Effects of pelvic organ prolapse repair on urinary symptoms: a comparative study between the laparoscopic and vaginal approach

Comparison of the effectiveness of sacrospinous ligament fixation and sacrocolpopexy: a meta-analysis

Introduction and hypothesis

Sacrocolpopexy and sacrospinous ligament fixation (SSLF) have been used for the restoration of apical support. Studies comparing sacrocolpopexy and SSLF have reported conflicting results. We aim to assess the current evidence regarding efficiency and the complications of sacrocolpopexy compared with SSLF.

Methods

We searched PubMed, Embase, and Cochrane Library and performed a systematic review meta-analysis to assess the two surgical approaches.

Results

5Five randomized controlled trials, 8 retrospective studies, and 2 prospective studies including 4,120 cases were identified. Compared with abdominal sacrocolpopexy (ASC), SSLF was associated with a lower success rate (88.32% and 91.45%; OR 0.52; 95% CI 0.29–0.95; p = 0.03), higher recurrence (11.58% and 8.32%; OR 1.97; 95% CI 1.04–3.46; p = 0.04), and dyspareunia rate (14.36% and 4.67%; OR 3.10; 95% CI 1.28–7.50; p = 0.01). Patients in this group may benefit from shorter operative time (weighted mean difference −25.08 min; 95% CI −42.29 to −7.88; p = 0.004), lower hemorrhage rate (0.85% and 2.58%; OR 0.45; 95% CI 0.25–0.85; p = 0.009), wound infection rate (3.30% and 5.76%; OR 0.55; 95% CI 0.39–0.77; p = 0.0005), and fewer gastrointestinal complications (1.33% and 6.19%; OR 0.33; 95% CI 0.15–0.76; p = 0.009).

Conclusion

Both sacrocolpopexy and SSLF offer an efficient alternative to the restoration of apical support. When anatomical durability and sexual function is a priority, ASC may be the preferred option. When considering factors of mesh erosion, operative time, gastrointestinal complications, hemorrhage, and wound infections, SSLF may be the better option.

Comparison of patients undergoing vaginal hysterectomy with sacrospinous ligament fixation, laparoscopic hysterectomy with sacrocolpopexy and abdominal hysterectomy with sacrocolpopexy in terms of postoperative quality of life and sexual function

AIM

To investigate whether there is a significant difference among the patients who underwent vaginal hysterectomy with sacrospinous ligament fixation (VH + SSLF), laparoscopic hysterectomy with sacrocolpopexy (LH + SCP) and abdominal hysterectomy with sacrocolpopexy (AH + SCP) in terms of sexual function and quality of life.

MATERIAL AND METHOD

Sixty-five patients undergoing vaginal hysterectomy with sacrospinous ligament fixation (VH + SSLF), laparoscopic hysterectomy with sacrocolpopexy (LH + SCP) or abdominal hysterectomy with sacrocolpopexy (AH + SCP) participated in the study. The Quality of Life Scale and Sexual Function Scale Index (PISQ-12) were used to see whether there is a significant difference among the three groups (VH + SSLF, LH + SCP, AH + SCP) at least 1 year after surgery. The Pelvic Floor Distress Inventory-20 (PFDI-20) Scale consisting of Pelvic Organ Prolapse Distress Inventory (POPDI-6), Urinary Distress Inventory (UDI-6), and Colorectal-Anal Distress Inventory (CRADI-8) was used to evaluate the functional outcomes.

RESULTS

The participants had a mean age of 60 ± 8.79 years. The mean PFDI-20 score in the VH + SSLF groups is higher than that in the AH + SCP group (p = 0.047). There is no significant difference among three VH + SSLF, LH + SCP and AH + SCP groups regarding scores of POPDI-6, UDI-6, CRADI-8, and PISQ-12.

CONCLUSION

In the present study, it was concluded that AH + SCP group had a higher quality of life than the VH + SSLF group did while the sexual function was not affected significantly by the vaginal or abdominal surgical procedures. The pelvic surgeon should skillfully choose different prolapse surgical techniques to tailor the surgical treatment to the patient's needs.

