RESUMEN

INTRODUCTION AND HYPOTHESIS: Transgender men and transmasculine individuals report a variety of lower urinary tract symptoms (LUTS), but little is known about LUTS in this population. One of the obstacles is the lack of validated questionnaires. This study was aimed at validating the International Consultation on Incontinence Questionnaire-Lower Urinary Tract Symptoms (ICIQ-LUTS), which measures filling, voiding, and incontinence symptoms, in transmasculine individuals. METHODS: This is an observational validation study that included transmasculine individuals receiving care within a single tertiary care hospital system. Construct validity was assessed by comparing the ICIQ-LUTS with severity of LUTS as measured by the Urinary Distress Inventory-Short Form (UDI-6), and concurrent validity by the association between ICIQ-LUTS and the Patient Perception of Bladder Condition (PPBC). Discriminant validity was determined by comparing ICIQ-LUTS scores in those with and those without self-reported LUTS. Spearman correlation, t test, and Kruskal-Wallis test were used for data analysis. RESULTS: A total of 131 respondents were included in the analysis. Only two individuals (1.5%) reported prior vaginectomy and/or phalloplasty. Concurrent validity was demonstrated by a significant association between ICIQ-LUTS subscales and PPBC (filling p < 0.001, voiding p < 0.001, incontinence p < 0.001). Construct validity was demonstrated by a significant correlation between ICIQ-LUTS and UDI-6 (filling ρ = 0.76, p < 0.001; voiding ρ = 0.48, p < 0.001; incontinence ρ = 0.61, p < 0.001). For discriminant validity, those with at least one self-reported LUTS had significantly higher (worse) ICIQ-LUTS subscale scores than those without self-reported LUTS. CONCLUSIONS: The ICIQ-LUTS is valid for measurement of LUTS severity in transmasculine individuals. This will be an important tool to use in future research to learn more about LUTS in this population.

RESUMEN

BACKGROUND: Stress urinary incontinence (SUI) is a common condition that can significantly impact a patient's quality of life. Although multiple diagnostic and treatment options exist, significant variability in SUI management exists between countries. Since women's SUI prevalence in Jordan is high, and Jordan is a lower-middle-income country, this study aimed to investigate how obstetricians and gynecologists (OBGYNs) across Jordan manage and treat women with SUI. METHOD: A Google Forms survey was prepared and sent out to Jordanian OBGYNs via WhatsApp. The results were collected and arranged in Microsoft Excel and then transferred to SPSS for statistical analysis. RESULTS: Out of the 804 Jordanian registered OBGYNs, 497 could be reached, 240 conduct gynecological surgeries, and 94 completed the survey, providing a response rate of 39.2%. Most of the respondents were females between 41 and 55 years old. More than 70% of the OBGYNs worked in the private sector, and 88.3% operated in the capital of Jordan. Most of the respondents favored lifestyle and behavior therapy (43.6%) or pelvic floor physiotherapy (40.4%) as the first-line management for SUI. The transobturator mid-urethral sling (MUS) was the most common initial surgical treatment option. The physicians preferred two-staged procedures for the repair of pelvic organ prolapse alongside concomitant SUI. In the case of recurrent SUI following surgery, 77% of the respondents chose to refer to a urologist or urogynecologist. CONCLUSIONS: The Jordanian OBGYNs preferred using lifestyle/behavioral therapy and pelvic floor muscle physiotherapy as the first-line treatment to manage SUI. Secondly, the MUS would be the most frequently preferred surgical choice. To effectively manage SUI, adequate training in urogynecology and referral resources are essential in lower-middle-income countries.

