Anorectal symptoms before and after laparoscopic sacrocolpoperineopexy for pelvic organ prolapse

Comparison of first versus second line sacrocolpopexies in terms of morbidity and mid-term efficacy

To compare pelvic organ prolapse (POP) recurrence and morbidity between first and second line sacrocolpopexies. We conducted a retrospective chart review of all laparoscopic or robotic sacrocolpopexies for POP-Q stage ≥ 2, with or without a history of previous prolapse repair, performed with a similar technique between January 2012 and June 2019 in 3 European Gynecologic Surgery Departments. Patients were separated into two groups: first line sacrocolpopexy (FLS) and second line sacrocolpopexy (SLS). Each patient from the SLS group was age-matched with a patient from the FLS group. The primary outcome measure was reoperation procedures for recurrent POP defined as a symptomatic POP-Q stage ≥ 2 POP in at least one vaginal compartment. Secondary outcomes included operative time, intraoperative organ trauma, intraoperative blood loss, postoperative POP recurrence (operated on or not), global reoperation and mesh-related complications. During this period, 332 patients were included. After age-matching, 170 patients were analyzed: 85 patients in the FLS and SLS groups, respectively. After a mean follow-up of 3 years, there was no statistically significant difference between the two groups in terms of recurrent POP (9.4% versus 10.6%, p = 0.7), recurrent POP reoperation (3.5% versus 5.9% p = 0.7), mesh-related reoperation (0% versus 2.4%, p = 0.5), global reoperation (3.5 versus 8.2%, p = 0.3), operative time (198 ± 67 min versus 193 ± 60 min, p = 0.5), intraoperative complications such as organ injury (4.7% versus 7.1%, p = 0.7) and blood loss > 500 mL (2.4% versus 0%, p = 0.5). Patients who underwent a first or a second line sacrocolpopexy seemed to have similar rates of prolapse recurrence and complications.

Transvaginal single-port versus multi-port laparoscopic sacrocolpopexy: a retrospective cohort study

Background

Sacrocolpopexy is the gold standard treatment for apical prolapse. With the development of minimally invasive surgical techniques, the new approach of transvaginal single-port laparoscopic sacrocolpopexy (TS-LSC) has become available. However, its therapeutic effects remain unclear. The aim of this study is to compare the middle-term clinical outcomes of transvaginal single-port laparoscopic sacrocolpopexy with multi-port laparoscopic sacrocolpopexy (LSC) for apical prolapse.

Methods

We conducted a retrospective cohort study. Patients with advanced apical prolapse who underwent either TS-LSC or LSC between May 2017 to June 2019 were enrolled. Baseline demographics, perioperative results, perioperative and postoperative complications, pelvic organ prolapse quantification (POPQ) scores, pelvic floor distress inventory (PFDI-20) score and pelvic organ prolapse/urinary incontinence sexual function questionnaire (PISQ-12) score were collected at 2 years.

Results

89 subjects were analyzed: 46 in TS-LSC and 43 in LSC group. Follow-up time was 38.67 ± 7.46 vs 41.81 ± 7.13 months, respectively. Baseline characteristics and perioperative outcomes were similar except that pain score was lower (2.37 ± 0.90 vs 3.74 ± 1.05) and cosmetic score was higher (9.02 ± 0.75 vs 7.21 ± 0.89) in TS-LSC group (P < 0.05). Complication rates did not differ between groups. 3 mesh exposure in each group were noted. Recurrence rate was 2.17% in TS-LSC and 6.98% in LSC, no apical recurrence occurred. Constipation was the most common postoperative symptom. Besides, patients in TS-LSC group had better POP-Q C point (− 6.83 ± 0.54 vs − 6.39 ± 0.62, P < 0.05), and similar Aa, Ap and TVL values. Bladder and pelvic symptoms were improved in both groups, but colorectal symptoms were not relieved. There were no differences of PISQ-12 scores between groups.

Conclusion

TS-LSC was not inferior to LSC at 2 years. Patients may benefit from its mild pain, better cosmetic effect and better apical support as well as good safety and efficacy. TS-LSC is a promising considerable choice for advanced vaginal apical prolapse.

Trial registration ChiCTR2000032334, 2020-4-26 (retrospectively registered)

Defecatory Dysfunction

Normal defecation is a complex and coordinated physiologic process that involves the rectum, anus, anal sphincter complex, and pelvic floor muscles. Any alteration of this process can be considered defecatory dysfunction, a term that covers a broad range of disorders, including slow-transit constipation, functional constipation, and functional or anatomic outlet obstruction. Evaluation should include history, physical, and consideration of additional testing such as colonoscopy, colonic transit studies, defecography, and/or anorectal manometry. Depending on the etiology, management options can include conservative measures such as dietary or lifestyle modifications, medications, pelvic floor physical therapy, or surgical repair.

