Laparoscopic sacrocolpopexy (LSC) for pelvic organ prolapse is a surgical procedure with few recurrences and complications, however, we experienced three cases of postoperative mesh infection such as spinal discitis and retroperitoneal abscess.

Case 1 complained fever and abdominal pain 11 days after LSC. Magnetic resonance imaging (MRI) scan revealed an abscess along the mesh, and mesh infection was suspected. Laparoscopic mesh removal surgery was performed due to suspicion of mesh infection.

Case 2 complained fever and low back pain 4 days after LSC. MRI revealed L5-S1 spinal discitis due to mesh infection.

Laparoscopic mesh removal was performed due to mesh infection.

Case 3 complained anorexia 13 days after LSC. Transvaginal ultrasonography revealed abscess formation. Laparoscopic mesh removal was performed due to mesh infection.

In all cases, the postoperative course was favorable, and no recurrence of infection was observed.

Early mesh removal is preferable for mesh infection after LSC. However, mesh removal surgery leaves pelvic organ prolapse untreated, and it is important to avoid infection itself.

An 89-year-old woman was referred to our division for management of her rectal prolapse, characterized by a 9-year history of gradually worsening severe anal pain. At rest, the rectal prolapse measured 16 cm. Vaginal prolapse was not observed. She was diagnosed with a high take-off prolapse and underwent a laparoscopic ventral mesh rectopexy (LVR) combined with postero-unilateral dissection and mesorectal promontofixation. A deep Douglas’ pouch and a highly stretched mesorectum around the sacrum were observed intraoperatively. The promontory peritoneum was incised to gain access to the presacral space. Then, an inverted J-shape incision was made, with posterior dissection of loose connective tissue that developed caudally beyond the level of lateral ligament. The right lateral ligament was preserved. After fixing the LVR mesh to the promontory, the mesorectum on the right side of the rectum was secured to the L5S1 anterior longitudinal ligament using a non-absorbable suture. The total operating time was 156 min, and the estimated blood loss was 20 ml. No postoperative complications, including constipation and recurrence, were observed five months later. This study highlights that, in LVR, severe rectal prolapse may require further fixation of the rectum or mesorectum around the promontory to prevent high take-off recurrence. Postero-unilateral rectal dissection and mesorectal suture promonotofixation are simple and feasible procedures that may be combined with LVR.

A seventy-year-old woman presented with difficulty of urination and was diagnosed with labial adhesions after a genital examination. Since labial adhesion has rarely been reported in postmenopausal women, its management remains unclear.

We performed blunt dissection and dilation of labial adhesion on the patient. The symptom disappeared immediately after the procedure and no recurrence has been noted during a two-month follow-up with the use of topical estrogens and dilating adhesions by fingers at home. Despite the negative impact that genitourinary syndrome of the menopause can have on a woman's quality of life, including labial adhesions, it is often inadequately diagnosed and managed.

We encountered two cases of paraurethral leiomyoma in our Female Urology Clinic. Case 1 was a 29-year-old premenopausal woman who was referred to us with complaints of urethral pain and a genital mass. Pelvic examination showed a red 17×10mm mass located at the external urethral meatus which resembled a urethral caruncle but was more firm. Due to the uncommon age of the patient to have a caruncle and the firmness of the mass, we recommended an excision, however, she hesitated to undergo the procedure. After 6 months, the mass enlarged to 18×13mm. MRI showed a sharply marginated mass that was hypointense on the axial T1-weighted image and was hyperintense to muscle on the axial T2-weighted image. Surgical excision was carried out 5mm away from the base of the mass. Case 2 was a 64-year old postmenopausal woman who was referred to us due to stress urinary incontinence. Pelvic examination adventitiously revealed a thumb-sized elastic soft mass at the anterior vaginal wall. Videourodynamics confirmed urodynamic stress urinary incontinence without detrusor overactivity. She underwent transvaginal resection of the mass at the midurethra’s 6 o’clock position prior to the TVT operation. In both cases, the histopathological diagnosis was paraurethral leiomyoma. No recurrence was observed during the follow-up. Although female paraurethral leiomyoma is relatively uncommon, gynecologists and urologists may encounter it with complaints including genital mass, voiding difficulty, or genital bleeding. As paraurethral leiomyoma must be differentiated from malignant tumors, surgical excision must be considered even if it resembles benign diseases such as caruncles.