RESUMEN

OBJECTIVE: To compare characteristics of Urogynecology training and number of "Incontinence and Pelvic Floor" cases logged between OB/GYN residencies affiliated and those not affiliated with Urogynecology fellowships. DESIGN: A retrospective descriptive analysis was performed of OB/GYN residency programs, their Urogynecology training, and association with Urogynecology fellowship programs during the 2023-2024 academic year. Program websites for ACGME-accredited OB/GYN residency programs were reviewed to determine availability, timing, and length of Urogynecology training. ACGME data for "Incontinence and Pelvic Floor" cases were analyzed by training year and association with Urogynecology fellowship programs from the 2012-2013 to 2022-2023 academic year. Data was analyzed using SPSS. SETTING: This research was conducted at Harbor-UCLA Medical Center. PARTICIPANTS: None. INTERVENTIONS: None RESULTS: Information was obtained for 85.9% of programs. Nearly all (97.0%) had dedicated Urogynecology rotations, and 64.4% had rotations in > 1 year of training. Association with Urogynecology fellowship did not affect the availability of Urogynecology training overall nor the overall number of rotations. Urogynecology rotations occurred most often in the third (PGY3) year of residency, though 43.6% of programs had training for junior (PGY1, PGY2) residents. Residencies with associated Urogynecology fellowships were more likely to have a rotation for PGY2 residents and for junior residents overall. From 2012-2023, the number of "Incontinence and Pelvic Floor" cases declined by 36.3%, with trainees at residencies not affiliated with Urogynecology fellowships logging more cases than those at a fellowship-affiliated residency. CONCLUSION: While the majority of OB/GYN residencies have dedicated Urogynecology training, most rotations are for senior residents. Training programs associated with Urogynecology fellowships are more likely to expose junior residents to the field, but their trainees log fewer "Incontinence and Pelvic Floor" cases overall. Earlier exposure may enrich surgical training and help residents prepare for their career, whether in Urogynecology or as a generalist.

RESUMEN

Introduction: Pelvic organs prolapse remains a significant health concern affecting millions of women worldwide. The use of native tissues to suspend the apex has acquired relevance in urogynecologic surgery. One of the most commonly used procedures performed without mesh is the technique described by Shull, consisting of suturing the vaginal apex to the uterosacral ligaments. The objective of the study is to evaluate the learning curve of laparoscopic Shull's repair for the correction of pelvic floor defects, including the surgery time and surgical outcomes. Materials and methods: This is a retrospective study conducted at the Policlinico G. Martino, University of Messina, Messina, Italy, and Policlinico Vanvitelli, Vanvitelli University, Naples, Italy. All patients affected by grade I-IV POP, consisting of apical prolapse with or without cystocele, and who underwent laparoscopic Shull's technique for prolapse correction were enrolled. The endpoints to estimate the learning curve for the procedure were the percentage of laparoscopic procedures completed, operative time, and the early complication rate. Results: A total of 31 laparoscopic Shull repairs were collected for the study. To evaluate the learning curve of the technique, we divided the 31 cases into three different groups: Procedures 0-10; 11-20; 21-31. The parameter for evaluating technique learning was the operative time. Group 21-31 demonstrated an operative time of 97 min (SD 20), compared with 121 min (SD 23) in group 0-10 and 120 min (SD 13) in group 11-20. A comparison of these means through ANOVA showed a p-value of 0.01 for the entire system, and 0.95 for the comparison between 0 and 10 and 11-20, 0.04 for 0-10 vs. 21-31, and 0.02 between 11 and 20 and 21-31. Conclusions: The rate of surgical improvement in terms of time became effective after an average of 20 procedures. However, the improvement seems to be effective case by case for surgeons skilled in basic endoscopy.

RESUMEN

In an epoch where digital innovation is redefining the medical landscape, electronic health records (EHRs) stand out as a pivotal transformative force. Urogynecology, a discipline anchored in intricate patient histories and meticulous follow-ups, is on the brink of profound transformation due to these digital strides. While EHRs have unified patient data, challenges related to data privacy, interoperability, and access persist. In response, we present Pelvic Health Place (PHPlace) - a multilingual, patient-centric application. Purposefully designed to bolster patient engagement, PHPlace provides clinicians with essential pre-consultation insights, streamlines the consent process, vividly delineates surgical pathways, and assures comprehensive long-term monitoring. This platform also establishes a foundation for global data amalgamation, promising to invigorate research and potentially harness artificial intelligence (AI) capabilities. With AI integration, we anticipate a more tailored treatment approach and enriched patient education, signaling a pivotal shift in urogynecology and emphasizing the imperative for ongoing academic inquiry.