Evaluating the morbidity and long-term efficacy of laparoscopic sacrocolpopexy with and without robotic assistance for pelvic organ prolapse

OBJECTIVE

The aim of our study was to compare the morbidity and long-term efficacy after laparoscopic sacrocolpopexy with and without robotic assistance.

METHODS

We conducted a retrospective chart review of all laparoscopic or robotic sacrocolpopexies for POP-Q stage 2-4 vaginal prolapse performed between September 2015 and October 2018 in 2 Gynecologic Surgery Departments of France. Patients were separated into two groups: a laparoscopic sacrocolpopexy group (LS) and a robotic-assisted sacrocolpopexy group (RAS). The primary outcome measure was reoperation procedures for recurrent pelvic organ prolapse (POP).

RESULTS

Two hundred and fourteen patients were included, 160 patients (75%) in the LS group and 54 patients (25%) in the RAS group. After a mean follow-up of 32.8 months, reoperation rate for recurrent POP and the recurrent POP rate were greater in the RAS group (9.2% versus 1.2%, p = 0.01 and 25.9% versus 7.5%, p = 0.0003, respectively). No significant difference was found in terms of immediate intraoperative (3.1% versus 1.8%, p = 1) and postoperative complications (1.9% versus 1.8%, p = 1). On comparing the 2 groups by bivariate analysis, RAS significantly increased the odds of reoperation for POP recurrence (OR = 7.8 CI 95% [1.5-41.6], p = 0.02) and the odds of global reoperation (OR = 3.8 CI 95% [1.4-10.4], p = 0.0095). Similarly, multivariate logistic analysis showed that RAS increased the risks of global reoperation (OR = 3.8 CI 95% [1.3-10.6], p = 0.01) after controlling high-grade prolapse.

CONCLUSION

Robotic sacrocolpopexy does not appear to give long-term clinical benefits. Recurrent POP and reoperation procedures seem to be more frequent in case of robotic-assisted surgery.

Efficacy and safety outcomes after genital prolapse repair by the vaginal route using the Avaulta Plus® mesh

OBJECTIVE(S)

With aging population, a rise in anterior wall prolapse surgery is expected. The aim of this study is to evaluate the efficacy and safety of genital prolapse repair by the vaginal route using a mixed polypropylene and porcine skin mesh (Avaulta Plus®).

STUDY DESIGN

Retrospective study conducted at Tenon University Hospital, Paris, France. We included seventy-nine women who underwent anterior wall prolapse repair using Avaulta Plus® mesh by the transobturator route for genital prolapse ≥ stage II from September 2008 to December 2017. Pre- and postoperative pelvic organ prolapse classification, functional symptoms, quality of life scores were evaluated, and complications were recorded.

RESULTS

The anatomical success rate for anterior wall prolapse was 97 %. The postoperative complication rate was 29.1 % among which the mesh exposure rate was 7.6 %. Pelvic symptoms such as vaginal discomfort and pelvic heaviness were significantly improved (p < 0.01). Voiding dysfunction were significantly improved (p < 0.01). A significant improvement in the PFDI-20 score (p < 0.01) and PFIQ-7 score (p < 0.01) was observed. After 3 years of follow-up, the recurrence rate was 12 %.

CONCLUSION(S)

Prolapse repair using the Avaulta Plus® mesh is effective and results in a significant improvement in quality of life. The complication rate, including mesh exposure, is acceptable.

Surgical interventions for posterior compartment prolapse and obstructed defecation symptoms: a systematic review with clinical practice recommendations

INTRODUCTION AND HYPOTHESIS

Several posterior compartment surgical approaches are used to address posterior vaginal wall prolapse and obstructed defecation. We aimed to compare outcomes for both conditions among different surgical approaches.

METHODS

A systematic review was performed comparing the impact of surgical interventions in the posterior compartment on prolapse and defecatory symptoms. MEDLINE, Embase, and ClinicalTrials.gov were searched from inception to 4 April 2018. Randomized controlled trials, prospective and retrospective comparative and single-group studies of women undergoing posterior vaginal compartment surgery for vaginal bulge or bowel symptoms were included. Studies had to include both anatomical and symptom outcomes both pre- and post-surgery.