<Introduction> Visual recognition and vesicovaginal connective tissue processing during laparoscopic sacrocolpopexy leads to a smooth and safe dissection. Recently, the connective fabric between organs has been called fascia, and various functions and their changes have been reported. Presently, we examined the bladder-vaginal fascia findings on transvaginal ultrasonography. <Participants and Methods> We reviewed the transvaginal ultrasonography findings of 148 patients who visited our hospital for uterine cancer screening. Hypothetically, the vesicovaginal fascia contains more water and is depicted as the hypoechoic area between the uterus and bladder. The low-echo range visibility was classified into three groups; level

1; visualized entire bladder-vaginal interstitium, level 2; visualized partial bladder-vaginal interstitium, and level 3; not visualized. <Results> There were 28 (18.9%) level 1 cases, 62 (41.9%) level 2 cases, and 58 (39.2%) level 3 cases. The mean group age and proportion of women who had cesarean section after menopause were significantly high in level 3. The percentage of transplants was significantly high in levels 2 and 3. There were four diaphragm wearers, all of whom were level

3 cases. <Conclusion> After childbirth, menopause, or vaginal inflammation, the hypoechoic area between the bladder and uterus disappears and is consistent with the characteristics of fascia. The hypoechoic area between the bladder and vagina may be depicting fascia. The difficulty of bladder dissection during laparoscopic sacrovaginal fusion can be estimated by assessing the hypoechoic area fascia between the bladder and vagina.

It is well known that stress urinary incontinence (SUI) can either worsen or newly appear after pelvic organ prolapse (POP) surgery. The same is true for laparoscopic sacrocolpopexy (LSC), especially when excessive tensioning of the mesh during fixation is a factor, and in such cases, the effect of a midurethral sling procedure cannot be expected, and a reduction procedure with mesh refixation is necessary. In the present case, the patient had SUI after LSC surgery for which mesh refixation surgery was performed. The patient was a 65-year-old woman, multipara and multigravida. She was diagnosed with cystocele stage III due to uterine descent, for which she underwent LSC (anterior mesh). However, the SUI appeared about 3 months after the surgery, was ineffective to drug therapy, and persisted 6 months later. With the use of a cystoscope, we observed over-tensioning of the mesh, and by performing reduction surgery using the mesh extension method while adjusting the tension during the procedure, the symptoms improved. In refixation of refractory SUI due to mesh over-tension, tension reduction by mesh extension is considered to be an effective procedure, and the use of a cystoscope during the procedure is useful for confirming optimal tension.

Objective: To evaluate the short-term outcomes of laparoscopic sacrocolpopexy with ventral rectopexy (LSCVR) for concomitant pelvic organ prolapse and rectal prolapse.

Method: Using the laparoscopic technique, the ventral side of the rectum and the anterior vaginal wall/uterine cervix were anchored to the L5S1 anterior longitudinal ligament with mesh.

Outcome: Fifty-six cases of LSCVR were performed between July 2015 and April 2023. The median age was 80 (range was 43-94) years, operative time 190 (range 106-338) min, and blood loss 0 (range 0-125) ml. Perioperative complications (Clavien-Dindo gradeⅢ or higher) occurred in 2 patients (3.6%); 2 (3.6%) recurrences were observed.

Conclusion: We found relatively positive results regarding LSCVR with elderly patients (short-term). This procedure appears to be a viable option for concomitant pelvic prolapse and rectal prolapse in cases where general anesthesia is applicable for transabdominal surgery.

We retrospectively examined the effects of transanal high-intensity focused ultrasound (HIFU) which irradiates the rectal muscular layer on 93 female patients (mean age: 67.7 years) with fecal and urinary incontinence from June 2018 to January 2022.

We also compared the effects of a newly developed thin cartridge for anal use with those of a cartridge for vaginal use.

For this evaluation, we used the Wexner score for fecal incontinence and the International Consultation on Incontinence Questionnaire-Shot Form (ICIQ-SF) for urinary incontinence. The Wexner score and ICIQ-SF were significantly lower in the early phase after the use of transanal HIFU than those measured before HIFU.

Fecal incontinence was evaluable up to 2 years in 41 of 75 patients and urinary incontinence in 18 of 43 patients, and The Wexner score and ICIQ-SF were significantly lower respectively, than those measured before HIFU, even after 2 years.