Asunto(s)

RESUMEN

PURPOSE: Hysterectomy may be a risk factor for pelvic organ prolapse (POP). We assessed the risk of recurrent POP (operations and visits) after hysterectomy among women with previous POP. We also studied patient and operation related risk factors for POP recurrence. METHODS: This retrospective cohort study included 1697 women having previous POP diagnosis or POP at the time of hysterectomy (FINHYST 2006 cohort). Follow-up was until the end of 2016. The data was derived from the Finnish National Care register linked to the cohort. Hysterectomy approaches and other demographics were compared to the risk of a prolapse diagnosis and/or surgery. Cox regression model was used to identify hazard ratios. RESULTS: Following hysterectomy, a total of 280 women (16.5%) had a POP reoperation and 359 (21.2%) had an outpatient visit due to POP. Vaginal vault prolapse repair was the most common POP reoperation (n = 181, 10.7%), followed by anterior wall repair (n = 120, 7.1%). Median time to POP reoperation was 3.7 years. Hysterectomy approach did not affect reoperations or visits. Previous cesarean section and anterior repair during hysterectomy were associated with decreased risk, whereas concomitant sacrospinous fixation and uterus prolapse as the main indication led to increased risk of anterior/vault prolapse reoperations. Concomitant posterior repair decreased posterior reoperations and visits, but uterus weight over 500 g caused a fivefold increased risk of posterior prolapse visit. Residential status was associated with elevated risk of any POP reoperations and visits. CONCLUSIONS: Approximately one out of five women suffering from POP ensue POP reoperation or visit after hysterectomy. These high rates are independent on hysterectomy approach, but probably indicate that hysterectomy may worsen previous pelvic floor dysfunction.

RESUMEN

INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy is the gold standard for the surgical management of apical prolapse. Over the years, surgical advancements have transformed the procedure from a laparotomy with a hospital stay of several days to a minimally invasive approach with a much shorter hospital stay. One recent innovation has the potential to transform minimally invasive sacrocolpopexy. METHODS: The da Vinci single-port robotic platform has allowed urological procedures to generate improved recovery, pain control, and cosmesis, with no differences in complications rates. RESULTS: Although the data with respect to sacrocolpopexy are more limited owing to the novelty of this application, the results appear to be similar to those of urological procedures such as prostatectomy. CONCLUSIONS: We present our surgical technique for completing single-port robotic sacrocolpopexy, with and without a hysterectomy, as well as a review of the relevant literature.

RESUMEN

Pain after vaginal prolapse repair surgery with mesh is generally attributed to the mesh fixation, particularly to mesh erosion, dislocation or the development of hematoma. However, once all the causes have been excluded, the urinary system, bladder and ureters should be accurately examined by means of endovaginal ultrasound. This report concerns the case of a 72-year-old woman who had undergone mesh-supported prolapse surgery 3 months prior, with no other relevant diseases, who visited the emergency department complaining of dull, right-sided colic pain. The endovaginal ultrasound examination revealed a prevesical ureteral calculus on the right side with consequent dilatation of the proximal ureter. Computed tomography of the abdomen and pelvis confirmed the calculus in the distal right ureter and revealed a right renal lower pole calculus. The patient underwent treatment via an operative ureterorenoscopy with removal of stones and placement of a double-J-stent. Two months later, a second ureterorenoscopy was performed with double-J-stent removal and concomitant stone extraction. It appears that no similar cases have been reported in the literature. This is why, during the urogynecological postoperative follow-up, it is of paramount importance to examine the entire urogenital system with endovaginal ultrasound. This case report highlights how, through a simple, non-invasive, radiation-free examination, like ultrasound, most of the post-operative complications of vaginal prolapse repair surgery using mesh, including urolithiasis, can be excluded.

