Patient-reported outcomes after sacrospinous fixation of vault prolapse with a suturing device: a retrospective national cohort study

Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review

OBJECTIVE

To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures.

DATA SOURCES

We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022.

METHODS OF STUDY SELECTION

Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated.

TABULATION, INTEGRATION, AND RESULTS

The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity.

CONCLUSION

Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022327490.

Comparison between anterior and posterior vaginal approach in apical prolapse repair in relation to anatomical structures and points of fixation to the sacrospinous ligament in fresh postmenopausal female cadavers

INTRODUCTION AND HYPOTHESIS

The high prevalence of pelvic organ prolapse (POP) in women requires attention and constant review of treatment options. Sacrospinous ligament fixation (SSLF) for apical prolapse has benefits, high efficacy, and low cost. Our objective is to compare anterior and posterior vaginal approach in SSLF in relation to anatomical structures and to correlate them with body mass index (BMI).

METHODS

Sacrospinous ligament fixation was performed in fresh female cadavers via anterior and posterior vaginal approaches, using the CAPIO®SLIM device (Boston Scientific, Natick, MA, USA). The distances from the point of fixation to the pudendal artery, pudendal nerve, and inferior gluteal artery were measured.

RESULTS

We evaluated 11 cadavers with a mean age of 70.1 ± 9.9 years and mean BMI 22.4 ± 4.6 kg/m². The mean distance from the posterior SSLF to the ischial spine, pudendal artery, pudendal nerve, and inferior gluteal artery were 21.18 ± 2.22 mm, 17.9 ± 7.3 mm, 19.2 ± 6.8 mm, and 18.9 ± 6.9 mm respectively. The same measurements relative to the anterior SSLF were 19.7 ± 2.7 mm, 18.6 ± 6.7 mm, 19.2 ± 6.9 mm, and 18.3 ± 6.7 mm. Statistical analysis showed no difference between the distances in the two approaches. The distances from the fixation point to the pudendal artery and nerve were directly proportional to the BMI.

CONCLUSIONS

There was no difference in the measurements obtained in the anterior and posterior vaginal approaches. A direct correlation between BMI and the distances to the pudendal artery and pudendal nerve was found.

Fast track sacrospinous ligament fixation: subjective and objective outcomes at 6 months

BACKGROUND

Sacrospinous ligament fixation (SSLF) is a widely used vaginal procedure for correction of apical vaginal prolapse. The objective of this study was to evaluate subjective and objective outcomes of SSLF performed in a fast-track setting.

METHODS

This was a prospective cohort study of sacrospinous ligament fixation performed using local anesthesia and light sedation in a fast-track setting at Aarhus University Hospital between April 2016 and December 2017. Objective signs of prolapse were assessed by gynecological examination preoperatively and at 6 months after the operation. Subjective symptoms were evaluated by questionnaires (the Pelvic Floor Distress Inventory (PFDI 20), and the Patient Global Impression of Improvement (PGI-I) supplemented with individual questions from the ICIQ-vaginal Symptoms (ICIQ-VS) and Sexual Questionnaire-IR (PISQ-12) questionnaires).

RESULTS

One hundred and three women with a median age of 65 (36-84) years were included. Previous hysterectomy had been performed in 40% of the women, and 43% had a history of previous prolapse operations. At follow-up, 75% of the women had apical descent less than stage 2. However, 18% had anterior vaginal wall prolapse beyond the hymen, and 25% had recurrence of the apical prolapse stage 2 or more and were offered reoperation. Bladder and anal symptoms improved in most women after the operation, and the number of women reporting dyspareunia was halved. In the overall assessment by Patient Global Impression of Improvement (PGI-I) questionnaire, 76% reported improvement. No serious operative complications were reported, and 81% of the patients were discharged on the day of the surgery.

CONCLUSION

In this cohort with a high rate of previous prolapse surgery, sacrospinous ligament fixation performed in a fast-track setting showed subjective and objective results comparable to the results of apical native tissue repair reported in the literature. Furthermore, the complication rate was low. Trial registration This study was notified to The Central Denmark Region Committees on Health Research Ethics on July 7, 2015, and was approved by The Danish Data Protection Agency (1-16-02-442-15). All methods were performed in accordance with the relevant guidelines and regulations. An informed consent for participation in the study and acceptance of using data for scientific purposes and publication was signed by all patients.

Sacrospinous ligament fixation: medium and long-term anatomical results, functional and quality of life results

BACKGROUND

To evaluate the medium and long-term anatomical results of sacrospinous ligament fixation (SLF) and its impact on quality of life (QoL).

METHODS

We conducted a retrospective and observational single centre study. Fifty-nine patients were interviewed using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire and underwent physical examination using POP-Q several years after SLF. Primary outcome was the comparison of anatomic results of SLF at medium-term (group 1: 1-5 years after surgery) and long-term (group 2: more than 5 years after surgery). The secondary outcome was QoL evaluation.

RESULTS

The overall recurrence and complication rates were respectively 22% and 10%, with no significant differences between groups 1 and 2. The recurrence rate was similar in both groups [twelve (35%) in group 1 and nine (20%) in group 2, p = 0.09]. Two patients (12%) in the recurrence and none in the no recurrence group had clinical symptoms (p = 0.08). Two patients (12%) in the recurrence and one patient (2%) in the no-recurrence group had a significant impact on their quality of life (p = 0.12).

CONCLUSION

This study showed sustainable anatomic and functional results of SLF in medium and long-term analysis with overall low morbidity.

