Does concurrent posterior repair for an asymptomatic rectocele reduce the risk of surgical failure in patients undergoing sacrocolpopexy?

Analysis of the Clinical Value of Laparoscopic Sacrocolpopexy to Support the Posterior Compartment in Women with Multicompartment Prolapse Including Rectocele

Background/Objectives: Laparoscopic sacrocolpopexy is regarded as the gold standard treatment for apical or multicompartment prolapse, predominantly with anterior compartment descent. However, the optimal surgical approach for concurrent rectocele is still debated. The aim of this study was to evaluate the effectiveness of nerve-sparing laparoscopic sacrocolpopexy in managing multicompartment prolapse with concurrent rectocele (≥stage II), analyzing the anatomical outcomes, the necessity for concomitant or subsequent posterior repair, and the impact on bowel function in women undergoing surgery. Methods: Data from all women who underwent laparoscopic sacrocolpopexy with or without posterior repair between 01/2017 and 07/2022 for symptomatic multicompartment prolapse, including apical and posterior compartment descent ≥ stage II, were retrospectively evaluated. All women underwent a standardized urogynecological examination, including assessment of genital prolapse using the POP-Q quantification system, and completed the German-validated Australian Pelvic Floor Questionnaire before and after surgery (6-12 weeks). Preoperative anatomic support and bowel symptoms were compared with postoperative values. Results: In total, 112 women met the criteria for surgical correction. The majority (87%) had stage II posterior descent, with only 10% undergoing concurrent posterior repair during laparoscopic sacrocolpopexy. Significant (p < 0.001) objective improvement was seen for all compartments post- compared with preoperatively (Ba: 0 (-1/2) vs. -3 (-3/-2), C: -1 (-2/0) vs. -8 (-12/-7), Bp: 0 (-1/0) vs. -3 (-2/-2); (median (25%/75% quartiles)). Subsequent surgery for persistent rectocele and/or stool outlet symptoms was required in 4% of cases. Most bowel-specific questions in the German-validated Australian Pelvic Floor Questionnaire showed significant improvement (p < 0.001). Conclusions: Nerve-sparing sacrocolpopexy alone appears to be a suitable surgical approach to correct multicompartment prolapse, including a rectocele ≥ stage II, and results in a reduction of objective signs and symptoms of pelvic organ prolapse.

Robotic sacrocolpopexy

Pelvic organ prolapse (POP) is a common cause of gynecological disease in elderly women. The prevalence of POP has increased with an aging society. Abdominal sacrocolpopexy (ASC) is safer and more effective than the vaginal approach in patients with apical compartment POP because it has a higher anatomical cure rate, a lower recurrence rate, less dyspareunia, and improved sexual function. Laparoscopic sacrocolpopexy (LSC) has replaced ASC. Robotic sacrocolpopexy (RSC) also helps overcome the challenges of LSC by facilitating deep pelvic dissection and multiple intracorporeal suturing. The RSC is technically easy to apply, has a steep learning curve, and offers many advantages over the LSC. However, insufficient data led us to conclude that the LSC is superior overall, especially in terms of costeffectiveness. The present review provides insights into different aspects of RSC, highlighting the most common benefits and concerns of this procedure. We searched for eligible articles discussing this issue from January 2019 to March 2022 to reveal the outcomes of RSC.

Surgical correction of the genital hiatus at the time of sacrocolpopexy - a 7-year Markov analysis: a cost-effectiveness analysis

INTRODUCTION AND HYPOTHESIS

To perform a cost-effectiveness analysis of concurrent posterior repair performed at the time of laparoscopic hysterectomy with sacrocolpopexy over a 7-year time period. We hypothesize it is not cost-effective to perform a posterior colporrhaphy.

METHODS

We used TreeAge Pro® to construct a decision model with Markov modeling to compare sacrocolpopexy with and without concurrent posterior repair (SCP and SCP+PR) over a time horizon of 7 years. Outcomes included probability and costs associated with prolapse recurrence, prolapse retreatment, and complications including rectal injury, rectovaginal hematoma requiring reoperation, and postoperative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) calculated as ∆ costs /∆ effectiveness and the willingness to pay (WTP) was set at $100,000/QALY.

RESULTS

Our model showed that SCP was the dominant strategy, with lower costs (-$ 2681.06) and higher effectiveness (+0.10) compared to SCP+PR over the 7-year period. In two-way sensitivity analyses, we varied the probability of prolapse recurrence after both strategies. Our conclusions would only change if the probability of recurrence after SCP was at least 29.7% higher than after SCP+PR. When varying the probabilities of dyspareunia for both strategies, SCP+PR only became the dominant strategy if the probability of dyspareunia for SCP+PR was lower than the rate of SCP alone.