RESUMEN

INTRODUCTION AND HYPOTHESIS: We describe the surgical management of intravesical mesh perforation following transvaginal mesh surgery for pelvic organ prolapse. METHODS: A 73-year-old woman presented with intravesical mesh perforation 17 years following transvaginal mesh-based prolapse repair at an outside hospital. The patient presented with intermittent hematuria and recurrent urinary tract infections. Cystoscopy demonstrated an approximately 3-cm area of intravesical mesh with associated stone spanning from the bladder neck through the left trigone and ureteral orifice. A robotic-assisted transvesical mesh excision and left ureteroneocystostomy was carried out. Robotic-assisted repair was performed transvesically via transverse bladder dome cystotomy. Dissection was carried out circumferentially around the mesh in the vesicovaginal plane, including a 1-cm margin of healthy tissue. The eroded mesh was excised, and the vaginal wall and bladder were closed with running absorbable sutures. Given the location of the mesh excision and repair, a left ureteral reimplantation was performed. The transverse cystotomy was closed and retrograde bladder filling with methylene blue-stained saline confirmed watertight repairs, with no vaginal extravasation. RESULTS: The patient was discharged the following morning and had an uneventful recovery, including transurethral indwelling catheter removal at 2 weeks after CT cystogram and subsequent ureteral stent removal at 6 weeks postoperatively. At 2-month follow-up she had no new urinary symptoms or obstruction of the ureteral reimplantation on renal ultrasound. CONCLUSIONS: A robotic-assisted approach is a feasible option for managing transvaginal prolapse mesh perforation into the bladder. Pelvic surgeons must be well equipped to handle transvaginal mesh complications in a patient-specific manner.

Asunto(s)

RESUMEN

AIMS: Urogynecology and Reconstructive Pelvic Surgery (URPS) fellowship can be pursued after completion of either a urology (URO) or obstetrics and gynecology (GYN) residency. Our aim is to determine differences in graduating fellow cohort (GFC) case logs between URO- and GYN-based URPS programs. METHODS: Accreditation Council for Graduate Medical Education case logs for URPS GFCs in both GYN- and URO-based programs were analyzed for the 2019-2023 academic years (AY). Unpaired t-tests with Welch's correction were used to compare annual mean logged cases between URO- versus GYN-based GFCs for select surgical categories and the top 11 most logged index cases. RESULTS: GYN-based GFCs logged more cases for all pelvic organ prolapse (POP) categories including surgery on apical POP, anterior wall POP, and posterior wall POP (all p < 0.01), while URO-based GFCs logged more cases for surgery on the urinary system (p = 0.03). For the top 11 logged procedures, URO-based GFCs logged more sacral neuromodulation cases (p = 0.02), whereas GYN-based GFCs logged more slings, vaginal hysterectomies, minimally-invasive hysterectomies, vaginal apical POP, vaginal posterior POP, vaginal anterior POP, and minimally-invasive apical POP cases (all p < 0.01). There was no difference between URO- and GYN-based GFCs for complex urodynamics, cystoscopy with botox injection, or periurethral injection cases. CONCLUSIONS: URO-based URPS fellows tend to graduate with more surgery on the urinary system and sacral neuromodulation cases, while GYN-based fellows perform more slings, hysterectomies, and POP surgery. These findings may help fellowships better understand potential differences in training among graduates from URO- and GYN-based programs and encourage collaboration to lessen these discrepancies.

