Letter to the editor: Comment on "Simultaneous treatment of anterior vaginal wall prolapse and stress urinary incontinence by using transobturator four arms polypropylene mesh".

We have read the article by Sharifiaghdas et al. [1], which was an interesting study that both investigated the safety and efficacy of the four-arm polypropylene mesh (Nazca-Tc, Promedon, Cordoba, Argentina) in the treatment of high-stage cystocele and evaluated clinical outcomes in a subgroup of patients with simultaneous stress urinary incontinence (SUI) via a double transobturator approach.

Although the study had strong limitations due to a relatively small number of patients and a single-arm rather than a double-arm study design, the Nazca-Tc system was deemed by the authors to be effective and safe in the treatment of advanced anterior vaginal wall prolapse with a low rate of complications after medium-term follow-up. Furthermore, the authors suggested that most of the subgroup with concomitant SUI was cured without a second simultaneous procedure.

This was a valid and well-conducted study, despite its limitations, and suggests interesting data and conclusions for consideration by urogynecologists. However, the study had a significant structural limitation: the lack of a correct evaluation of pre- and postoperative sexual function. The authors reported that only 29 of 64 patients (45.3%) were sexually active at baseline; of these women, 20 reported improvement in sexual activity and 7 had no change in sexual function. Moreover, 2 patients complained of worsening dyspareunia after surgery.

On the one hand, one wonders how one can draw these conclusions by using only nonspecific questionnaires to assess sexual function, such as the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7). On the other hand, it is emphasized that the presence of a significant percentage of patients who were not sexually active (35 of 64) does not at all represent an absolute limit in the evaluation of sexual function.

In fact, several analytical tools are available in the literature for the evaluation of sexual function in patients undergoing surgery for pelvic organ prolapse and SUI. These include the Female Sexual Function Index (FSFI) questionnaire and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the evaluation of changes in clitoral vascularization by use of color Doppler sonography. In particular, the FSFI consists of six domains—desire (2 items), arousal (4 items), lubrication (4r items), orgasm (3 items), satisfaction (3 items), and pain (3 items)—that are answered on a 5-point Likert scale [2]. The PISQ-12, instead, is composed of 12 items and examines 3 factors: the behavioral emotive factor (items 1–4), the physical factor (items 5–9), and the partner-related factor score (items 10–12) [3]. The use instead of translabial color Doppler sonography to calculate peak systolic velocity, end-diastolic velocity, resistant index, and pulsatility index on major identifiable vessels, placing the probe sagittally on the clitoris with an angle of <20°, would allow the definition of the potential impact on sexual activity more objectively even in patients who, at baseline, were not sexually active [4].

In conclusion, although the Nazca-Tc system was deemed effective and safe in the treatment of advanced anterior vaginal wall prolapse, as well as of concomitant SUI, it would be appropriate to assess its impact on sexual function through specific methods of investigation, both subjective and objective, and to considerably increase the study sample size.