Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion

Posterior mesh fixation versus non-fixation in sacrocolpopexy: A randomized clinical trial

INTRODUCTION

Urogenital prolapse affects up to 50% of women, and its treatment is essential for improving quality of life. Laparoscopic sacrocolpopexy is considered the gold standard, but there is no consensus on the optimal surgical approach. This study tests the hypothesis that the absence of posterior mesh fixation is non-inferior to its fixation.

MATERIALS AND METHODS

We conducted a randomized, single-blinded, monocentric, non-inferiority trial in Italy (NCT04358978). In Group A, the posterior mesh was placed without fixation, while in Group B, it was fixed to the rectovaginal fascia and levator ani muscle. The primary outcome was the correction of prolapse, with secondary outcomes including intraoperative parameters, postoperative characteristics, and urogenital prolapse correction at 1, 6 and 12, months, as well as long-term morbidity.

RESULTS

120 women were randomized into two groups with no significant differences. At 12 months, both groups reported no bulge symptoms, and pelvic pain was 3,3 %. Urinary dysfunction decreased in both groups, with a reduction in de novo incontinence (Group A: 1.6 %, Group B: 3.3 %) and persistent incontinence (Group A: 0 %, Group B: 7 %). Persistent constipation at 12 months was 3.3 % in Group A and 13 % in Group B. No cases of obstructed defecation or mesh erosion were observed. Five cases of failure (8.3 %) were reported in both groups, defined as Ba point reaching the hymen.

CONCLUSIONS

The absence of posterior mesh fixation is non-inferior to fixation in laparoscopic sacrocolpopexy in terms of treatment success and postoperative complications.

Quality of Life Assessment After Pelvic Prolapse Surgery With and Without Mesh: A Literature Review

Background/Objectives: The quality of life (QoL) in patients undergoing pelvic prolapse surgery is a critical area of research in urogynecology. Pelvic organ prolapse (POP) is a prevalent condition affecting a significant number of women, leading to various physical and psychological symptoms that can severely impact their quality of life. Surgical intervention aims not only to correct the anatomical defects but also to enhance the overall well-being of patients. Methods: A comprehensive literature search in the main databases was conducted for studies evaluating quality of life after surgical treatment using techniques with and without mesh. Results: A total of 35 studies met the inclusion criteria, involving a total of 4603 patients. Twenty-two distinct patient-reported outcomes (PRO) questionnaires have been identified as post-surgical QoL assessment tools. Conclusions: Quality of life is significantly improved by surgical treatment of pelvic organ prolapse. Post-surgical PRO scores do not seem to be influenced by the surgical technique used, with no significant differences between methods using mesh or not.

Epidural Anesthesia and Pelvic Floor Outcomes in Primiparas: A Retrospective Transperineal Ultrasound Study

PURPOSE

This study evaluated pelvic organ positions in primiparas with painful and painless deliveries using transperineal ultrasound (TPU) and assessed the effects of epidural anesthesia on pelvic floor function.

METHODS

From January 2022 to March 2023, 512 primiparas with vaginal deliveries at our hospital underwent pelvic floor ultrasound examinations 42 days postpartum. The study included 138 women with painful deliveries and 375 with painless deliveries. Measurements included the urethral tilt angle (UTA), retrovesical angle at rest (RVA-R), bladder neck-symphysis pubis distance (BSD) at rest, retrovesical angle at Valsalva maneuver (RVA-V), urethral rotation angle (URA), bladder neck descent (BND), rectal ampulla distance, and levator hiatal area (LHa) at maximum Valsalva maneuver. Statistical analysis was performed using SPSS 26.0.

RESULTS

No significant differences were found between the painful and painless delivery groups in terms of age, gestational age, newborn birth weight, BMI, UTA, RVA-R, RVA-V, URA, and BND (P > 0.05). Although the second stage and total duration of labor were significantly longer in the painless delivery group, there were no significant differences in the incidences of cystocele, internal urethral orifice opening, uterine prolapse, rectocele, and LHa expansion between the groups (P > 0.05).

CONCLUSION

Transperineal ultrasound showed no significant difference in pelvic floor dysfunction incidence between primiparas with painful and painless deliveries. Epidural anesthesia did not significantly affect pelvic floor function in the early postpartum period.