Cough stress tests to diagnose stress urinary incontinence in women with pelvic organ prolapse with indication for surgical treatment

AIMS

To evaluate the diagnostic ability of different cough stress tests (CSTs) in women with pelvic organ prolapse (POP), performed during outpatient urogynaecological exams.

METHODS

Prospective, multicentre observational study involving women on waiting lists for POP surgery. With a subjectively full bladder, patients were asked to perform five different CSTs: without prolapse reduction ([a] standing, followed by [b] semilithotomy position); keeping semilithotomy position with prolapse reduced (by [c] posterior speculum, followed by [d] pessary); [e] standing again with the pessary in place. Primary outcome was positive CST in at least one of the five CSTs. Bladder volume was measured and symptoms of stress urinary incontinence (SUI) were detected by two validated questionnaires.

RESULTS

A total of 297 women completed all CSTs and were included in the analyses. Mean (SD) age, parity, and body mass index were 64.8 (9.9) years, 2.7 (1.3) deliveries, and 26.6 (3.4) kg/m² , respectively. In total, 99 women (33.3%) reported SUI symptoms. At least one positive CST was recorded in 152 patients (51.1%), and in 90 (59.2%) of these 152, a positive CST was observed only when POP was reduced (occult SUI). The CST was positive in 92 (92.9%) of the 99 patients with coexisting SUI symptoms and in 60 (30.3%) of the 205 asymptomatic patients. The percentage of patients with a positive CST was significantly lower when bladder volume was <200 mL vs ≥200 mL (P = .046).

CONCLUSIONS

The identification of urinary leakage cases with CSTs is best achieved using multiple different patient positions, different prolapse reduction methods, and bladder volumes ≥200 mL.

Medium-term outcomes of laparoscopic sacrocolpopexy or sacrohysteropexy versus vaginal sacrospinous ligament fixation for middle compartment prolapse

OBJECTIVE

To compare laparoscopic sacrocolpopexy (LSC) or sacrohysteropexy (LSH) with vaginal sacrospinous ligament fixation (VSSLF) for middle compartment pelvic organ prolapse (POP).

METHODS

Data were retrospectively reviewed from patients with POP (stage 3 or worse) who underwent LSC, LSH, or VSSLF at a center in Shanghai between January 2009 and March 2014. POP quantification (POP-Q) and Pelvic Floor Distress Inventory scores were compared at the 2-year follow-up.

RESULTS

Data were available for the 2-year follow-up for 102 LSC, 11 LSH, and 94 VSSLF procedures. Compared with patients who had undergone VSSLF, those who had undergone LSC/LSH had better POP-Q C values (P<0.001), longer total vaginal length (TVL) (P<0.001), and lower Aa and Ba scores (P=0.003 and P=0.002, respectively). Apical compartment and overall success rates of LSC/LSH and VSSLF did not differ significantly. Quality of life was improved in both groups (P<0.001). Both groups achieved symptomatic relief, although bowel and urinary functions were significantly improved only in the VSSLF group (P<0.001 for both). More patients in the LSC/LSH group were sexually active at 2 years (P<0.001); improvement in sex life was similar between the groups.

CONCLUSION

Although LSC/LSH achieved longer TVL, both groups achieved the same success rate and improvement in quality of life. Specifically, VSSLF yielded a significant improvement in bowel and urinary function.

[Results, safety and patient satisfaction at 6 months of vaginal anterior wall prolapse surgery by transvaginal repair with mesh use]

OBJECTIVE

To assess at 6 months the efficiency, the safety and the satisfaction of a lightweight polypropylene mesh used for the transvaginal repair of cystocele by bilateral anterior sacrospinous ligament fixation (NUVIA™ SI).

MATERIEL AND METHODS

A prospective cohort study was performed from January 2014 to June 2015. Preoperative assessment included an evaluation using the Pelvic Organ Prolapse Quantification system (POP-Q) and 3 questionnaires about symptoms, quality of life and quality of sex life (PFDI-20, PFIQ7, PISQ-12). Results were evaluated by a composite criteria: Ba≤0, absence of bulge sensation and absence of reoperation for cystocele recurrence. Secondary objectives were to assess the complications rates and patient's satisfaction.