CONCLUSIONS

In this 7-year Markov cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy. SCP+PR costs more with lower effectiveness than SCP alone, due to higher surgical cost of SCP+PR and higher probability of dyspareunia after SCP+PR.

Is there an association between 6-month genital hiatus size and 24-month composite prolapse recurrence following minimally invasive sacrocolpopexy?

INTRODUCTION AND HYPOTHESIS

Although an enlarged postoperative genital hiatus (GH) size has been identified as a predictor of recurrence following pelvic organ prolapse (POP) surgery, the protective role of concurrent level III support procedures to reduce the GH size at the time of minimally invasive sacrocolpopexy (MI-SCP) remains unclear. The objective of this study was to compare 24-month composite prolapse recurrence following MI-SCP between patients with a 6-month postoperative GH measurement of <3 cm versus ≥3 cm; and to explore the impact of concurrent level III support procedures on prolapse recurrence, bowel, and sexual function.

METHODS

This was a secondary analysis of two randomized controlled trials of women who underwent MI-SCP from 2014 to 2020. Our primary outcome was composite prolapse recurrence defined as retreatment with either pessary or surgery, and/or subjective bothersome vaginal bulge. A receiver operating characteristic (ROC) curve was generated to identify a 6-month GH cutoff point associated with 24-month composite recurrence.

RESULTS

Of the 108 women who met the inclusion criteria, 13 (12%) had composite prolapse recurrence at 24 months: 12 patients (11.1%) reported a bothersome vaginal bulge, and 3 patients (2.8%) underwent retreatment with surgery. A ROC curve demonstrated that a 6-month postoperative GH size of 3 cm had 84.6% sensitivity to predict vaginal bulge and/or retreatment at 24 months (area under curve = 0.52). There was no difference in the composite prolapse recurrence between the groups; however, only patients with a 6-month GH >3 cm underwent retreatment.

CONCLUSIONS

Twenty-four-month composite prolapse recurrence does not differ based on 6-month GH size; however, surgical failure may be more common in those with a GH size greater than 3 cm.

Laparoscopic posterior vaginal plication plus sacral colpopexy for severe posterior vaginal prolapse: A randomized clinical trial

AIM

A randomized clinical trial proposing a new laparoscopic prosthetic and fascial approach to severe posterior vaginal prolapse. The primary endpoint was to evaluate the objective and subjective outcomes of our laparoscopic posterior plication (LPP) combined to "two-mesh" sacral colpopexy (laparoscopic sacral colpopexy [LSC]) in severe posterior vaginal prolapse, with a 1-year follow-up. The secondary endpoint was to evaluate the safety of this surgical procedure.

METHODS

This is single-center prospective randomized double-blinded clinical trial. A total of 130 consecutive patients with anterior and/or apical pelvic organ prolapse (POP) (POP-Q stage ≥II) and severe posterior vaginal prolapse (posterior POP-Q stage ≥III) were prospectively assessed for inclusion into the study from November 2018 to January 2020. Patients underwent "two-meshes" LSC and were randomized in Group A (LSC plus LPP) and Group A (LSC alone). Of the 130 included subjects, 8 were excluded, not meeting inclusion criteria. Cure rate was evaluated objectively, using POP-Q study, and subjectively using PGI-I, POPDI-6, and FSDS questionnaires. Complications were assessed intra-, peri-, and postoperatively. Twelve-month follow-ups were analyzed for the study.

RESULTS

We found in LSC plus LPP Group a significant improvement of Ap and genital hiatus POP-Q points. Our subjective study showed, at 12 months, a statistical difference in PGI-I successful outcomes rate in favor of LPP. Also the FSDS resulted significantly much more improved in Group A. We observed no statistical differences in terms of postoperative complications.

CONCLUSIONS

Our LPP approach to LSC could be considered an effective and safe technique to POP patients with severe posterior prolapse.

Comparison of the Perineal Body Between Chinese Women With Pelvic Organ Prolapse and Women With Normal Support by Magnetic Resonance Imaging With 3-Dimensional Reconstruction

OBJECTIVE

This study aimed to determine whether the perineal body (PB) is different between women with and without prolapse and to analyze its association with prolapse.

METHODS

This cross-sectional observational study was performed in a tertiary-level urology department and included patients with stage II-IV pelvic organ prolapse (POP) and normal controls with all points 1 cm or more above the hymen. The patients underwent supine midsagittal magnetic resonance imaging (MRI) at rest and during the maximum Valsalva maneuver. Perineal mobility and PB length, height, perimeter, and area were measured; in addition, the genital hiatus and PB were measured according to the definition of the Pelvic Organ Prolapse Quantification system. Univariate associations of POP with characteristics were assessed using the chi-square test or Fisher exact test for categorical variables and the t test for continuous variables. Multivariate logistic regression analysis was used to estimate the adjusted odds ratios and 95% confidence intervals.

