Publications by authors named "Rodolfo Milani"

95 Publications

Transvaginal primary layered repair of postsurgical urethrovaginal fistula.

Int Urogynecol J 2021 May 5. Epub 2021 May 5.

ASST Monza, Ospedale San Gerardo, via G.B. Pergolesi, 33 20900, Monza, Italy.

Introduction And Hypothesis: Urethrovaginal fistula (UVF) is a rare disorder, which implies the presence of an abnormal communication between the urethra and the vagina.

Methods: Surgical repair options include transurethral, transabdominal and transvaginal procedures, either with or without tissue interposition. The vaginal route is considered a safe and effective option to correct UVF. This video is aimed to present a case of direct transvaginal layered repair of urethrovaginal fistula, without the use of tissue interposition. The featured patient is a 66-year-old woman who developed a symptomatic UVF after a complicated laparoscopic hysterectomy for endometrial cancer 3 years before. Cystoscopy demonstrated the presence of a 7 mm urethral orifice a few millimeters caudal from the bladder neck. After proper informed consent, the patient was admitted to transvaginal primary layered repair, according to the technique demonstrated in the video. The featured procedure was completed in 60 min and blood loss was < 100 ml. No surgical complications were observed.

Results: The procedure was successful in restoring the anatomy and relieving the symptoms.

Conclusion: Transvaginal layered repair without tissue interposition represents a safe and effective procedure for the surgical management of postsurgical urethrovaginal fistula.
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http://dx.doi.org/10.1007/s00192-021-04819-6DOI Listing
May 2021

Inability to walk and persistent thigh pain after transobturator tape procedure for stress urinary incontinence: surgical management.

Int Urogynecol J 2021 May 3;32(5):1317-1319. Epub 2021 Mar 3.

ASST Monza, Ospedale San Gerardo, via G.B. Pergolesi, 33 20900, Monza, Italy.

Introduction And Hypothesis: Groin pain after transobturator tape is often a self-limiting situation, but can occasionally persist and be associated with serious neurological sequelae. The video is aimed at presenting the surgical management of persistent groin pain and inability to walk after transobturator sling placement and subsequent partial removal.

Methods: The featured patient is a 31-year-old woman unable to walk after transobturator sling implantation 2 years before. She reported left thigh pain immediately after surgery that was not responsive to postoperative medication. Six months later, suburethral portion excision was performed but no pain relief was obtained. She was unable to walk, and needed a wheelchair. Electromyography showed axonal injury of the left obturator nerve. After providing proper informed consent, the patient was admitted for combined transvaginal and transcutaneous transobturator tape arm removal.

Results: The featured procedure was completed in 120 min and blood loss was <100 ml. No surgical complications were observed. The patient is currently doing left leg rehabilitation, has regained the ability to walk with the aid of a crutch, and the need for chronic pain control medication is greatly reduced.

Conclusion: This represents a valid surgical approach for the late management of this mesh-related complication.
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http://dx.doi.org/10.1007/s00192-020-04666-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7927782PMC
May 2021

Single-incision slings for the treatment of stress urinary incontinence: efficacy and adverse effects at 10-year follow-up.

Int Urogynecol J 2021 Jan 9;32(1):187-191. Epub 2020 Sep 9.

ASST Santi Paolo e Carlo, Ospedale San Paolo, via Antonio di Rudini, Milan, Italy.

Introduction And Hypothesis: Single-incision slings are not considered a first-choice surgical treatment owing to a lack of data about long-term outcomes. We aimed to assess the long-term results of urinary incontinence treatment after single-incision sling implantation at 10 years' follow-up and to investigate possible deterioration over time.

Methods: This retrospective study analyzed women with subjective and urodynamically proven stress urinary incontinence who underwent single-incision sling procedure. The objective cure rate was assessed with a 300-ml stress test. The subjective cure rate was determined by the Patient Global Impression of Improvement (PGI-I) questionnaire. International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire scores and self-answered patient-satisfaction scales were collected to assess symptom severity. Findings were compared with short-term outcomes in the same patients, available through our previous database, in order to detect possible outcome deterioration over time.

Results: The records of 60 patients were analyzed. Nine patients (15%) were lost to follow-up. A total of 51 patients completed the evaluation, with a mean follow-up of 10.3 ± 0.7 years. Objective and subjective cure resulted 86.3% and 88.2% respectively. Mean PGI-I scores and ICIQ-SF were 1.5 ± 1.0 and 3.2 ± 4.8 respectively. Patients' satisfaction scored 8.6 ± 2.6 out of 10. No long-term complications occurred. Comparison of short-term (2.6 ± 1.4 years after surgery) and long-term follow-up did not show a significant deterioration of outcome over time.

