org/10.1016/j.ejogrb.2016.03.003 Robotic sacrocolpopexy – efficacy in treating vaginal vault prolapse O.E. O’Sullivan 1, S.E. Schraffordt Koops 2, B.A. O’Reilly 1on behalf of the PARSEC group 1
Department of Urogynaecology, Cork University Maternity Hospital, Cork, Ireland 2 Department of Gynaecology and Obstetrics, Meander MEDICAL Center, Amersfoort, The Netherlands Introduction: Sacrocolpopexy remains the gold standard for the treatment of vaginal vault prolapse (VVP). Robotic surgery rates are increasing with few large prospective studies available to assess the benefits. Objective: The primary aim was to assess the efficacy of the procedure. The secondary aims included assessing the safety profile and surgical variables using the robot. Methods: A prospective European multi-centred cohort study was performed from August 2011 to August 2014. There were strict entry criteria: VVP stage 2 (simplified POP-Q point C 2). The primary outcome was anatomical cure at 6 weeks and 1 year using the simplified POP-Q. Secondary outcomes included mesh erosion rates, reoperations rate and intra-peri and post-operative complications. Statistical analysis was performed using student ttest and linear regression where appropriate. Results: 172 women were enrolled, mean age was 64years (range 38–83years), mean parity: 3 (range 0–12), mean BMI: 26.7 (range 20.46–37.1). The prolapse results: Table 1. The conversion rate was 2.9% (5/172). Intraoperative complication rate was 1.1%(2/172). 17% (30/172) had concomitant surgery. The reoperation rate was 9.3% (16/172) none for recurrent VVP. No mesh erosions have been reported. Console time varied from 53 to 141 min with longer console times reported for the more challenging cases.
Point A Point B Point C *
There are few clinical conditions encountered by the Urogynaecologist that causes more clinician frustration as Bladder Pain Syndrome (BPS). There is a trend towards delayed diagnosis. The impact of this chronicity on disease progression is unknown. Despite excellent care, some patients never find relief of their pain, even post cystectomy. Is this a peripheral pathology with pain originating in the bladder, or has the pain become centralized? We aim to study the effect of local anaesthetics on pain and urodynamic parameters in patients with BPS, thus determining those patients with peripheral pain and those with pain centralization. 24 female patients with histories indicative of BPS were recruited. Written consent was given and urodynamic assessment completed. Participants completed a Visual Analogue Scale (VAS) at cystometric capacity. Participants were randomly assigned to ‘lidocaine’ or ‘control’ groups; ‘lidocaine’ participants received 20 ml of 2% alkalinized lidocaine, while the ‘control’ participants received 20 ml normal saline. These solutions were allowed to remain in situ for 10 min and urodynamics repeated. Lidocaine treatment resulted in decreased pain perception, leading to an increase in urodynamic parameters and volumes. There was a lack of analgesic effect in 5 of the 16 patients who received lidocaine, with a corresponding deterioration in their urodynamic parameters, similar to the saline controls. This study allowed the evaluation of BPS from a pain perspective, and can thus facilitate the treatment of BPS by differentiating those patients that are likely to respond to peripheral treatment strategies and those patients for whom the pain has become centralized. http://dx.doi.org/10.1016/j.ejogrb.2016.03.005 Is there any difference in pelvic floor muscles morphology and function between continent and incontinent athletes? Thuane Da Roza 1,2, Sofia Branda˜o 2,3, Teresa Mascarenhas 3, Marco Parente 2, Renato Natal Jorge 2 1
CEFID-UDESC – Biomechanics Laboratory, Floriano´polis, Brazil LAETA, INEGI – Po´lo FEUP, Faculty of Engineering, University of Porto, Portugal 3 Centro Hospitalar de Sa˜o Joa˜o-EPE, Faculty of Medicine, University of Porto, Portugal 2
Table 1 Simplified POP-Q
129
Pre-op 3 2 3
6/52 post op *
0 0* 0*
1 year post-op 1* 1* 1*
p = 0.0001.
Discussion: Robot-assisted sacrocolpopexy has good anatomical outcomes at one year. It is safe and effective in managing VVP. Surgeons must be cognizant of the need to treat residual anterior/ posterior compartment prolapse that is not cured with the sacrocolpopexy. http://dx.doi.org/10.1016/j.ejogrb.2016.03.004
Understanding stress urinary incontinence (SUI), and the attempt to prevent urine leakage [1] includes different biomechanical aspects – anatomy, strength and correct contraction of the pelvic floor muscles (PFM) [2]. In this context, this study aims to assess if structural and biomechanical characteristics of the PFM may lead to urine leakage in nulliparous athletes. For this purpose, the participants took a questionnaire to collect demographic and clinical data, and took pelvic Magnetic Resonance examination, from which the computational models were built (Fig. 1). Twelve athletes (7 continent and 5 incontinent ones)
The effect of lidocaine on urodynamic parameters in the Bladder Pain Syndrome Ifeoma Offiah 1,2, Elaine Dilloughery 1, Stephen McMahon 2, Barry O’Reilly 1 1
Department of Urogynaecology, Cork University Maternity Hospital, University College Cork, Co., Cork, Ireland 2 Neurorestoration Group, Wolfson CARD, King’s College London, London SE1 1UL, United Kingdom
Fig. 1. Manual segmentation (a) of the pubovisceral muscle to create a 3D model (b).