RESULTS

Seventy-two controls and 130 patients were analyzed. The PB length, height, and area measurements were significantly lower in the POP group. The perineal mobility in different directions was significantly higher in the POP group. Multivariate analysis demonstrated that the PB area and perineal mobility in the ventral-dorsal and cranio-caudal directions were associated with POP.

CONCLUSIONS

Our data suggest that a smaller PB area and greater dorsal or caudal mobility are associated with prolapse.

Determining the Ideal Intraoperative Resting Genital Hiatus Size-Balancing Surgical and Functional Outcomes

IMPORTANCE

The intraoperative resting genital hiatus (GH) size can be surgically modified but its relationship to prolapse recurrence is unclear.

OBJECTIVES

The objective of this study was to identify the optimal intraoperative resting GH size as it relates to prolapse recurrence and functional outcomes at 1 year.

STUDY DESIGN

This prospective cohort study was conducted at 2 hospitals from 2019 to 2021. Intraoperative measurements of the resting GH, perineal body, and total vaginal length were collected. The composite primary outcome consisted of anatomic recurrence, subjective recurrence, and/or conservative or surgical retreatment at 1 year. Comparisons of anatomic, functional, and sexual outcomes were compared between patients stratified by the optimal intraoperative GH size identified by receiver operating characteristic curve analysis.

RESULTS

Sixty-eight patients (median age of 63 years) underwent surgery, with 59 (86.8%) presenting for follow-up at 1 year. Based on the 13 patients (22%) with composite recurrence, receiver operating characteristic curve analysis demonstrated an intraoperative resting GH size of 3 cm, had 76.9% sensitivity (confidence interval [CI], 54-99.8%), and 34.8% specificity (CI, 21.0-48.5%) for composite recurrence at 1 year (area under curve = 0.61). Nineteen patients had an intraoperative GH less than 3 cm (32.2%) and 40 had a GH of 3 cm or greater (67.8%). The intraoperative resting GH size was significantly larger in patients with prolapse beyond the hymen at 1 year (4 cm [3.0, 4.0]) compared with those with prolapse at or proximal to the hymen (3.0 cm [2.5, 3.5], P = 0.009).

CONCLUSIONS

Intraoperative GH size may not reliably predict composite prolapse recurrence at 1 year, although there was an association between intraoperative resting GH size with prolapse beyond the hymen.

Advanced Cystocele is a Risk Factor for Surgical Failure Following Robotic-Assisted Laparoscopic Sacrocolpopexy

STUDY OBJECTIVE

To assess the outcome of robotic-assisted laparoscopic sacrocolpopexy (RALSCP) and to identify risk factors for surgical failure and long term complications in patients at high risk for surgical failure.

DESIGN

Retrospective cohort study.

SETTING

A university hospital.

PATIENTS

Sixty-seven women with pelvic organ prolapse at high risk for surgical failure.

INTERVENTIONS

RALSCP from November 2012 to July 2020.

MEASUREMENTS AND MAIN RESULTS

Information was collected from the electronic medical records. Pre-operative and post-operative assessment included a urogynecologic history, prolapse staging, cough stress test, and validated quality of life questionnaires. Anatomical success was defined as POP stage less than 2 at last follow-up. Mean follow-up was 24.6 ± 17.9 months. Sixteen women (23.9%) reported bulge symptoms at the latest follow-up; upon POP-Q staging, surgical failure or recurrence was observed in 35 (52.2%) patients. On multiple logistic regression analysis, a pre-operative POP-Q point Ba measurement ≥ 3 cm beyond the hymen was independently related to surgical failure. Late post-operative complications included three (4.5%) cases of post-operative ventral hernia and five (7.5%) cases of mesh erosion, all in patients operated using Ethibond sutures.

CONCLUSIONS

Anatomical success of RALSCP in POP patients at high risk for surgical failure is worse than previously reported. Advanced pre-operative anterior vaginal wall prolapse is a risk factor for surgical failure. Delayed absorbable sutures for vaginal mesh fixation seem to be safer than multifilament, permanent sutures, in terms of the risk for mesh erosion.