Conclusions: Single-incision slings were shown to be a procedure with a great efficacy and safety profile at very long-term follow-up. Cure rates and functional outcomes did not show any deterioration over time compared with short-term results.
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http://dx.doi.org/10.1007/s00192-020-04499-8DOI Listing
January 2021

Surgical management of bladder erosion and pelvic pain after laparoscopic lateral suspension for pelvic organ prolapse.

Int Urogynecol J 2020 04 5;31(4):843-845. Epub 2020 Mar 5.

ASST Monza, San Gerardo Hospital, Monza, Italy.

Introduction And Hypothesis: Mesh-augmented lateral suspension for prolapse repair seems to be associated with few complications. However, mesh-related complications can negatively affect the quality of life and may be challenging to manage. This video is aimed at presenting the surgical management of a case of severe pelvic pain and dyspareunia after lateral laparoscopic suspension associated with mesh erosion in the bladder.

Methods: A 46-year-old woman was referred to our Unit for severe pelvic pain and inability to have sexual intercourses since undergoing a uterus-sparing laparoscopic lateral suspension procedure for genital prolapse 2 years before in another hospital. Moreover, she reported bladder pain and recurrent urinary tract infections. Cystoscopy showed mesh erosion in the bladder. She was admitted to laparoscopic hysterectomy plus subtotal mesh excision and bladder reconstruction (video).

Results: No surgical complications were observed. The postoperative course was uneventful. At the current follow-up, the patient reported complete resolution of her symptoms.

Conclusion: The featured video shows laparoscopic subtotal mesh excision, concomitant hysterectomy and bladder repair for pelvic pain, dyspareunia and bladder erosion after lateral suspension. This video may be useful in providing anatomical views and surgical steps necessary for achieving successful surgical management of this mesh-related complication.
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http://dx.doi.org/10.1007/s00192-020-04261-0DOI Listing
April 2020

Locally-advanced vaginal cancer with complete utero-vaginal prolapse.

Int J Gynecol Cancer 2020 05 5;30(5):705-708. Epub 2020 Mar 5.

Department of Radiotherapy, San Gerardo Hospital, Monza, Italy.

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http://dx.doi.org/10.1136/ijgc-2020-001326DOI Listing
May 2020

Surgical treatment of complete uterovaginal prolapse and concomitant vaginal cancer: a video case report.

Int Urogynecol J 2020 08 3;31(8):1703-1705. Epub 2020 Mar 3.

ASST Monza, Ospedale San Gerardo, Monza, Italy.

Introduction And Hypothesis: The concurrence of vaginal cancer with irreducible uterine prolapse is rare. Reports about the management of vaginal cancer and concomitant irreducible prolapse are scanty in the literature, and there is no consensus on optimal treatment. In this video case report, we show surgical management of vaginal cancer and concomitant stage IV uterovaginal prolapse.

Methods: The featured video shows surgical management of vaginal cancer and concomitant stage IV uterovaginal prolapse through anterior colpectomy and retrograde hysterectomy en bloc plus transvaginal levator ani plication as a non-obliterative native-tissue technique for apical support.

Results: Final examination revealed good apical support and vaginal "habitability" preservation. The patient underwent five sessions of intracavity brachytherapy for a total of 20 Gy as adjuvant therapy.

Conclusion: Surgical management of vaginal cancer and concomitant stage IV uterovaginal prolapse was successfully achieved without complications. Transvaginal levator ani plication can provide a versatile non-obliterative native-tissue technique for apical support, allowing subsequent adjuvant brachytherapy.
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http://dx.doi.org/10.1007/s00192-020-04263-yDOI Listing
August 2020

Surgical excision of paraurethral cyst.

Int Braz J Urol 2020 Mar-Apr;46(2):298-299

Department Ginecologia Chirurgica, San Gerardo Hospital, Monza, Italy.

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http://dx.doi.org/10.1590/S1677-5538.IBJU.2018.0761DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7025852PMC
May 2020

Transvaginal uterosacral ligament hysteropexy versus hysterectomy plus uterosacral ligament suspension: a matched cohort study.

Int Urogynecol J 2020 09 17;31(9):1867-1872. Epub 2019 Dec 17.

Department of Obstetrics and Gynaecology, San Gerardo Hospital, ASST Monza, Monza, Italy.