Levator Ani Avulsion in Ultrasound Increases Recurrence in Sacrospinous Fixation

IMPORTANCE

Pelvic floor translabial ultrasound (TLUS) can identify levator ani muscle (LAM) avulsion and ballooning, which some studies have shown to be possible risk factors for prolapse recurrence. Our group uses TLUS to counsel patients preoperatively. If any of these risk factors exist, we offer sacrocolpopexy over vaginal repair. However, some patients, even though they have these possible risk factors, prefer to undergo vaginal surgery.

OBJECTIVE

The objective of this study was to determine if TLUS LAM avulsion and/or ballooning are risk factors for composite outcome recurrence in patients undergoing sacrospinous ligament fixation for pelvic organ prolapse.

STUDY DESIGN

This was a retrospective observational study. All patients with vaginal apical repair with sacrospinous ligament fixation with preoperative TLUS were included. Demographics, clinical characteristics, and follow-up were analyzed. Multivariable logistic regression analysis was performed for composite outcome that included TLUS risk factors, age, Pelvic Organ Prolapse Quantification System measurements and stage, and variables with P < 0.1 in the univariate analysis.

RESULTS

Eighty-two patients were included. All patients had symptomatic vaginal bulge; 65.4% had stage III prolapse. Concomitant hysterectomy was performed in 54.3%. Median follow-up was 20 months (interquartile range, 8-35 months); 19.8% had LAM avulsion, and 43.2% had ballooning. Anatomic recurrence rate was 23.5%, symptomatic was 22.2%, and reoperation was 1.2%. The composite recurrence rate was 29.6%. In the multivariable logistic regression analysis, unilateral/bilateral avulsion in TLUS was found to be a significant risk factor for composite outcome with an odds ratio of 4.33 (confidence interval, 1.219-15.398; P = 0.023).

CONCLUSIONS

Composite outcome of recurrence in our study was 29.6%. Avulsion on TLUS increased the risk of recurrence of pelvic organ prolapse by fourfold.

Identification of potential molecular mechanisms and therapeutic targets for recurrent pelvic organ prolapse

Background

The pathogenesis of recurrent pelvic organ prolapse (POP) is currently unclear. Therefore, developing targeted preventive measures is difficult. This study identified potential key pathways, crucial genes, comorbidities, and therapeutic targets associated with the occurrence and development of recurrent POP.

Methods

The original microarray data GSE28660, GSE53868, and GSE12852 were downloaded from the GEO database. Identification and validation of differentially expressed genes (DEGs) and hub genes associated with recurrent POP were performed using R software and cytoHubba of Cytoscape. Protein-protein interaction (PPI) networks were constructed using the STRING tool and visualized using Cytoscape. Gene ontology (GO) and Kyoto Encyclopedia of Gene and Genome (KEGG) enrichment analyses were effectively performed using DAVID platforms. In addition, the NetworkAnalyst platform was used to explore and visualize the miRNA-hub gene network, TF-hub gene network, hub gene-disease network, and hub gene-drug/chemical network.

Results

A total of 110 DEGs and 6 hub genes (ADIPOQ, IL6, PPARG, CEBPA, LPL, and LIPE) were identified in this study. These genes were primarily enriched in the PPAR, AMPK, and adipocytokine, non-alcoholic fatty liver disease, and signaling pathways related to glycerol metabolism. Moreover, 96 miRNAs and 97 TFs were identified to as being associated with recurrent POP. These genes were closely linked to adipocyte metabolism and distribution, energy metabolism, and the longevity regulatory pathway. In addition, 192 diseases or chronic complications were potentially related to the recurrence of POP, including diabetes, hypertension, obesity, inflammatory diseases, and chronic obstructive pulmonary disease. Furthermore, 954 drugs or compounds were shown to have therapeutic potential for recurrent POP, and the most critical target drugs were dexamethasone, bisphenol A, efavirenz, 1-methyl-3-isobutylxanthine, and estradiol.

Conclusions

The results of this study revealed that ADIPOQ, IL6, PPARG, CEBPA, LPL, and LIPE as potential hub genes associated with recurrent POP, and these hub genes may aid in the understanding of the mechanism underlying POP recurrence and the development of potential molecular drugs.