RESUMEN

OBJECTIVE: This study explores the opportunities of social media advertisements as a recruitment strategy in women with stress urinary incontinence (SUI). STUDY DESIGN: This feasibility study was part of a larger clinical trial on the effects of a patient decision aid for SUI treatment. We started a 61-day social media advertisement campaign to recruit women for the trial. The primary outcome of our study was enrolment pace. Secondary outcomes involved cost per participant, baseline demographic comparison and ad campaign performance metrics. Additionally, we interviewed recruited participants to identify the facilitators and barriers of our approach. RESULTS: Ten participants were recruited, of whom 8 completed the full study protocol (2 questionnaires 6 months apart). The enrolment pace, 4.0 study participants per month, was faster compared to the average of 2.7 participants per month through conventional methods. The campaign reached 87 clicks on the advertisement per day and 1 % of these women showed interest in our study by contacting us. The overall conversion rate from click to full participation was 0.2 %. The costs per participant were €112. Besides higher age, the demographics of the social media recruited participants were comparable to the conventional inclusions. Qualitative analysis identified more user-oriented enrolment procedures and potential participant benefit as facilitators of social media recruitment. CONCLUSION: This study shows that social media recruitment can be feasible in trials for women with SUI. It can accelerate recruitment of eligible participants. Optimising the enrolment procedure to better meet participants' needs and recruitment benefits may improve participation and cost-effectiveness. Trial registration ID 2017-3540.

Asunto(s)

RESUMEN

OBJECTIVE: To evaluate the effectiveness of ChatGPT in providing insights into common urinary incontinence concerns within urogynecology. By analyzing the model's responses against established benchmarks of accuracy, completeness, and safety, the study aimed to quantify its usefulness for informing patients and aiding healthcare providers. METHODS: An expert-driven questionnaire was developed, inviting urogynecologists worldwide to assess ChatGPT's answers to 10 carefully selected questions on urinary incontinence (UI). These assessments focused on the accuracy of the responses, their comprehensiveness, and whether they raised any safety issues. Subsequent statistical analyses determined the average consensus among experts and identified the proportion of responses receiving favorable evaluations (a score of 4 or higher). RESULTS: Of 50 urogynecologists that were approached worldwide, 37 responded, offering insights into ChatGPT's responses on UI. The overall feedback averaged a score of 4.0, indicating a positive acceptance. Accuracy scores averaged 3.9 with 71% rated favorably, whereas comprehensiveness scored slightly higher at 4 with 74% favorable ratings. Safety assessments also averaged 4 with 74% favorable responses. CONCLUSION: This investigation underlines ChatGPT's favorable performance across the evaluated domains of accuracy, comprehensiveness, and safety within the context of UI queries. However, despite this broadly positive reception, the study also signals a clear avenue for improvement, particularly in the precision of the provided information. Refining ChatGPT's accuracy and ensuring the delivery of more pinpointed responses are essential steps forward, aiming to bolster its utility as a comprehensive educational resource for patients and a supportive tool for healthcare practitioners.

RESUMEN

IMPORTANCE: Social media platforms are increasingly utilized to distribute medical information. Our study emphasizes the need for accuracy in pelvic health education on social media and the involvement of female pelvic floor (FPF) specialists in content creation. AIMS: In this cross-sectional study, we assessed the FPF TikTok videos with the highest engagement for quality of information and misinformation and investigated the relationship between misinformation and user engagement. METHODS: We collected all TikTok videos on the US app with hashtags related to FPF conditions, including 76 on pelvic organ prolapse, 323 on urinary tract infection, 84 on overactive bladder, and 972 on incontinence. The top 20 videos for each FPF condition were selected based on highest engagement, and 74 videos total met inclusion criteria. TikTok videos were scored with the validated DISCERN instrument for quality of consumer health information and a 5-point Likert scale for misinformation. The correlation between misinformation and user engagement was assessed. RESULTS: Our analysis revealed positive correlations among higher average misinformation scores and shares (r = 0.37, p < 0.001), likes (r = 0.23, p = 0.004), and overall engagement (r = 0.25, p = 0.002) in FPF TikTok videos as a group, likely driven by the #UTI category. Most TikTok videos (96%) had poor quality of information (DISCERN score < 3), and 18% of TikTok videos contained misinformation. CONCLUSION: The poor quality and prevalence of misinformation in FPF-related TikTok videos with the highest engagement raise concerns about the propagation of nonevidence-based health information.