Introduction And Hypothesis: Uterine-sparing procedures are associated with shorter operative time, less blood loss and faster return to activities. Moreover, they are attractive for patients seeking to preserve fertility or concerned about the change of their corporeal image and sexuality after hysterectomy. This study aimed to compare outcomes of transvaginal uterosacral hysteropexy with transvaginal hysterectomy plus uterosacral suspension.

Methods: This retrospective study compared all patients who underwent uterosacral hysteropexy for symptomatic prolapse at our institute to matched control patients who underwent hysterectomy plus uterosacral ligament suspension. Anatomic recurrence was defined as postoperative prolapse stage ≥ II or reoperation for prolapse. Subjective recurrence was defined as the presence of bulging symptoms. PGI-I score was used to evaluate the patients' satisfaction.

Results: One hundred four patients (52 for each group) were analyzed. Mean follow-up was 35 months. Hysteropexy was associated with shorter operative time and less bleeding compared with hysterectomy (p < 0.0001), without differences in complication rates. Moreover, overall anatomic and subjective cure rate and patient satisfaction were similar between groups. However, hysteropexy was found to be associated with a significantly higher central recurrence rate (21.2% versus 1.9%, p = 0.002), mostly related to cervical elongation, and subsequently a higher reoperation rate (13.5% versus 1.9%, p = 0.04). A 42.9% pregnancy rate in patients still desiring childbirth was found.

Conclusions: Transvaginal uterosacral hysteropexy resulted in similar objective and subjective cure rates, and patient satisfaction, without differences in complication rates, compared with vaginal hysterectomy. However, postoperative cervical elongation may lead to higher central recurrence rates and need for reoperation.
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http://dx.doi.org/10.1007/s00192-019-04206-2DOI Listing
September 2020

Surgical management of dyspareunia after laparoscopic lateral suspension for pelvic organ prolapse.

Eur J Obstet Gynecol Reprod Biol 2020 Jan 1;244:205. Epub 2019 Nov 1.

AUSL Romagna, Infermi Hospital, Rimini, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.ejogrb.2019.10.044DOI Listing
January 2020

Transvaginal hysteropexy to levator myorrhaphy: A novel technique for uterine preservation.

Int J Gynaecol Obstet 2020 01 16;148(1):125-126. Epub 2019 Oct 16.

ASST Monza, Ospedale San Gerardo, University of Milano-Bicocca, Monza, Italy.

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http://dx.doi.org/10.1002/ijgo.12989DOI Listing
January 2020

Long-term outcomes and five-year recurrence-free survival curves after native-tissue prolapse repair.

Int J Gynaecol Obstet 2019 Nov 22;147(2):238-245. Epub 2019 Aug 22.

School of Medicine, University Milano-Bicocca, Milan, Italy.

Objective: To evaluate the long-term objective and subjective outcomes to build recurrence-free survival curves after mesh-free uterosacral ligament suspension and to evaluate the long-term impact of prognostic factors on outcome measures.

Methods: A retrospective study analyzed 5-year follow-up after repair of primary prolapse through high uterosacral ligament suspension. Bulging symptoms and post-operative prolapse stage II or above were considered subjective and objective recurrences, respectively. The cumulative proportion of relapse-free patients in time was analyzed by Kaplan-Meier curves.

Results: A total of 353 women were analyzed. Five-year recurrence rates were 15.0% for objective recurrence, 13.0% for subjective recurrence, and 4.0% for the combined objective and subjective recurrences. Premenopausal status was shown to be a risk factor for anatomic (P=0.022), symptomatic (P=0.001), and combined (P=0.047) recurrence. Conversely, anterior repair was shown to be a protective factor for symptomatic (P=0.012) and combined (P=0.002) recurrence. Most of the recurrences occurred within 2 years after surgery.

Conclusion: Long-term outcomes after high uterosacral ligament suspension were satisfactory. Premenopausal status and lack of anterior repair represented risk factors for recurrence in the long term.
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http://dx.doi.org/10.1002/ijgo.12938DOI Listing
November 2019

Pelvic organ prolapse and voiding function before and after surgery.

Minerva Ginecol 2019 Jun 6;71(3):253-256. Epub 2019 Feb 6.

ASST Monza, San Gerardo Hospital, Monza, Italy.

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http://dx.doi.org/10.23736/S0026-4784.19.04313-2DOI Listing
June 2019

Risk factors for persistent, de novo and overall overactive bladder syndrome after surgical prolapse repair.