The Effect of Growth Factors on Vaginal Wound Healing: A Systematic Review and Meta-analysis

Surgical outcomes of pelvic organ prolapse (POP) surgery are poor, resulting in a 20% recurrence risk. Following the hypothesis that impaired wound healing is the main determinant of recurrent POP, growth factors have the potential to promote wound healing and may improve surgical outcomes. In this study, we systematically reviewed the effect of growth factors on vaginal wound healing in both in vitro and animal studies. For each independent comparison, the standardized mean difference and 95% CI were calculated using the Hedges' g correction. Of the 3858 retrieved studies, seven studies were included, of which six were included in meta-analysis (three in vitro studies and four in vivo studies). In vitro, basic fibroblast growth factor (bFGF) promotes proliferation, differentiation, and collagen types I and III production. Epidermal growth factor stimulates proliferation and connective tissue growth factor promotes Tenascin-C expression. These effects, however, are less pronounced in vivo; only bFGF slightly promotes collagen production. The review shows that growth factors, particularly bFGF, are able to promote vaginal wound healing in vitro. The uncertain in vivo findings suggest that preclinical models should be improved. The ultimate goal is to develop effective growth factor-supplemented therapies that improve surgical outcomes for POP.

Impact of Laparoscopic Prolapse Repair in the Levator Hiatus Area

STUDY OBJECTIVE

To determine whether laparoscopic surgery by sacrocolpopexy or sacrocervicopexy with posterior mesh attachment to levator ani to treat pelvic organ prolapse reduces the levator hiatus area, as measured by transperineal 3- and 4-dimensional ultrasound. The secondary objective was to assess the risk factors for prolapse recurrence.

DESIGN

This is a prospective cohort study.

SETTING

A university tertiary hospital.

PATIENTS

Women with symptomatic apical prolapse at a high risk of recurrence were included. High risk of recurrence was defined as age <60 years and levator injury (avulsion and/or ballooning) or stage III-IV prolapse Pelvic Organ Prolapse Quantification.

INTERVENTIONS

Women were treated with laparoscopic sacrocolpopexy or sacrocervicopexy.

MEASUREMENTS AND MAIN RESULTS

Women underwent clinical examination according to assessment by the Pelvic Organ Prolapse Quantification system and transperineal ultrasound for the levator hiatus area at Valsalva. We collected demographic, clinical, and ultrasound data before surgery from clinical records and performed a comparative analysis of the levator hiatus areas before and after surgery and univariate and multivariate analyses of the risk factors for recurrence. Among the 30 women who enrolled, the levator hiatus area at Valsalva decreased significantly after surgery by an average of 4.68 cm² (p = .028). However, despite a recurrence rate of 13.3%, we found no risk factors associated with recurrence in either the univariate or the multivariate analyses.

CONCLUSION

Laparoscopic surgery by sacrocolpopexy or sacrocervicopexy for pelvic organ prolapse with mesh posterior attachment to levator ani significantly reduces the levator hiatus area measured by transperineal ultrasound. Further large-scale studies will be needed to confirm our results and identify risk factors for recurrence.

Ultralight type I transvaginal mesh: an alternative for recurrent severe posterior vaginal prolapse

OBJECTIVE

This study aimed to analyze the medium-term outcomes of ultralight type I mesh for postmenopausal women with recurrent severe posterior vaginal prolapse (PVP).

METHODS

All participants underwent transvaginal ultralight type I mesh repair between April 2016 and April 2021 and were followed until May 2022. Pelvic Organ Prolapse Quantification System (POP-Q) staging, mesh-related complications, Patient Global Impression of Improvement (PGI-I) scale and quality of life questionnaire responses were evaluated. The primary outcome was composite surgical success rate at the last follow-up, composite success being defined as no vaginal bulge symptoms, no POP-Q point at or beyond the hymen and no re-treatment for POP. Secondary outcomes included anatomic outcomes (POP-Q score), symptomatic relief and complications.

RESULTS

The median follow-up was 37.3 months. At the last follow-up, the composite success rate was 75%, and POP-Q scores for the vault and posterior wall and quality of life questionnaire scores were significantly improved (p < 0.01). The subjective satisfaction (PGI-I ≤ 2) rate was 83.3%. There were no mesh-related complications.

CONCLUSIONS

Ultralight mesh can achieve good clinical outcomes and substantially improve the quality of life of patients with severe recurrent PVP in the medium term, and may thus be a viable alternative for treating this condition.

Comparing Minimally Invasive Sacrocolpopexy With Vaginal Uterosacral Ligament Suspension: A Multicenter Retrospective Cohort Study Through the Fellows' Pelvic Research Network

IMPORTANCE

Comparing one-year surgical outcomes of two widely used surgical procedures for apical suspension.