130
European Journal of Obstetrics & Gynecology and Reproductive Biology 200 (2016) 128–131
were included. Mean age and BMI were 25.1 6.0 years and 21.9 2.2 kg/m2, respectively. The results showed that there were no differences either in the Oxford Scale (strength) or in the displacement of the PFM (function) during biomechanical simulation in between the groups. However, the morphological measurements showed that incontinent women had thicker muscles at the level of midvagina when compared to the continent ones (p = 0.028 in the left and p = 0.019 in the right sides). This suggests that, among athletes, urine leakage may be related to alterations in the intrafusal fibers than just the result of thicker or stronger muscles. Additionally, the results from the numerical simulations evidenced a low percent error (1.47–17.20%), with values of displacement similar from that of the dynamic images acquired at maximal contraction (6.42 0.36 mm vs. 6.10 0.47 mm; p = 0.130). The models were able to replicate PFM maximal contraction. Perhaps, incontinent athletes need different PFM training protocols to be effective in the treatment of SUI.
Image 1. Introital ultrasound, midsaggital plane, recurrent cystocele due to apical mesh dislocation, missing mesh along the vaginal apex and shrunken mesh level II.
References [1] Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010;21(1):5–26. [2] Bø K, Kvarstein B, Hagen RR, Larsen S. Pelvic floor muscle exercise for the treatment of female stress urinary incontinence: II. Validity of vaginal pressure measurements of pelvic floor muscle strength and the necessity of supplementary methods for control of correct contraction. Neurourol Urodyn 1990;9(5):479–87. http://dx.doi.org/10.1016/j.ejogrb.2016.03.006 Minimally invasive mesh preserving surgical technique to treat recurrent cystocele after transvaginal mesh interposition J. Marschke, K. Beilecke, R. Tunn Deutsches Beckenbodenzentrum, Fachbereich Urogyna¨kologie, St. Hedwig Kliniken Berlin, Berlin Introduction: Single-incision transvaginal repair using Elevate anterior1 mesh to treat recurrent or advanced cystocele provides anatomical cure rates superior to native tissue repair, nonetheless failure with recurrence can occur. Objective: In cystocele after transvaginal mesh reconstruction our examination includes ultrasound. Mesh failure can be discriminated between apical (Level I) and distal (Level II) defects. In apical failure (Image 1) we perform colposacropexy. Presuming correct positioning of mesh arms two factors can cause Level II mesh failure: mesh deviation in bladder neck region or an oversize of the preshaped mesh (Image 2). Methods: We demonstrate a transvaginal approach to reconstruct a symptomatic recurrence of cystocele in Level II mesh failure due to an oversized mesh. Midline colpotomy is performed cutting all layers of vaginal wall including the mesh. The mesh is separated from vaginal wall and subvesical endopelvin connective tissue thus creating a separate layer. Native tissue reconstruction is performed to reduce pressure on the mesh and colpotomy. Trimming of mesh edges is followed by tension-free readaptation using non-resorbable single stitch suture. A running suture closes the colpotomy. Discussion: Discussion about transvaginal meshes has led to a restricted reaction to complications regardless their type: anatomical failure, dyspareunia, erosion/exposure. Choice of treatment
Image 2. Introital ultrasound, midsaggital plane, recurrent cystocele due to central mesh dislocation level II, correctly placed mesh along the bladder neck and vaginal cuff.
is usually limited to subtotal mesh removal, which implies invasive surgery and leads to recurrence of prolapse. We emphasise the use of sonomorphological description to diagnose reasons for mesh failure and to indicate appropriate treatment. Furthermore we present a method to treat anatomical mesh failure in a minimally invasive route. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.ejogrb.2016. 03.049. http://dx.doi.org/10.1016/j.ejogrb.2016.03.049 The diverging role of Robotics in complex Urogynaecology O.E. O’Sullivan, M. Wilkinson, B.A. O’Reilly Department of Urogynaecology, Cork University Maternity Hospital, Cork Introduction: Challenging cases in Urogynaecology can now be performed through minimally invasive surgery for which robotics are proving to be essential.