Eur J Obstet Gynecol Reprod Biol 2019 Feb 26;233:141-145. Epub 2018 Dec 26.

ASST Monza, Ospedale San Gerardo, Monza, Italy.

Objective: Overactive bladder (OAB) symptoms are frequently associated with pelvic organ prolapse (POP) and both postoperative improvement and de novo onset of OAB symptoms have been described. The aim of the study is to identify risk factors for persistent, de novo and overall postoperative OAB after POP repair.

Study Design: This was a retrospective study including patients who underwent primary POP surgery. Medical interview, urogenital examination and urodynamics were performed preoperatively; patients were examined one and six months after surgery and then yearly.

Results: 518 patients were included. 36.1% of women preoperatively complained of OAB symptoms while detrusor overactivity was found in 20.5%. The rate of persistent and de novo OAB after surgery were respectively 14.1% and 13.5%. Multivariate analysis found age, BMI, preoperative OAB, sling placement and postoperative SUI as independent risk factors for overall OAB after surgery. Moreover, preoperative OAB and postoperative constipations were associated with OAB persistence after surgery. Finally, age, sling placement, postoperative SUI and voiding symptoms were independently associated with de novo OAB.

Conclusion: Preoperative OAB symptoms are associated with OAB persistence after POP surgery, while age and sling placement correlate with de novo OAB. Finally, increased BMI is related to postoperative OAB.
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http://dx.doi.org/10.1016/j.ejogrb.2018.12.024DOI Listing
February 2019

Efficacy of needle retractor device in single-incision slings for treatment of stress urinary incontinence.

Minerva Ginecol 2018 Dec 26;70(6):724-728. Epub 2018 Sep 26.

ASST Monza, San Gerardo Hospital, Monza, Italy.

Background: Single-incision slings demonstrated overall similar effectiveness and less pain and recovery time compared to standard tapes. Efficacy rates vary widely among different commercial kits and may be affected by device characteristics. The aim was to evaluate the impact needle removal device of single-incision sling on objective, subjective and functional outcomes.

Methods: This was a retrospective study. Single-incision sling without needle removal device (Group A) were compared to same single-incision sling with needle removal device (Group B) in terms of complications, objective, subjective and functional outcomes.

Results: A total of 191 patients were analyzed: 51 in group A and 140 in group B. Estimated blood loss, operative time and overall complications were not different. No bladder perforation or other intraoperative complications were observed. At 12-month follow-up visit, objective cure rate was similar irrespective of the presence of the needle retractor lever (Group A: 84.3%, Group B: 87.1%; P=0.61). Subjective outcomes evaluated as International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score, ICIQ-SF score improvement and Patient Global Impression of Improvement score were similar between groups. De-novo onset of overactive bladder syndrome resulted more frequent in Group A (Group A: 19.6%, Group: B 7.9%; P=0.02) while voiding symptoms were reported without differences between groups.

Conclusions: The current study showed that the presence of a needle retractor device to avoid unintentional tip displacement for single-incision sling had no impact on objective and subjective postoperative continence. However, a reduced rate of de-novo overactive bladder syndrome was observed after implantation of single-incision sling with needle retractor.
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http://dx.doi.org/10.23736/S0026-4784.18.04207-7DOI Listing
December 2018

Transvaginal native-tissue repair of enterocele.

Int Urogynecol J 2018 Nov 22;29(11):1705-1707. Epub 2018 Jun 22.

ASST Monza, San Gerardo Hospital, Monza, Italy.

Introduction And Hypothesis: Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).

Methods: A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.

Results: Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.

Conclusions: Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.
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http://dx.doi.org/10.1007/s00192-018-3686-3DOI Listing
November 2018

Gluteo-vaginal fistula after prolapse mesh surgery.

Eur J Obstet Gynecol Reprod Biol 2018 06 30;225:266-267. Epub 2018 Apr 30.

ASST Monza, Ospedale San Gerardo, Monza, Italy.

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http://dx.doi.org/10.1016/j.ejogrb.2018.04.035DOI Listing
June 2018

Outcomes of Transvaginal High Uterosacral Ligaments Suspension: Over 500-Patient Single-Center Study.

Female Pelvic Med Reconstr Surg 2018 May/Jun;24(3):203-206

Background: Uterosacral ligament (USL) suspension is a safe and effective procedure in terms of anatomical, functional, and subjective outcomes for primary surgical treatment of prolapse.