Asunto(s)

RESUMEN

Objective: Urogynecology patients skew older and often require intimate exams to treat non-life-threatening conditions, thus making care particularly susceptible to the effects of COVID-19. We aim to understand COVID-19 vaccination attitudes amongst urogynecology patients during the pandemic, which has adversely affected healthcare delivery, to identify measures that can be undertaken to improve care going forward. Study design: Cross-sectional surveys of urogynecology patients were conducted in three different states (Delaware, New Jersey, and Pennsylvania) between March and August 2021. Demographics, vaccination status, and COVID-19 attitudes were analyzed. Chi-square tests investigated group differences between vaccine-hesitant and unhesitant subjects. Results: Out of 158 surveys, eighty-three percent of respondents were vaccinated or planning to get vaccinated. Older age and regular flu vaccination predicted COVID-19 vaccination. Ninety-three percent of subjects were comfortable attending in-person visits. However, vaccine-hesitant individuals were less comfortable attending in-person and were significantly less likely to be comforted by clinic interventions, such as masking. Hesitant and unhesitant groups trusted doctors or medical professionals most for their source of COVID-19 information. Conclusions: Urogynecology patients mirror the general older population's COVID-19 vaccination attitudes, with distinct differences between hesitant and unhesitant groups. Vaccine-hesitant subjects appear less comfortable coming to in-person visits and less comforted by possible interventions, posing a difficult obstacle for clinics to overcome. High levels of patient trust suggest healthcare providers can play a crucial role in encouraging COVID-19 vaccination and combating misinformation.

RESUMEN

Recently, the debate surrounding the use of mesh in urogynecological procedures has intensified, leading to FDA warnings and heightened safety concerns. This clinical opinion emphasizes the vital need to specify mesh types in these procedures, drawing attention to the risk profiles and clinical outcomes associated with various meshes and the procedures that utilize them. A significant issue identified in contemporary literature is the tendency to group diverse mesh types under the same umbrella, disregarding their unique characteristics and applications. We describe the range of mesh types, their application routes, and associated complications, highlighting the risks of this nonspecific approach to patient safety and informed decision making. We critically examine the generalization of mesh terminology in clinical and research dialogues. Concluding with specific recommendations for health care providers and researchers, the paper advocates for a more nuanced understanding and communication in the field, ultimately aiming to improve patient care and safety in urogynecological practice.

RESUMEN

INTRODUCTION AND HYPOTHESIS: Training in urogynecology is an important mission of the International Urogynecological Association (IUGA). Promoting official training programs in countries around the world is an integral part of this mission. METHODS: The IUGA established the Fellowship Development Committee to develop a roadmap to assist countries to develop a professional training program in urogynecology. Two focus groups were created: the curricula topics focus group and the survey focus group. The curricula topics focus group is aimed at developing a list of subjects that can be the basis for a training syllabus. The survey focus group is aimed at understanding the main steps and the difficulties in establishing an official training program by interviewing representatives from both accredited and non-accredited countries and developing a roadmap for an official training program recognized by the local authorities. RESULTS: The fellowship development committee included 13 members. The curricula topics focus group developed a format for the description of each included topic. Each topic had to include a description of the required related skills and procedures. Two curricula topics lists were created: one for basic training and a second for advanced training. The survey focus group conducted two table discussions with representatives from countries with accredited training programs and countries without accredited training programs. The comments of these meetings were summarized in documents submitted to the IUGA board of directors. CONCLUSION: The fellowship development committee studied the main hurdles to developing an official training program in urogynecology. The roadmap document should form the basis of the IUGA international initiative to assist countries around the world to develop an official training program in urogynecology recognized by the local authority.