OBJECTIVES

The objective of this study is to compare anatomic outcomes after minimally invasive sacrocolpopexy (MISC) and vaginal uterosacral ligament suspension (vUSLS).

STUDY DESIGN

This was a multicenter, retrospective cohort study through the Fellows' Pelvic Research Network. Patients with ≥ stage II pelvic organ prolapse (POP) who underwent MISC or vUSLS from January 2013 to January 2016, identified through the Current Procedural Terminology codes, with 1 year or longer postoperative data were included. Patients with prior POP surgery or history of connective tissue disorders were excluded. Anatomic success was defined as Pelvic Organ Prolapse Quantification System measurements: Ba/Bp ≤ 0 or C ≤ -TVL/2. Data were compared using χ 2 or Fisher exact tests. Continuous data were compared using Wilcoxon rank sum test.

RESULTS

Three hundred thirty-seven patients underwent MISC (171 laparoscopic, 166 robotic) and 165 underwent vUSLS. The MISC group had longer operative time (205.9 minutes vs 187.5 minutes, P = 0.006) and lower blood loss (77.8 mL vs 187.4 mL; P < 0.001). Two patients (0.6%) in the MISC group had mesh exposure requiring surgical excision. Permanent suture exposure was higher after vUSLS (6.1%). At 1 year, anatomic success was comparable in the apical (322 [97%] MISC vs 160 [97%] vUSLS, P = 0.99) and posterior compartments (326 [97.6%] MISC vs 164 [99.4%] vUSLS; P = 0.28). Anterior compartment success was higher in the MISC group (328 [97.9%] vs 156 [94.9%], P = 0.04) along with longer total vaginal length (9.2 ± 1.8 vs 8.4 ± 1.5, P < 0.001).

CONCLUSION

At 1 year, patients who underwent MISC or vUSLS had similar apical support. Low rates of mesh and suture exposures, less anterior recurrence, and longer TVL were noted after MISC.

Robot-assisted Sacrocolpopexy for Recurrent Pelvic Organ Prolapse: Insights for a Challenging Surgical Setting

BACKGROUND

No consensus exists regarding the management of recurrent pelvic organ prolapse (POP). The aim of this study was to evaluate robot-assisted laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse (POP), and to investigate postoperative outcomes.

METHODS

We conducted a single-centre retrospective study including 10 consecutive patients who underwent a robot-assisted sacrocolpopexy for symptomatic POP recurrence from February 2017 to December 2019. Recurrence rates and patient satisfaction, measured by the Pelvic Floor Impact Questionnaire (PFIQ-7) were recorded.

RESULTS

Median age was 57 years (IQR: 54-67). No intraoperative complications were reported. The median hospital stay after surgery was 2 nights (IQR: 1-4). Two patients (20%) experienced early recurrence: at 1 month for one and at 4.5 months for the other. The median follow-up for the remaining eight patients was 18 months (IQR: 12-23). Among the recurrence-free patients, the median PFIQ-7 score was 11.4 at 12 months.

CONCLUSIONS

Robot-assisted sacrocolpopexy is feasible and safe for the management of POP recurrence, with a high patient satisfaction.

Automatic Extraction of Hiatal Dimensions in 3-D Transperineal Pelvic Ultrasound Recordings

The aims of this work were to create a robust automatic software tool for measurement of the levator hiatal area on transperineal ultrasound (TPUS) volumes and to measure the potential reduction in variability and time taken for analysis in a clinical setting. The proposed tool automatically detects the C-plane (i.e., the plane of minimal hiatal dimensions) from a 3-D TPUS volume and subsequently uses the extracted plane to automatically segment the levator hiatus, using a convolutional neural network. The automatic pipeline was tested using 73 representative TPUS volumes. Reference hiatal outlines were obtained manually by two experts and compared with the pipeline's automated outlines. The Hausdorff distance, area, a clinical quality score, C-plane angle and C-plane Euclidean distance were used to evaluate C-plane detection and quantify levator hiatus segmentation accuracy. A visual Turing test was created to compare the performance of the software with that of the expert, based on the visual assessment of C-plane and hiatal segmentation quality. The overall time taken to extract the hiatal area with both measurement methods (i.e., manual and automatic) was measured. Each metric was calculated both for computer-observer differences and for inter-and intra-observer differences. The automatic method gave results similar to those of the expert when determining the hiatal outline from a TPUS volume. Indeed, the hiatal area measured by the algorithm and by an expert were within the intra-observer variability. Similarly, the method identified the C-plane with an accuracy of 5.76 ± 5.06° and 6.46 ± 5.18 mm in comparison to the inter-observer variability of 9.39 ± 6.21° and 8.48 ± 6.62 mm. The visual Turing test suggested that the automatic method identified the C-plane position within the TPUS volume visually as well as the expert. The average time taken to identify the C-plane and segment the hiatal area manually was 2 min and 35 ± 17 s, compared with 35 ± 4 s for the automatic result. This study presents a method for automatically measuring the levator hiatal area using artificial intelligence-based methodologies whereby the C-plane within a TPUS volume is detected and subsequently traced for the levator hiatal outline. The proposed solution was determined to be accurate, relatively quick, robust and reliable and, importantly, to reduce time and expertise required for pelvic floor disorder assessment.