Objectives: There has been a renewed interest toward native tissue prolapse repair by vaginal route because of low cost and lack of mesh-related complications. Uterosacral ligaments are considered safe, effective, and durable as suspending structures for primary surgical repair of the apical compartment. Our aim was to evaluate complications, anatomical, functional and subjective outcomes of high USL suspension for primary prolapse repair.

Methods: Data of patients who underwent vaginal hysterectomy followed by high USL suspension for pelvic organ prolapse were retrospectively analyzed. Operative data, as well as complications, were recorded. Anatomical recurrence was defined as descent of any compartment stage II or greater according to the Pelvic Organ Prolapse Quantification system. Functional outcomes focused on urinary, bowel, and sexual dysfunctions. International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, Wexner, and Patient Global Impression of Improvement questionnaires were collected.

Results: Data of 533 women were analyzed. Mean follow-up was 32 (SD, 19) months (dropout rate, 2.6%). Most frequent complication was ureteral kinking (2.6%). Total recurrence rate was 13.7%, with anterior compartment being the most frequent (9.4%), whereas reoperation for symptomatic prolapse recurrence was required in only 1% of patients. Improvement of urinary incontinence, voiding dysfunction, constipation, and dyspareunia was observed. Overall subjective satisfaction was high (Patient Global Impression of Improvement score, 1.3), ranging from "much improved" to "very much improved."

Conclusions: Uterosacral ligament suspension is a safe and effective procedure in primary surgical treatment of pelvic organ prolapse. Anatomical, functional, and subjective outcomes were very satisfactory, and reoperation rate for recurrence was only 1%.
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http://dx.doi.org/10.1097/01.spv.0000533751.41539.5bDOI Listing
February 2019

Management of unrecognized bladder perforation following suburethral tape procedure.

Int J Gynaecol Obstet 2018 07 14;142(1):118-119. Epub 2018 Apr 14.

San Gerardo Hospital, Monza, Italy.

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http://dx.doi.org/10.1002/ijgo.12493DOI Listing
July 2018

Quality of life in women with advanced pelvic organ prolapse treated with Gellhorn pessary.

Minerva Ginecol 2018 08 13;70(4):490-492. Epub 2018 Feb 13.

ASST Monza, San Gerardo Hospital, Monza, Italy.

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http://dx.doi.org/10.23736/S0026-4784.18.04199-0DOI Listing
August 2018

Transvaginal native-tissue repair of vaginal vault prolapse.

Minerva Ginecol 2018 Aug 26;70(4):371-377. Epub 2018 Jan 26.

Department of Obstetrics and Gynecology, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy -

Background: Posthysterectomy vaginal vault prolapse repair is a challenge for pelvic floor surgeons. Native-tissue repair procedures imply lower costs and reduced morbidity. Our study aims to evaluate operative data, complications, objective, subjective and functional outcomes of transvaginal native-tissue repair for posthysterectomy vaginal vault prolapse. We also investigated differences among available techniques.

Methods: Retrospective study including patients with symptomatic vaginal vault prolapse (≥stage 2), previously treated with transvaginal vault suspension through native-tissue repair. Objective recurrence was defined as the descent of at least one compartment ≥II stage according to Pelvic Organ Prolapse Quantification (POP-Q) system or need of reoperation. Subjective recurrence was defined as the presence of bulging symptoms. Patients satisfaction was evaluated with PGI-I Score.

Results: The study included 111 patients. Apical suspension was achieved either by uterosacral ligament suspension (16), levator myorrhaphy (17), iliococcygeus fascia fixation (65) or sacrospinous ligament fixation (13). No intraoperative complications were observed. Perioperative/postoperative complications occurred in 8 patients (7.2%). Mean follow-up was 24.5±12.1 months. Objective recurrence was observed in 28 patients (25.2%). Reintervention was required by 3 patients (2.7%). Subjective recurrence was referred by 6 patients (5.4%). Mean satisfaction evaluated with PGI-I Score was 1.2±0.6. No differences in terms of operative data, overall complications, objective, subjective cure rate and perceived satisfaction were found among different techniques.

Conclusions: Transvaginal repair with native-tissue procedures is safe and effective in correcting posthysterectomy vaginal vault prolapse and represents a valid alternative to prosthetic procedures for vaginal vault prolapse treatment.
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http://dx.doi.org/10.23736/S0026-4784.18.04191-6DOI Listing
August 2018

Risk factors for stress urinary incontinence recurrence after single-incision sling.

Neurourol Urodyn 2018 06 17;37(5):1711-1716. Epub 2018 Jan 17.