Asunto(s)

RESUMEN

OBJECTIVES: The purpose of this systematic review is to present and compare results from studies that have been using autologous tissue for POP repair. METHODS: Systematic review was done according to the Cochrane Handbook for Systematic Reviews. We aimed to retrieve reports of published and ongoing studies on the efficacy and safety of autologous tissue in vaginal vault prolapse repair. The databases searched were MEDLINE (PubMed interface), Scopus, Cohrane Central Register of Controlled Trials (CENTRAL) and ClinicalTrials.gov. RESULTS: The success rate varied among studies. In fascia-lata group success rate reports varied from 83 to a 100%, with a median follow-up from 12 to 52 months among studies. Rectus fascia reported success rates from 87 to a 100% with a follow-up of 12 months to longest of 98 months. CONCLUSION: Autologous tissues show satisfying outcomes in terms of safety and efficacy. Sacrocolpopexy procedure with fascia lata has better outcome in term of treatment of prolapse. Harvesting place on lateral side of buttock has more complications in comparison with rectus fascia but size of the graft can be wider in fascia-lata group.

Asunto(s)

RESUMEN

Pelvic organ prolapse (POP) is a very common problem that can affect any aspect of the pelvic floor. Often, vaginal and rectal prolapse occur simultaneously. Prior case reports have suggested resolution of symptoms of rectal prolapse in those with concomitant rectal and vaginal prolapse; however, the overall body of evidence is limited. We present the cases of two patients who had complete resolution of their symptoms of rectal prolapse after repair of a concomitant vaginal prolapse. Both patients underwent a traditional rectocele repair and perineoplasty, and subsequently reported complete resolution of their symptoms of rectal prolapse, which persisted at their six-month post-operative visits. The second patient ultimately canceled a previously scheduled rectopexy with colorectal surgery. Perhaps a rectocele repair with perineoplasty is limiting rectal mobility, and therefore eliminating its ability to prolapse or intussuscept and cause bothersome symptoms. We suggest that those with concomitant vaginal and rectal prolapse desiring corrective surgery first undergo a less invasive vaginal repair. Post-operative re-evaluation of the symptoms rectal prolapse might then demonstrate that a more invasive rectal prolapse repair, which may involve a colon resection and prolonged hospital stay, was not in fact needed. Further prospective and randomized study is needed to determine the long-term outcomes of concomitant rectal and vaginal prolapse in those who first undergo a vaginal repair.

RESUMEN

BACKGROUND: Obstructed labor leading to a vesicovaginal fistula remains a devastating outcome of childbirth in low-resource countries. Women with an irreparable vesicovaginal fistula may be candidates for a urinary diversion, such as the Mainz II modified ureterosigmoidostomy procedure. Previous reviews state that the procedure should be considered in low-resource countries. However, given the limited duration of postoperative follow-up, these studies do not adequately represent the long-term morbidity and mortality that is likely associated with this procedure. We present data that strongly support avoiding the procedure in low-resource countries. OBJECTIVE: This study aimed to evaluate the postoperative status of the patient (dead, alive, lost to follow-up) and time to death following the Mainz II procedure. STUDY DESIGN: This is a case series including 21 patients who underwent a Mainz II urinary diversion from April 2013 to June 2015 for management of irreparable vesicovaginal fistula at the Fistula Care Centre in Lilongwe, Malawi. Patients were seen postoperatively at 3, 6, 9, and 12 months, followed by every 6 to 12 months thereafter. Descriptive statistics were performed to summarize the data. RESULTS: During the postoperative period, 8 (38.1%; 8/21) patients died, 5 (23.8%; 5/21) were lost to follow-up, and 8 (38.1%; 8/21) are currently alive and followed up at the Fistula Care Centre. We strongly suspect that 7 of the 8 deaths were related to the procedure given that the patients had illnesses that exacerbated the metabolic consequences of the procedure. The eighth patient died after being attacked by robbers. Unfortunately, the exact cause of death could not be determined for these patients. Given that most of the suspected illnesses would be treatable in an otherwise healthy patient, even in this low-resource setting, we surmised that the metabolic compromise from the Mainz II procedure likely contributed to their untimely death. The average time from procedure to death was 58 months, with the earliest death at 10 months and the most recent at 7 years after the procedure. CONCLUSION: The Mainz II procedure is an option for patients with irreparable fistula. However, it should likely not be performed in low-resource countries given the long-term complications that often cannot be adequately addressed in these settings, leading to significant morbidity and mortality.