Improving of long-term follow-up after cystocele repair

INTRODUCTION

The anterior vaginal wall is the most common site of repair compared with apex and posterior vaginal wall, and is also the site with the highest recurrence rate after surgery. The aim of this study was to evaluate the anatomical location of apex in patients with cystocele staged 2-3 (POP-Q), to correct all anatomical defects and to improve cystocele repair results.

MATERIALS AND METHODS

This was a single-center prospective study of women with cystocele of stage 2-3 with and without apical prolapse who underwent combined surgical treatment. The authors performed combined surgical procedures in women with apical prolapse, including pectopexy. Clinical and anatomical follow-ups were carried out at least in 12 months.

RESULTS

All patients revealed good to excellent results, with a high rate of satisfaction. There were no significant differences in recurrence among women with and without apical prolapse. Of the 22 women after pectopexy, the only one had apical prolapse of grade 1. The median cystocele recurrence rate was 3.8% in group without apical prolapse (grade 1), and 4.5% (grade 1) in pectopexy group. Sexual matters, incontinence score and QoL were significantly improved in both groups. The main reason for cystocele low recurrence rate is defect-oriented multicompartment strategy in all cases including patients with and without apical defect.

CONCLUSION

Pectopexy can be a good choice for prolapse surgery, including the positive effect in cases of lateral anterior wall defect. Using this strategy, it becomes possible to perform native tissue vaginal repair with encouraged long-term follow-ups.

The vertical rectus abdominis myocutaneous flap to manage vaginal evisceration

BACKGROUND

Pelvic organ prolapse (POP) is a significant issue requiring surgical correction in 19% of the female population by age 85 years. Complications of POP, especially in women who have undergone hysterectomy, include vaginal evisceration-a serious complication that carries high morbidity and mortality rates. Rarely, vaginal evisceration occurs after colpocleisis.

CASE

A 69-year-old female with recurrent vaginal evisceration following colpocleisis underwent surgical repair using a vertical rectus abdominis myocutaneous (VRAM) flap.

CONCLUSION

Recurrent cases of POP and vaginal evisceration that are refractory to conventional treatment require consideration of novel management options. To our knowledge, this is the first case using a VRAM flap for the management of vaginal evisceration.

Outcomes of vaginal hysterectomy combined with anterior and posterior colporrhaphy for pelvic organ prolapse: a single center retrospective study

Objective

To evaluate the efficacy of vaginal hysterectomy combined with anterior and posterior colporrhaphy (VH APR) for the management of pelvic organ prolapse (POP).

Methods

A total of 610 patients with POP who underwent VH APR from January 2010 to June 2019 at Asan Medical Center were included in this study. We analyzed the patient characteristics and surgical outcomes. In addition, we compared the POP quantification system (POP-Q) pre- and postoperatively at 2 weeks, 3 months, and 1 year, and analyzed the risk factors for recurrence.

Results

The mean age of the patients was 65.5±7.6 years. The most common preoperative POP-Q stage was stage 2 (60.8%), followed by stage 3 (35.9%). Complications were identified during surgery in 1.6% of the patients. The most common postoperative complication (6.4%) was voiding difficulty. All POP-Q scores significantly decreased at 1 year after surgery (P<0.0001). The recurrence rate was 9.6%, and most recurrences (77.5%) occurred in the anterior compartment. An advanced stage of preoperative POP was a risk factor for recurrence (stage 3 or 4 vs. stage 1 or 2; odds ratio [OR], 5.337, 95% confidence interval [CI], 2.58–11.036, P<0.0001). Only two patients underwent surgical correction for POP recurrence, and most of the remaining patients did not undergo further treatment for prolapse.