University of Milano-Bicocca, ASST Monza, San Gerardo Hospital, Monza, Italy.

Aims: The aim of the study was to identify in a pure stress urinary incontinence (SUI) population risk factors for recurrence after single-incision slings (SIS).

Methods: This retrospective study analyzed women with complaints of SUI symptoms and urodynamically proven SUI. Exclusion criteria were recurrent SUI, overactive bladder syndrome/detrusor overactivity, preoperative postvoid residual >100 mL, reduced urethral mobility (<10° at the Q-tip test), concomitant anterior prolapse >I stage and previous history of radical pelvic surgery. Objective cure rate was assessed with stress test.

Results: A total of 192 patients were analyzed. Objective cure rate was obtained in 86.5% of patients. According to univariate analysis, recurrences had higher prevalence of severe ICIQ-SF score (≥18 points), higher prevalence of reduced urethral mobility (Qtip ≤30°), higher prevalence of low detrusor pressures during voiding phase (opening pressure <15 cmH O, pressure at maximum flow <20 cmH O, closing pressure <15 cmH O), and higher prevalence of postoperative complications According to multivariate analysis ICIQ-SF score ≥18 points (P = 0.02; OR = 2.7) and detrusor pressure at maximum flow <20 cmH O (P < 0.01; OR = 3.6) resulted as independent risk factors for SUI recurrence (Table 3). A trend was found for urethral mobility ≤30° (P = 0.07; OR = 2.2).

Conclusions: Our study identifies SUI severity expressed with ICIQ-SF scores and low detrusor pressure at maximum flow as independent risk factors for SUI recurrence after SIS implantation while only a trend was found for reduced urethral mobility. Therefore, preoperative assessment of symptoms and urodynamics evaluation may play a key role in improving preoperative counseling and tailoring surgical treatment.
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http://dx.doi.org/10.1002/nau.23487DOI Listing
June 2018

Risk factors for stress urinary incontinence after native-tissue vaginal repair of pelvic organ prolapse.

Int J Gynaecol Obstet 2018 Jun 2;141(3):349-353. Epub 2018 Feb 2.

ASST Monza, Ospedale San Gerardo, Monza, Italy.

Objective: To identify risk factors for postoperative stress urinary incontinence (POSUI) after native-tissue prolapse repair without a concomitant anti-incontinence procedure.

Methods: The present single-center retrospective study included women with genital prolapse who underwent high uterosacral ligament suspension without a concomitant anti-incontinence procedure during 2008-2013. Univariate and multivariate analyses were performed to identify risk factors for POSUI (identified through clinical interview and International Consultation on Incontinence Modular Questionnaire-Short Form [ICIQ-SF] self-administration) at 6 months.

Results: In total, 87 (20.9%) of 417 women developed POSUI. Preoperative stress urinary incontinence (SUI) and urodynamically diagnosed SUI were significantly associated with POSUI; moreover, women with POSUI had a higher preoperative ICIQ-SF score, a lower opening detrusor pressure, and a lower detrusor pressure at maximum flow than did women without POSUI (P<0.05 for all comparisons). In the multivariate analysis, preoperative SUI (odds ratio 3.11), a detrusor pressure at maximum flow of less than 30 cm H O (odds ratio 2.93), and urodynamically diagnosed SUI (odds ratio 2.26) were independent risk factors for POSUI.

Conclusion: Preoperative urodynamic parameters, obtained before prolapse repair surgery, were associated with POSUI and could be useful in providing adequate counseling to facilitate decision making on whether to add a concomitant anti-incontinence procedure.
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http://dx.doi.org/10.1002/ijgo.12443DOI Listing
June 2018

Incidence and risk factors of third- and fourth-degree perineal tears in a single Italian scenario.

Eur J Obstet Gynecol Reprod Biol 2018 Feb 26;221:139-143. Epub 2017 Dec 26.

ASST Monza, Ospedale San Gerardo, Monza, Italy; School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Italy.

Objective: This study aimed to evaluate III and IV degree tears rates and related risk factors in a single Italian centre. The secondary goal was to build a predictive model based on identified risk factors.

Study Design: This was a retrospective cohort study. All vaginal deliveries from 2011 to 2015 in a single Italian University Hospital were analysed. Univariate analysis was applied to evaluate the overall association between each factor and severe tear. Multivariate logistic regression was used to build a predictive model for the absolute risk of severe tear. We computed a resampling validated measure (AUC) of the predictive accuracy of the model and we provided a nomogram for the risk calculation in clinical practice.

