The posterior IVS delivered satisfactory results for vault and posterior compartment prolapse, with a 75% improvement in vault prolapse. It was not possible, however, to separate the effect of posterior IVS and posterior colporrhaphy on the prevention of recurrent prolapse nor on the improvement of difficulty in defecation. Due to the utilization of the now-abandoned vaginal anterior colposuspension procedure for the treatment of anterior compartment prolapse, no conclusions regarding the impact of the posterior IVS on the anterior compartment can be made.

Objective The aim of this study was to evaluate the efficacy of uterine artery embolisation (UAE) in myomatous uteri larger than 24 week's gestation (780 cm 3 ). Design Prospective case control study.Setting Universitas Hospital, University of the Free State, Bloemfontein, South Africa.Population Sixty-one women, who underwent UAE, were included in the study. The study group comprised of 12 women with uteri !780 cm 3 and the control group 49 women with uteri <780 cm 3 . Methods UAE was performed and the difference in outcome for the two groups was determined at 12 months.Main outcome measure Symptomatic improvement with embolisation of the large uterus.Results Reduction of dysmenorrhoea, menorrhagia and pressure effects was similar for both groups. The median reduction in uterine volume (pre-to post-embolisation) was 188 cm 3 (range 28-2038 cm 3 ) with a 95% CI for the median difference for paired data of 146.5 and 236. Only 66% of the study group had, however, a reduction in volume to <780 cm 3 . The complication rates were similar for the two groups with regards to post-embolisation syndrome, fibroid slough, haematoma formation, infection, hysterectomy and failure to embolise. Satisfaction was similar between the two groups, with 91% of women satisfied with the procedure. Conclusion The large uterus does not decrease UAE's efficacy. Although 33.3% of the study group still had a uterus of !780 cm 3 , symptom reduction was still similar for both groups. Women may thus still be left with a large uterine volume but without symptoms. This must be taken into consideration when counselling women with an extremely large uterus for UAE.

Uterine artery embolization can be performed effectively and safely at centers with the necessary expertise and can be used with success in Africa.

No abstract

A cystocele is a pathological descent of the anterior vaginal wall and bladder base [1]. Because of the bladder's relatively poor support, a large cystocele is difficult to treat. This review of the experience obtained at the Department of Obstetrics and Gynecology of the University of the Free State, Bloemfontein, South Africa, was approved by the local ethics committee.The records of 50 consecutive patients with stage IV cystocele [2] were retrieved from the urogynecology data base and analyzed. Sacrocolpopexy was performed by placing a mesh both anteriorly and posteriorly to the vagina and extending it to the sacrum (S1). The mesh used was Vypro (Johnson and Johnson, Brussels, Belgium), a semiabsorbable mesh consisting of polyglactin and prolene. In 80% of the patients, mobilization, elevation, and fixation of the rectum to the mesh were also performed.The patients had a median age of 65 years and a median parity of 3. Urinary symptoms were present in 30% of the patients and bowel problems in 40%.No major perioperative complications occurred. All patients were followed up for 1 to 50 months, for a median of 12 months. Grade 3 and grade 4 prolapse reoccurred in 10 patients (20%): there were 8 cystoceles (16%), 2 rectoceles (4%; 1 patient had a cystocele and a rectocele), and 1 vaginal vault prolapse (2%). No cystocele reoccurred in the 8 patients in whom the mesh supporting the bladder extended from the urethra to the sacrum. Recurrences occurred only when the mesh extended from the mid-bladder base to the sacrum ( P = .09; 95% confidence interval [CI], À 1.7% to 38.1%). The relative risk of developing a recurrent cystocele when the mesh supported the bladder partially rather than completely was 6.89 (95% CI, 0.42-12.02).Long-term follow-up revealed overactive bladder symptoms (28%), urinary stress incontinence (16%), and a 28% decrease in manual assistance with defecation; dyspareunia remained unchanged at 8%.