Conclusion

VH APR is a safe and effective surgical procedure for POP, with a low recurrence rate. In addition, advanced preoperative stage was the only risk factor for recurrent POP.

Clinical risk factors for recurrence of pelvic organ prolapse after primary native tissue prolapse repair

OBJECTIVE

To define potential risk factors for recurrence of prolapse.

METHODS

This short report included all women who presented with recurrence of prolapse as well as without any recurrence signs after a vaginal approach of native tissue prolapse repair at an urogynecological center in Austria.

RESULTS

A total of 124 recurrence cases and 64 women with no signs of recurrence after their index prolapse surgery were included. Multivariate analysis identified advanced preoperative POP‑Q stage (pelvic organ prolapse-quantification) as an independent risk factor for postoperative recurrence of prolapse (p = 0.045).

CONCLUSION

Initial proper preoperative counseling is of particular importance to modulate patients' expectations after prolapse surgery.

Comparison of absorbable and permanent sutures for laparoscopic sacrocervicopexy: A randomized controlled trial

INTRODUCTION

Pelvic organ prolapse is a common cause of morbidity and decreased quality of life among women and is treatable by laparoscopic sacrocolpopexy. Recent data suggest that absorbable sutures are a feasible and appealing option for mesh attachment given a potential decreased risk of complications related to mesh erosion. The aim of the present study was to demonstrate the non-inferiority of absorbable sutures to permanent sutures for laparoscopic sacrocervicopexy.

MATERIAL AND METHODS

We performed a randomized, single-blinded, non-inferiority trial comparing late-absorbable sutures (group A) to non-absorbable sutures (group B) for anterior and posterior vaginal mesh fixation during laparoscopic sacrocervicopexy at a single center in Italy. The primary outcome was prolapse correction at 12 months after surgery, defined as the absence of a pelvic organ prolapse leading edge reaching or extending below the level of the hymen and the absence of bulge symptoms. Secondary outcomes included intraoperative parameters, postoperative characteristics, and long-term morbidity. Statistical analyses were performed using STATA version 16.

RESULTS

A total of 150 patients with pelvic organ prolapse were prospectively randomized 1:1 into two groups (A or B). Baseline characteristics and intraoperative parameters including blood loss, operation time, and intraoperative complications were comparable between groups. The success rate was 100% in both groups and no differences in prolapse correction were observed. The rates of de novo urinary incontinence and persistent urinary incontinence were also similar between groups. The rate of mesh erosion at 12 months was 0% in group A and 4% in group B (P = .24).

CONCLUSIONS

Late absorbable sutures are non-inferior to non-absorbable sutures for laparoscopic sacrocervicopexy in terms of procedural success. Moreover we did not see any differences in terms of operative parameters, or intraoperative and postoperative characteristics, although the study was not powered to these outcomes.

Preoperative ultrasound findings as risk factors of recurrence of pelvic organ prolapse after laparoscopic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

The objective of this study is to evaluate levator ani muscle avulsion (LAMA) and ballooning as risk factors for recurrence of pelvic organ prolapse (POP) after laparoscopic sacrocolpopexy (SCP). We hypothesize that these ultrasound findings are associated with a higher risk of POP recurrence.

METHODS

Retrospective cohort study of patients who underwent laparoscopic SCP between January 2015 and December 2018. Baseline translabial 3D ultrasound of the pelvic floor was performed. Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) were applied. Both univariate and multivariate analyses were carried out.

RESULTS

One hundred thirty-four patients were included. On ultrasound, 32% of patients had levator ani muscle avulsion, and 36.5% had ballooning. Mean follow-up time was 16 months. There was a 13.4% anatomic recurrence; five of them (3.7%) also had symptomatic recurrence. After multivariate analysis we found that LAMA and ballooning were not significant: OR 0.99 (95% CI 0.098-10.1; p = 0.99) and OR 1.1 (95% CI 0.99-1.2; p = 0.06), respectively.

CONCLUSIONS

LAMA and ballooning on pelvic floor US are not significant risk factors for anatomic POP recurrence after laparoscopic SCP. Laparoscopic SCP has a 13.4% and 3.4% anatomic and symptomatic recurrence rate, respectively, and the majority of patients reported significant improvement in quality of life.