RESULTS

Forty-six eligible studies reported on six surgery types. Prolapse and defecatory symptoms improved with native-tissue transvaginal rectocele repair, transanal rectocele repair, and stapled transanal rectocele repair (STARR) surgeries. Although prolapse was improved with sacrocolpoperineopexy, defecatory symptoms worsened. STARR caused high rates of fecal urgency postoperatively, but this symptom typically resolved with time. Site-specific posterior repairs improved prolapse stage and symptoms of obstructed defecation. Compared with the transanal route, native-tissue transvaginal repair resulted in greater improvement in anatomical outcomes, improved obstructed defecation symptoms, and lower chances of rectal injury, but higher rates of dyspareunia.

CONCLUSIONS

Surgery in the posterior vaginal compartment typically has a high rate of success for anatomical outcomes, obstructed defecation, and bulge symptoms, although these may not persist over time. Based on this evidence, to improve anatomical and symptomatic outcomes, a native-tissue transvaginal rectocele repair should be preferentially performed.

Posterior Compartment Surgery Provides No Differential Benefit for Defecatory Symptoms Before or After Concomitant Mesh-Augmented Apical Suspension

OBJECTIVES

The aim of this study was to determine the value of posterior compartment surgery during concomitant mesh-augmented apical suspension by comparing obstructed defecatory symptoms after laparoscopic sacrocolpopexy (LSC) with LSC with posterior repair (LSC + PR) and laparoscopic sacrocolpoperineopexy (LSCP) procedures.

METHODS

This was a retrospective cohort study of women who underwent LSC, LSC + PR, and LSCP between July 2007 and July 2016 at a tertiary referral center in Indianapolis, Ind. Our primary outcome was differential change in Colorectal-Anal Distress Inventory (CRADI-8) and Colorectal-Anal Impact Questionnaire (CRAIQ-7) scores between the groups including patient-specific symptoms of splinting, straining, incomplete emptying, and pain with defecation. Our secondary outcomes were the rates of postoperative persistent, new, and resolved obstructed defecation symptoms. Anatomic outcomes were also compared between the groups as measured by change in Pelvic Organ Prolapse Quantification System points Ap, GH, and PB.

RESULTS

A total of 312 women were included in the study (47 LSC, 133 LSC + PR, and 132 LSCP), with a median follow-up time of 366 days. The majority of patients who underwent surgery had stage III pelvic organ prolapse (61%). Baseline demographics were similar between groups, including preoperative CRADI-8 and CRAIQ-7 scores. All surgical groups demonstrated improvement in CRADI-8 and CRAIQ-7 scores postoperatively (P < 0.001). However, despite differential change in Pelvic Organ Prolapse Quantification System points Ap, GH, and PB, there was no change in CRADI-8 and CRAIQ-7 scores or rates of persistent, new, and resolved symptoms of splinting to defecate, incomplete emptying, and pain with defecation between the groups. The only factor that seemed to be differentially improved by the addition of a posterior compartment repair was postoperative straining. There was a greater rate of de novo straining in the LSC group compared with LSCP (P = 0.01) (LSC + PR v LSCP, P = NS, for both).

CONCLUSIONS

We cannot recommend posterior compartment surgery as providing any patient-centered benefit beyond improved cosmesis because the addition of perineal body stabilization either before (LSCP) or posterior repair after (LSC + PR) concomitant mesh-augmented apical suspension did not differentially affect bowel symptoms compared with LSC alone.

Outcomes of laparoscopic management of multicompartmental pelvic organ prolapse

BACKGROUND

Pelvic organ prolapse (POP) is an increasing medical problem with complex diagnostics and controversial surgical management. It causes a series of dysfunctions in the gynecological, urinary, and anorectal organs. Numerous procedures have been proposed to treat these conditions, but in recent years, ventral mesh rectocolposacropexy (VMRCS) has emerged as the procedure of choice for the surgical treatment of POP, especially by a laparoscopic approach. This surgical technique limits the risk of autonomic nerve damage, and the colpopexy allows the correction of concomitant prolapse of the middle compartment. However, symptoms derived from anterior compartment prolapse remain a major morbidity and sometimes require an additional procedure. The aim of this study is to evaluate the results of laparoscopic prosthetic rectocolposacropexy (LRCS) and colposacropexy (LCS) procedures performed to manage combined multicompartmental POP.

METHODS

Between November 2008 and December 2017, 38 patients with symptomatic POP underwent rectocolposacropexy (RCS) or colposacropexy (CS) by a laparoscopic approach. Demographics, mortality, morbidity, hospital stay, and functional outcomes were retrospectively analyzed.

RESULTS

The median operating time was 200 min (IQR 160-220). Additional simultaneous surgery for POP was performed in nine cases: five suburethral slings and four hysterectomies were performed. No mortality was recorded. The conversion rate was 7.89%. There were two intraoperative complications (5.26%): one enterotomy and one urinary bladder tear. Late complications occurred in 5.26% of cases. After a mean follow-up of 20 months, constipation was completely resolved or improved in 83.33% of patients, urinary stress incontinence was resolved or improved in 52.94%, and gynecological symptomatology was resolved or improved in 93.75%. The recurrence rate was 5.26%.