Regarding both fecal and urinary incontinence, the patients became aware of an improvement in their symptoms in an early phase (Day 7 after HIFU: median) and the maximum squeeze pressure, which indicates the strength of the external anal sphincter muscle, was found to have significantly increased in the early phase after HIFU in comparison to that measured before HIFU. Based on these findings, it was suggested that the longitudinal muscle layer of the rectum and anus contracted due to thermal coagulation by HIFU, which might have affected the external anal sphincter muscle.

When diagnosing refractory non-bacterial cystitis, drug-induced cystitis must be ruled out. We previously reported a case of allergic cystitis with delayed diagnosis caused by 8 years usage of Bofutsushosan. In this study, we conducted a literature review. We found 37 case reports (all from Japan) on cystitis induced by herbal medicine, including Kampo medicine, using the PubMed and JAMAS (Ichushi-Web) databases. The patient ages showed a bimodal distribution with peaks in childhood and old age (2-72, median 11). The ratio of male to female was 14 to 23. Sterile pyuria continued and cystoscopy showed severe inflammatory findings with occasional tumor-like masses. Bladder biopsy was done in 17 cases and 14 cases (82.4%) showed eosinophilic infiltration. The majority of causative Kampo drugs (94.6%) contained Scutellariae Radix (ogon) as a common ingredient. These drugs were used for chronic diseases such as bronchial asthma, atopic dermatitis, nephrosis syndrome, and hepatitis. The period of drug administration at the onset was 3 weeks to 10 years (median 2 years): 93.3% used Kampo drugs for more than 6 months before onset. Cystitis symptoms immediately disappeared after patients stopped using the drugs (3-42 days, median 10 days). Challenge tests (including unintended ones) were done in 12 cases which confirmed test-retest reliability without exception. Kampo medicine is widely used both as ethical drugs and OTC drugs in Japan. Therefore, physicians must be cautious about its adverse effects, especially allergic responses to ogon such as interstitial pneumonia, hepatic injury, and allergic cystitis.

Encountering patients aged over 90 years with pelvic organ prolapse (POP) is not uncommon currently. Although conservative treatment is considered first, colpocleisis may be necessary due to difficulties in pessary management. However, surgical treatment of coexisting stress urinary incontinence (SUI) remains controversial. We report a case of a 93-year old, gravida 2 para 2, woman with POP who underwent Le Fort colpocleisis and posterior pubourethral ligament plication (PPLP) with a good postoperative course. She presented with a chief complaint of vaginal pain and exhibited complete uterine prolapse and extensive painful erosions of the vaginal wall. She also had a severe stress urinary incontinence, and vulvar dermatitis. Although various types of pessaries were used, vaginal retention could not be achieved. Therefore, surgical treatment including Le Fort colpocleisis and posterior colporrhaphy for pelvic organ prolapse and PPLP for stress urinary incontinence was performed. The PPLP procedure comprised a 2-cm longitudinal incision in the vaginal wall at the level of the middle urethra and placement of delayed absorbable sutures in the pubourethral ligament on either side of the urethra. The patient was discharged on postoperative day three. One month postoperatively, the patient showed no prolapse recurrence, urinary disorder, or vulvar dermatitis, and mild urinary incontinence. Simultaneous performance of anti-incontinence procedures remains controversial in POP cases in which post-operative SUI could be expected. Although tension-free vaginal tape/transobturator tape placement is a minimally invasive procedure, the PPLP developed by Nichols et al. is less invasive and may be useful for very elderly patients.

Purpose: Transvaginal mesh (TVM) surgery is still an important treatment for pelvic organ prolapse in Japan because of its minimal invasiveness and low recurrence rate, although it is no longer performed in some countries due to mesh-related complications. Here we report a case of granuloma formation in the anterior vaginal wall that was diagnosed 14 years after TVM surgery. Case: A 76-year-old woman underwent simultaneous vaginal hysterectomy and Prolift-type TVM surgery (combined anterior and posterior mesh) at the age of 62 years. Fourteen years after the surgery, she noticed increased vaginal discharge and continuous minimal vaginal bleeding; hence, she came to our clinic. A transvaginal tumor resection was performed, and the vaginal wall was repaired in two layers with partial excision of the mesh that was integrated with the tumor. The tumor was a granuloma that appeared to have developed in association with the mesh. Discussion: The frequency of mesh-related complications is lower in Japan than in other countries. However, it is important to raise awareness of the fact that they can occur even more than 10 years after surgery. We hope such awareness will lead to appropriate medical care and treatment.