RESULTS

In 10 months, 16 patients, with a mean age of 61.9±8.8years, were included and evaluated by an independent observator at 6months. Four patients were sexually active before surgery and 5 at 6 months. Results were optimal in 93.75% cases (15/16) with one intraoperative injury (bladder injury) and one postoperative complication (increase of preoperative dyspareunia). Satisfaction rate was 93.75% (15/16) and questionnaires PFDI-20 and PFIQ-7 were statistically improved (P<0.0001 and P=0.0013). Three patients had a reintervention but not about anterior wall prolapse (section of a suburethral sling for urinary retention, suburethral sling exposure and cure of stress urinary incontinence).

CONCLUSION

At short term, transvaginal mesh repair by anterior sacrospinous ligament fixation with NUVIA™ presents 93.75% optimal result with one case of increased dyspareunia and 3 reoperations which don't concern anterior wall (urinary outcomes).

LEVEL OF EVIDENCE

4.

Genital prolapse repair with Avaulta Plus mesh: functional results and quality of life

PURPOSE

Evaluate anatomic and functional outcomes of genital prolapse repair by vaginal route using a mixed polypropylene and porcine skin mesh.

PATIENTS AND METHODS

Prospective pilot study from January 2009 to January 2011 in the gynecologic department of a tertiary university hospital. Twenty patients with stage II-III genital prolapse underwent anterior wall prolapse repair with anterior Avaulta Plus mesh. Functional results were evaluated using the pelvic floor distress inventory-short form (PFDI-20), the pelvic floor impact questionnaire-7 (PFIQ-7) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual questionnaires (PISQ-12).

RESULTS

No per-operative complications occurred. One postoperative hematoma (5%) occurred requiring a second surgery. At a mean follow-up of 19.7 months, three patients had vaginal mesh exposure (15%) requiring a second surgery for two of them. Of the 20 women, 17 (85%) had optimal anatomic results and three (15%) had residual genital prolapse (Ba=-2 in two cases and Bp = -2 in the one). No recurrence was observed during the study period. A significant improvement in the PFDI-20 (P<0.001) and PFIQ-7 scores (P<0.001) was observed but no improvement in the PISQ-12 score.

CONCLUSION

In this series, we reported that genital prolapse repair using Avaulta Plus mesh resulted in a high success rate and improved quality of life but with an important prevalence of vaginal mesh exposure.

Voiding difficulties after vaginal mesh cystocele repair: does the perivesical dissection matter?

INTRODUCTION AND HYPOTHESIS

Our purpose was to verify whether extensive dissection toward the sacrospinous ligament (SSL) needed for mesh fixation during anterior compartment repair increases the risk of postoperative voiding difficulties.

METHODS

A total of 124 patients after anterior compartment mesh repair without simultaneous suburethral sling placement operated on in the period 2005-2012 were enrolled in this retrospective observational study. Patients with previous anti-incontinence surgery with normal urodynamics were not excluded; 30 patients with incomplete data, severe perioperative complications, and urinary retention before and after the surgery were excluded. Urinary retention was defined as post-void residual over 150 ml more than 48 h after permanent catheter removal. The rate of urinary retention after anterior compartment repair by mesh anchored to the SSL from an anterior approach (SSLS group) was compared to that following transobturator mesh repair often combined with SSL fixation from the posterior approach (TOT group).

RESULTS

Of the 94 patients considered for statistical analysis, 62 were from the SLSS group and 32 from the TOT group. The groups were comparable in age (mean 65.5 vs 66.3), body mass index (24.8 vs 25.9), and parity (2.4 vs 2.9). Patients from the SSLS group had higher rates of prior vaginal reconstructive (27 vs 19 %) and anti-incontinence surgery (26 vs 19 %). Postoperative urinary retention was statistically significantly more frequent in the SSLS group compared to the TOT group [(17 (27 %) vs 2 (6.25 %), odds ratio 5.7, 95 % confidence interval 1.2-26.3, p = 0.027]. Hospital discharge with self-catheterization was statistically insignificantly more frequent in the SSLS group [8 % (5) vs 3 % (1)].

CONCLUSIONS

Extensive dissection needed for SSL suspension from an anterior approach may lead to more frequent postoperative voiding difficulties. This phenomenon could be explained by more considerable injury to pelvic splanchnic nerves during the dissection. A large prospective study is needed for validation of our results.