LeFort colpocleisis for recurrent pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The causes of recurrence of pelvic organ prolapse (POP) are sufficiently understood. However, few studies are available evaluating reoperation for recurrence of POP. This study evaluates the efficacy and safety of LeFort colpocleisis for recurrent POP.

METHODS

We reviewed data from patients with recurrent POP who underwent LerFort colpocleisis at a center between March 2012 and April 2017. Quality of life was assessed using the Pelvic Floor Distress Inventory Questionnaire (PFDI-20) scores. The Patient Global Impression of Improvement scale (PGI-I) was used to assess self-perceived success and subjective measures of satisfaction. The Clavien-Dindo classification (CD) was used to assess the safety of the procedure. Chi-square and paired t-tests were used to compare the same patients before and after treatment in the follow-up.

RESULTS

Twenty-six patients with recurrent POP after previous prolapse surgery underwent LeFort colpocleisis. Most of these patients had at least one comorbidity. The mean age (years) was 71.8 (7.3). The mean time to recurrent POP was 5.602 (3.643) years. There were no intraoperative bladder lesions or rectal lesions. At mean follow-up of 33.1 months, all patients had no recurrence (< stage 2), significant resolution of awareness of prolapse (P < 0.05), and significantly improved satisfaction on PGI-I after surgery. Minor complications were classified as CD II level in four cases (15.4%).

CONCLUSION

This study suggests that LeFort colpocleisis is feasible and safe for recurrent POP, especially in older women with comorbidities.

[Evolution of clinical practices in the surgical management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015: A paradigm shift towards pluripotency]

OBJECTIVES

To determine whether the 2011 FDA alert and French Guidelines have impacted the routine surgical practice in the management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015.

METHODS

Retrospective study involving all patients undergoing surgical management of anterior and/or apical symptomatic pelvic organ prolapse during the civil years 2010 and 2015. Both naive and relapsed prolapses were eligible.

RESULTS

Overall, 338 patients were included: 187 in 2010 and 151 in 2015. Among patients with naive prolapse, we observed a significant increase in the number of laparoscopic sacrocolpopexies (11.1% in 2010 versus 34.4% in 2015, P=0.001) and a significant decline in the use of native tissue repair (67.6% in 2010 versus 39% in 2015, P=0.001). While the number of transvaginal meshes did not decline over the study period, their indications displayed a significant evolution towards a restricted use to advanced stages. We did not observe any difference regarding the treatment of recurred pelvic organ prolapse. Vaginal route remained the preferred approach in this indication.

CONCLUSION

In our "vaginalist" team, routine practice has significantly evolved over the period 2010-2015, resulting in a diversification of the healthcare offer. This paradigm shift towards pluripotency is mandatory, since patients' preference should also drive the choice of both surgical route and technique.

No. 351-Transvaginal Mesh Procedures for Pelvic Organ Prolapse

OBJECTIVE

This guideline reviews the evidence related to the risks and benefits of using transvaginal mesh in pelvic organ prolapse repairs in order to update recommendations initially made in 2011.

INTENDED USERS

Gynaecologists, residents, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with pelvic organ prolapse.

TARGET POPULATION

Adult women with symptomatic pelvic organ prolapse considering surgery and those who have previously undergone transvaginal mesh procedures for the treatment of pelvic organ prolapse.

OPTIONS

The discussion relates to transvaginal mesh procedures compared with other surgical options for pelvic organ prolapse (mainly about vaginal native tissue repairs and minimally about other alternatives such as biological and absorbable vaginal mesh and abdominally placed surgical mesh).

OUTCOMES

The outcomes of interest are objective and subjective success rates and intraoperative and postoperative complications, such as adjacent organ injury (urinary, gastrointestinal), infection, hematoma/bleeding, vaginal mesh exposure, persistent pain, dyspareunia, de novo stress urinary incontinence, and reoperation.

EVIDENCE

PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words pelvic organ prolapse/surgery*, prolapse/surgery*, surgical mesh, surgical mesh*/adverse effects, transvaginal mesh, and pelvic organ prolapse.

RESULTS

were restricted to English or French language and human research. Articles obtained through this search strategy were included until the end of June 2016. Pertinent new studies were added up to September 2016. Grey literature was not searched. Clinical practice guidelines and guidelines of specialty societies were reviewed. Systematic reviews were included when available. Randomized controlled trials and observational studies were included when evidence for the outcome of interest or in the target population was not available from systematic reviews. New studies not yet included in systematic reviews were also included. Only publications with study groups larger than 20 individuals were selected because this criterion was used in the largest meta-analysis referenced in this guideline. A total of 1470 studies were obtained; after selecting only applicable studies and excluding duplicates, 68 manuscripts were reviewed and included.