CONCLUSIONS

Laparoscopic mesh rectocolposacropexy and colposacropexy are safe and effective techniques associated with very low morbidity. In the medium term, they provide good results for POP and associated symptoms, but urinary symptomology has a worse outcome.

Robot-Assisted Sacrocolporectopexy for Multicompartment Prolapse of the Pelvic Floor: A Prospective Cohort Study Evaluating Functional and Sexual Outcome

BACKGROUND

Pelvic floor disorders are a major public health issue. For female genital prolapse, sacrocolpopexy is the gold standard. Laparoscopic ventral mesh rectopexy is a relatively new and promising technique correcting rectal prolapse. There is no literature combining the 2 robotically assisted techniques.

OBJECTIVE

This study was designed to evaluate the safety, quality of life, and functional and sexual outcomes of robot-assisted sacrocolporectopexy for multicompartment prolapse of the pelvic floor.

DESIGN

This was a prospective, observational cohort study.

SETTINGS

The study was conducted in a tertiary care setting.

PATIENTS

All sexually active patients undergoing robot-assisted sacrocolporectopexy at our institution between 2012 and 2014 were included.

INTERVENTION

Robot-assisted sacrocolporectopexy was the study intervention.

MAIN OUTCOME MEASURES

Preoperative and postoperative (12 months) questionnaires using the Urinary Distress Inventory, Pescatori Incontinence Scale, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and Pelvic Floor Impact Questionnaire were completed. In addition Wexner and Vaizey incontinence scores and the Wexner constipation score were recorded postoperatively.

RESULTS

Fifty-one patients underwent robot-assisted sacrocolporectopexy (median follow-up, 12.5 months). The simplified Pelvic Organ Prolapse Quantification improved significantly (p < 0.0005) for all 4 of the anatomic landmarks. Both median fecal (preoperative and postoperative Pescatori 4 vs 3, p = 0.002) and urinary incontinence scores (Urinary Distress Inventory, 27.8 vs 22.2; p < 0.0005) improved significantly at 12 months. Postoperatively median Wexner (3) and Vaizey incontinence (6) and Wexner Constipation (7) scores were noted. A positive effect on sexual function (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire score 31.8 vs 35.9; p = 0.002) and quality of life for each compartment (p < 0.0005) was observed. One patient (2%) developed mesh erosion. No multicompartment recurrences were detected.

LIMITATIONS

This was a observational study with a limited follow-up, no control group, and no preoperatively validated constipation score.

CONCLUSIONS

Robot-assisted sacrocolporectopexy is a safe and effective technique for multicompartment prolapse in terms of functional outcome, quality of life, and sexual function.

Outlet constipation 1 year after robotic sacrocolpopexy with and without concomitant posterior repair

OBJECTIVES

The aim of this study was to estimate the rate of outlet constipation at 1 year after robotic sacrocolpopexy (RSCP) with and without a concomitant distal posterior repair (PR). We sought, first, to determine the rate of persistent outlet constipation and second, to determine de novo outlet constipation.

METHODS

This was a cohort study of women who underwent RSCP alone versus RSCP + PR, at each surgeon's discretion, between November 2007 and February 2011 at an academic center. Specific questions in the Pelvic Floor Distress Inventory Short Form correlating to outlet constipation and its colorectal-anal subscale scores were compared between and within groups. Rates of posterior compartment reoperation were assessed.

RESULTS

Of the 77 women who underwent RSCP, 21 (27%) had a concomitant distal PR. Overall, there was significant improvement in pelvic floor function and quality of life at 1 year after surgery (P = 0.01). Preoperatively, outlet constipation was present in 63.4% of those who underwent RSCP only and in 53.3% of those with concomitant PR. Postoperatively at 1 year, 56% of preoperative outlet constipation resolved and 44% persisted (P = 0.001), with no differences between groups (RSCP vs RSCP + PR). The rate of postoperative de novo outlet constipation was 13.6%. At 1 year after RSCP, 18.2% of patients had symptomatic posterior prolapse, with no difference between both groups (P = 0.746). Overall, 11.7% underwent a subsequent PR, none of whom underwent PR with the initial RSCP (P = 0.104).

CONCLUSIONS

At 1 year after RSCP, there was a high rate of persistent outlet constipation and a moderate rate of de novo outlet constipation. Concomitant PR did not significantly affect these bowel symptoms.