Results: 62 out of 10133 patients (0.61%) had a severe perineal tear. Univariate analysis identified gestational age >40 weeks, nulliparity, moderate/severe obesity, oxytocin use in pushing stage, sinciput presentation, instrumental delivery, shoulder dystocia, pushing stage ≥90 min, lithotomy position, birth weight >4 kg, head circumference at birth >34 cm and length at birth >50 cm as risk factors. Multivariate analysis identify moderate/severe obesity (OR = 2.8), instrumental delivery (OR = 2.6) and birth weight (OR = 1.1/hg) as independent risk factors. Using the predicted risk score from the final model (bootstrap-validated AUC 70%), we designed a nomogram for severe perineal tears absolute risk calculation.

Conclusion: Moderate/severe obesity, instrumental delivery and foetal weight resulted as independent risk factors for severe obstetrical tears.
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http://dx.doi.org/10.1016/j.ejogrb.2017.12.042DOI Listing
February 2018

Detrusor underactivity in pelvic organ prolapse.

Int Urogynecol J 2018 08 21;29(8):1111-1116. Epub 2017 Dec 21.

ASST Monza, Ospedale San Gerardo, U.O. Ginecologia, Via Pergolesi, 33, 20900, Monza, MB, Italy.

Introduction And Hypothesis: The association between pelvic organ prolapse (POP) and detrusor underactivity (DU) is not well defined. The primary outcome of this study was to evaluate the prevalence of DU in a cohort of patients with POP and its association with symptoms, anatomy. and urodynamic findings. The secondary outcome was to evaluate the evolution of lower urinary tract symptoms after POP repair between DU and non-DU patients.

Methods: Consecutive patients who underwent preoperative urodynamic tests were retrospectively analyzed. Detrusor underactivity was evaluated by the Bladder Contractility Index (BCI = pDetQmax + Qmax × 5) proposed by Abrams. A BCI < 100 was considered indicative of an underactive bladder. Patients with underactive bladder were considered group A, whereas the remaining patients were classified as group B.

Results: A total of 518 patients were studied. According to BCI, detrusor underactivity was identified in 212 (40.9%) patients (group A). Group A showed higher rates of voiding symptoms (59.4% vs 36.3%, p < 0.0001) and positive (>100 ml) postvoid residual (29.7% vs 9.8%, p < 0.0001). Conversely, they displayed lower rates of urge incontinence (15.1% vs 23.2%, p = 0.02) and detrusor overactivity (15.6% vs 23.9%, p = 0.02). Preoperative Pelvic Organ Prolapse Quantification (POP-Q) demonstrated greater Aa (+1.1 ± 1.5 vs +0.9 ± 1.5, p = 0.03) and Ba (+1.4 ± 1.7 vs +1.2 ± 1.7, p = 0.04) points values in patients in group A. After POP surgery, postoperative voiding symptoms were similar in the two groups (16% vs 15.7%, p = 0.91).

Conclusions: Our study showed a 40.9% prevalence of DU in POP patients. DU was associated with the presence of voiding symptoms and positive PVR. Moreover, cystocele showed to be more severe in DU group. After surgical repair of POP, voiding symptoms of DU patients became equal to non-DU ones, suggesting that obstruction removal might recover DU in these patients.
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http://dx.doi.org/10.1007/s00192-017-3532-zDOI Listing
August 2018

Transvaginal levator myorrhaphy for posthysterectomy vaginal vault prolapse repair.

Int Urogynecol J 2018 Jun 14;29(6):913-915. Epub 2017 Dec 14.

ASST Monza, Ospedale San Gerardo, Monza, Italy.

Introduction And Hypothesis: Posthysterectomy vaginal vault prolapse repair represents a surgical challenge. Surgical management can be successfully achieved with native-tissue repair through levator myorrhaphy. Despite low morbidity, levator myorrhaphy is not a common procedure. The aim of the video is to provide anatomic views and surgical steps necessary to achieve a successful transvaginal levator myorrhaphy for vaginal vault prolapse repair.

Methods: A 72-year-old woman with symptomatic stage IV vaginal vault prolapse was admitted for transvaginal levator myorrhaphy according to the described technique.

Results: Surgical repair was successfully achieved without complications. The final examination revealed good apical support and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know how.

Conclusions: Transvaginal levator myorrhaphy provides an alternative technique for apical support without using prosthetic materials. This technique can be indicated when abdominal approach or synthetic device are not recommended or when peritoneum opening may be challenging. However, due to its possible constricting effect, it should be reserved to sexually inactive patients.
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http://dx.doi.org/10.1007/s00192-017-3526-xDOI Listing
June 2018

Repair of a vesicouterine fistula following cesarean section.