VALUES

The content and recommendations were drafted and agreed upon by the principal authors and members of the Urogynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. The Summary of Findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

It is expected that this guideline will benefit women with pelvic organ prolapse by ensuring that health care providers are aware of outcomes related to transvaginal mesh procedures and steps in the management of related complications. This should guide patient-informed consent before such procedures are undertaken. The benefits clearly outweigh the potential harms or costs of implementation of this guideline, although no direct harms or costs are identified.

GUIDELINE UPDATE

Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Biomechanical paradigm and interpretation of female pelvic floor conditions before a treatment

BACKGROUND

Further progress in restoring a woman's health may be possible if a patient with a damaged pelvic floor could undergo medical imaging and biomechanical diagnostic tests. The results of such tests could contribute to the analysis of multiple treatment options and suggest the optimal one for that patient.

AIM

To develop a new approach for the biomechanical characterization of vaginal conditions, muscles, and connective tissues in the female pelvic floor.

METHODS

Vaginal tactile imaging (VTI) allows biomechanical assessment of the soft tissue along the entire length of the anterior, posterior, and lateral vaginal walls at rest, with manually applied deflection pressures and with muscle contraction, muscle relaxation, and Valsalva maneuver. VTI allows a large body of measurements to evaluate individual variations in tissue elasticity, support defects, as well as pelvic muscle function. Presuming that 1) the female pelvic floor organs are suspended by ligaments against which muscles contract to open or close the outlets and 2) damaged ligaments weaken the support and may reduce the force of muscle contraction, we made an attempt to characterize multiple pelvic floor structures from VTI data.

RESULTS

All of the 138 women enrolled in the study were successfully examined with the VTI. The study subjects have had normal pelvic support or pelvic organ prolapse (stages I-IV). The average age of this group of subjects was 60±15 years. We transposed a set of 31 VTI parameters into a quantitative characterization of pelvic muscles and ligamentous structures. Interpretation of the acquired VTI data for normal pelvic floor support and prolapse conditions is proposed based on biomechanical assessment of the functional anatomy.

CONCLUSION

Vaginal tactile imaging allows biomechanical characterization of female pelvic floor structures and tissues in vivo, which may help to optimize treatment of the diseased conditions such as prolapse, incontinence, atrophy, and some forms of pelvic pain.

Turkish adaptation of the Pelvic Organ Prolapse Symptom Score and its validity and reliability

INTRODUCTION AND HYPOTHESIS

The purpose of this study was to adapt the Pelvic Organ Prolapse Symptom Score (POP-SS) into Turkish and evaluate its reliability and validity.

METHODS

The POP-SS was adapted into Turkish by following the steps of the intercultural adaptation process. One hundred and three women with symptomatic or asymptomatic pelvic organ prolapse (POP) completed the Turkish POP-SS and other valid and reliable Turkish tools for POP: Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6), Colorectal-Anal Distress Inventory 8 (CRADI-8), Urinary Distress Inventory 6 (UDI-6), Pelvic Floor Distress Inventory 20 (PFDI-20), and Pelvic Organ Prolapse Impact Questionnaire 7 (POPIQ-7). Pelvic Organ Prolapse Quantification (POP-Q) system was also used to assess pelvic support, and patients were divided into three groups based on POP-Q scores. Cronbach's alpha was used to determine internal consistency, and intraclass correlation coefficient (ICC) was estimated for test-retest reliability. POP-SS validity was assessed by using the Spearman rank correlation and Kruskal-Wallis analyses. The underlying scale structure was determined by exploratory factor analysis.

RESULTS

The POP-SS scale had high internal consistency (Cronbach's alpha = 0.705) and test-retest reliability (ICC = 0.981; p < 0.001). Among groups, there was statistically significant differences in POP-SS scores. POP-SS scores were also significantly correlated with POPDI-6 (r = 0.830), CRADI-8 (r = 0.525), UDI-6 (r = 0.385), PFDI-20 (r = 0.752), and POPIQ-7 (r = 0.690) (p < 0.001). Two factors were identified by exploratory factor analysis.

CONCLUSIONS

The Turkish version of POP-SS is a valid and reliable tool for Turkish women with POP.