Pelvic Organ Prolapse Repair with Mesh: Description of Surgical Technique Using the Surelift® Anterior Repair System

INTRODUCTION

Although the use of transvaginal mesh (TVM) in the repair of pelvic organ prolapse (POP) has been restricted, there are still some cases in which TVM may be the most appropriate approach. The TVM Surelift® anterior repair surgical technique has not been described previously.

OBJECTIVE

The aim of this study was to describe the surgical technique and to report our preliminary results regarding efficacy and complications.

METHODS

A step-by-step description of surgical technique is presented. A descriptive retrospective analysis was performed to evaluate our preliminary results in 17 women who underwent POP repair using the Surelift® anterior repair system in our department between 2014 and 2017. TVM was offered to patients with symptomatic apical (primary or recurrent) or recurrent anterior POP stage ≥2. POP recurrence was classified as asymptomatic anatomic or symptomatic. Patients rated satisfaction with surgery on a scale from 0 to 10. Complications during follow-up were classified according to the International Urogynecological Association/International Continence Society recommendations.

RESULTS

Median (IQR) follow-up was 19.9 months (24.8). Two (11.8%) anatomic recurrences were identified, both symptomatic, but neither required further surgery. No cases of pelvic pain, dyspareunia, voiding, or defecatory dysfunction were detected. Two (11.8%) patients presented a <1-cm vaginal mesh exposure (2AaT3S2) requiring partial mesh removal through a vaginal approach. At the end of follow-up, median satisfaction (IQR) with the surgery was 9 (3.1).

CONCLUSION

The Surelift® anterior repair system is effective in correcting apical or recurrent anterior POP, with a high patient satisfaction rate. Complications after this surgery are infrequent and are mostly related to vaginal mesh exposure.

Update in native tissue vaginal vault prolapse repair

The lifetime risk of women for undergoing surgery for pelvic organ prolapse (POP) is estimated to be 11-19%, and 30% of these women will require subsequent reoperation over time. Following hysterectomy, 3.6 per 1,000 person-years need surgical correction of prolapse, and in two-thirds of these cases multi-compartment prolapse is present. In the last decades, vaginally synthetic meshes were widely used in pelvic reconstructive surgery. However, after the decision of the Food and Drug Administration in 2019 to stop selling all surgical mesh devices for transvaginal prolapse repair, native tissue (NT) vaginal repair seems to regain an important role in pelvic reconstructive surgery. In the literature, various surgical techniques have been described for apical repair, but the best surgical approach is still to be proven. This paper analyzes the current evidence from recent literature on NT vaginal vault prolapse (VVP) repair, with special focus on the safety and efficacy of the various vaginal techniques.

Vaginal posterior isthmic sling: A report of 53 cases

INTRODUCTION

Sacrospinofixation is used for fundic vaginal vault's prolapse or to prevent mid-level or posterior prolapse. It can lead to complications such as dyspareunia, chronic pain, and quality of life impairment. Anchoring a posterior isthmic sling to the two sacrospinous ligaments is an alternative to classic Richter's sacrospinofixation. Objective of this study is to report the first cases of vaginal posterior isthmic slings.

METHODS

This study is retrospective and unicentric. It includes women who had posterior isthmic sling at the time of a surgery with a mesh for anterior prolapse by vaginal way between 2010 and 2016 in the gynecologic department of a teaching hospital. Report of efficacy and tolerance was performed.

RESULTS

Between 2010 and 2016, 53 women were included with a posterior isthmic sling and a mesh for an anterior prolapse. POP-Q evolution during the follow-up in the posterior isthmic sling group assess of a good efficacy of the sling. Four women (7.5%) required second surgery in 28 months following initial surgery (only 1 for excision). Four women (7.5%) had a prolapse recurrence in a mean time of 30 months without recurrent surgery. Women's satisfaction level was high (8.0/10 [7,1-8,8]).

CONCLUSION

Efficacy and tolerance of the posterior isthmic sling seems good. It might then be an option for mid-level prolapses in case of vaginal surgery with mesh for anterior prolapse. A non-inferiority trial should be performed to be able to conclude on the place of this alternative to Richter's sacrospinofixation.

Pelvic Organ Prolapse Repair with Mesh: Mid-Term Efficacy and Complications

INTRODUCTION

Our aim was to assess the efficacy and complications of pelvic organ prolapse (POP) correction with transvaginal mesh (TVM).

MATERIALS AND METHODS

We retrospectively assessed patients who had undergone a repair of an apical (primary or recurrent) or recurrent POP using TVM in our department since 2007. Meshes used were Prolift®, Elevate®, and Surelift®. Satisfaction with surgery was assessed on a 0-10 scale.

RESULTS

A total of 83 patients were included (33 Prolift®, 36 Elevate®, 14 Surelift®), with a mean age of 67.8 ± 9.7 years. Eighteen (21.6%) patients underwent a recurrent POP correction. Follow-up was 49 ± 34 months. Twelve (14.4%) symptomatic recurrences were identified, 3 of which required further surgery. Satisfaction was 8.7. Four (4.8%) vaginal exposures were detected, 2 of which required partial mesh removal. Three (3.6%) cases of dyspareunia and 1 (1.2%) case of mild pelvic pain were reported, which did not require further treatment.

CONCLUSION

The use of TVM for apical or recurrent POP repair is effective and is associated with a high satisfaction rate while complications are infrequent.