Int Urogynecol J 2018 02 16;29(2):309-311. Epub 2017 Nov 16.

Department of Obstetrics and Gynaecology, San Gerardo Hospital, University of Milano-Bicocca, Via Pergolesi 33, Monza, MB, Italy.

Introduction And Hypothesis: Vesicouterine fistula is a rare complication of cesarean section. The aim of this video is to present a case report and to provide a tutorial on the surgical technique of delayed transvaginal repair of a high vesicouterine fistula that developed after cesarean section with manual removal of a morbidly adherent placenta.

Methods: A 43-year-old woman was referred to our unit for continuous urinary leakage 3 months after undergoing a cesarean section with manual removal of a morbidly adherent placenta. A vesicouterine fistula starting from the posterior bladder wall was identified. The surgical repair consisted of a transvaginal layered repair as shown in the video.

Results: No surgical complications were observed postoperatively. Two months after surgery the fistula had not recurred and the patient reported no urinary leakage.

Conclusions: Transvaginal layered primary repair of vesicouterine fistula was shown to be a safe and effective procedure for restoring continence. The vaginal route can be particularly attractive for urogynecological surgeons.
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http://dx.doi.org/10.1007/s00192-017-3506-1DOI Listing
February 2018

Tips and tricks for uterosacral ligament suspension: how to avoid ureteral injury.

Int Urogynecol J 2018 01 16;29(1):161-163. Epub 2017 Oct 16.

AUSL della Romagna - Ospedale Infermi, Rimini, Italy.

Introduction And Hypothesis: Uterosacral ligament (USL) suspension is an effective and versatile surgical technique for repairing pelvic organ prolapse. However, ureteral injury is a feared complication that may act as a significant deterrent to the use of USL suspension. The aim of the video is to provide key steps to minimize the risk of ureteral injury while achieving successful transvaginal USL suspension.

Methods: The featured video provides a series of surgical tips and tricks that can be applied to protect the ureters while achieving USL suspension whether the procedure contemplated is vaginal hysterectomy, vaginal vault repair after hysterectomy, or hysteropexy.

Results: The tips and tricks are classified into four categories: identification of the USLs, identification of the ureters, passage of the sutures, and final measures.

Conclusions: The USL suspension technique requires adequate surgical training and an understanding of pelvic anatomy. This tips and tricks video tutorial may be an important tool for improving surgical know-how, and thus for reducing the risk of ureteral injury. In particular, identification of the USLs and ureters, proper suture positioning and final cystoscopy are key points to minimize ureteral damage.
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http://dx.doi.org/10.1007/s00192-017-3497-yDOI Listing
January 2018

Learning curve for the single-incision suburethral sling procedure for female stress urinary incontinence.

Int J Gynaecol Obstet 2017 Dec 7;139(3):363-367. Epub 2017 Oct 7.

University of Milano-Bicocca, Milan, Italy.

Objective: To evaluate the learning curve for the single-incision sling (SIS) procedure in a single-surgeon case series.

Methods: Data were retrospectively analyzed from women with non-recurrent symptomatic stress urinary incontinence confirmed by urodynamics and treated at San Gerardo Hospital, Monza, Italy, between October 2008 and November 2015. All women underwent the SIS procedure using a MiniArc sling fitted by the same urogynecologic surgeon. Blood loss, operative time, and complications were recorded. At follow-up visits, objective cure was assessed with a stress test and subjective outcome was determined by International Consultation on Incontinence Questionnaire-Short Form and Patient Global Impression of Improvement scores. Postoperative overactive bladder syndrome and voiding symptoms were recorded.

Results: In total, 192 patients underwent the SIS procedure. Estimated blood loss, operative time, and complication rate were not influenced by the number of procedures performed. Among 191 patients who completed 12 months of follow-up, neither objective nor subjective outcomes at longest follow-up available were influenced by surgeon's experience. Conversely, de novo overactive bladder syndrome (P<0.001) and voiding symptoms (P=0.029) decreased with increasing experience.

Conclusion: SIS showed encouraging objective and subjective outcomes with a minimal complication rate even at the beginning of the learning curve. However, increasing experience reduced postoperative voiding symptoms and overactive bladder syndrome.
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http://dx.doi.org/10.1002/ijgo.12317DOI Listing
December 2017