Importance of Translabial Ultrasound for the Diagnosis of Pelvic Organ Prolapse and Its Correlation with the POP-Q Examination: Analysis of 363 Cases

The incidence of pelvic organ prolapse (POP) is increasing in our aging society. We aimed to evaluate the clinical usefulness of translabial ultrasound (TLUS) by comparing the findings of POP-Q examination and TLUS in advanced POP patients and we also aimed to evaluate the prevalence of rectocele and enterocele on the TLUS. We analyzed the TLUS and POP-Q exam findings of 363 symptomatic POP patients who visited our clinic from March 2019 to April 2021. We excluded three patients who had conditions mimicking POP, as revealed by the TLUS. The most common POP type was anterior compartment POP (68.61%), followed by apical compartment (38.61%) and posterior compartment (16.11%) POP. Agreement between the POP-Q exam and TLUS was tested using Cohen’s kappa (κ). p values < 0.05 were considered statistically significant. The incidence of rectocele or enterocele was only 1.67% (6/360) and there was no rectocele or enterocele in most patients (246/252, 96.63%) when the POP-Q exam revealed posterior compartment POP, suggesting that they only had posterior vaginal wall relaxation. The positive predictive value of the POP-Q exam for detecting rectocele or enterocele (as revealed by TLUS) was only 2.38%, whereas the negative predictive value was 100%. In conclusion, the application of TLUS is useful in the diagnosis of POP, especially for differentiation of true POP from conditions mimicking POP. The correlation between the POP-Q exam and TLUS is low, especially in posterior compartment POP, and therefore, patients with POP-Q exam findings suggesting posterior compartment POP should undergo TLUS to check for rectocele or enterocele. The use of TLUS in the diagnosis of POP patients can improve the accuracy of the diagnosis of POP patients in conjunction with a POP-Q exam.

Posterior repair versus no posterior repair for posterior vaginal wall prolapse resolved under simulated apical support at the time of native tissue apical suspension

INTRODUCTION AND HYPOTHESIS

The aim of this study was to evaluate the impact of an adjuvant posterior repair (PR) on treatment outcomes of native tissue apical suspension.

MATERIALS AND METHODS

This retrospective cohort study included 194 women who underwent iliococcygeus or uterosacral ligament suspension with or without PR for Pelvic Organ Prolapse Quantification (POPQ) stage 2-4 posterior vaginal wall prolapse that resolved under simulated preoperative apical support and who completed a 1-year follow-up. The primary outcome was composite surgical failure defined as the presence of vaginal bulge symptoms, descent of the vaginal apex more than one-third of the way into the vaginal canal (apical recurrence), anterior or posterior vaginal wall descent beyond the hymen (anterior or posterior recurrence), or retreatment for prolapse. Secondary outcomes included anatomical outcomes, perioperative outcomes, obstructed defecation, dyspareunia, and adverse events.

RESULTS

One hundred thirty women underwent concomitant PR, and 64 did not. Surgical failure rates were significantly higher in the group not receiving PR than in the group receiving PR (29.7% vs. 12.3%, p < 0.01). Anatomically, anterior and apical recurrence was more common in the group not receiving PR (p < 0.05). Concomitant PR was associated with a longer operating time and more blood loss (p < 0.01). However, there were few adverse events related to PR, and the rates of de novo obstructed defecation and dyspareunia were low in both groups, with no significant difference between the groups.

CONCLUSION

Concomitant PR at the time of native tissue apical suspension may reduce the recurrence of symptomatic anterior and apical prolapse without significant morbidity.

Surgical Repair of the Genital Hiatus: A Narrative Review

INTRODUCTION AND HYPOTHESIS

An enlarged genital hiatus (GH) is associated with the development of prolapse and may be associated with prolapse recurrence following surgery; however, there is insufficient evidence to support surgical reduction of the GH as prophylaxis against future prolapse. The objective of this review is (1) to review the association between GH size and pelvic organ prolapse and (2) to discuss the existing literature on surgical procedures that narrow the GH.

METHODS

A literature search was performed in the PubMed search engine, using the keyword "genital hiatus." Articles were included if they addressed any of the following topics: (1) normative GH values; (2) associations between the GH and prolapse development or recurrence; (3) surgical alteration of the GH; (4) indications, risks or benefits of surgical alteration of the GH.

RESULTS

An enlarging GH has been observed prior to the development of prolapse. Multiple studies show that an enlarged pre- and/or postoperative GH is associated with an increased risk of recurrent prolapse following prolapse repair surgery. There are limited data on the specific risks of GH alteration related to bowel and sexual function.

CONCLUSIONS

GH size and prolapse appear to be strongly associated. Because GH size appears to be a risk factor for pelvic organ prolapse, the GH size should be carefully considered at the time of surgery. Surgeons should discuss with their patients the risks and potential benefits of additional procedures designed to reduce GH size.

Impact of Genital Hiatus Size on Anatomic Outcomes After Mesh-Augmented Sacrospinous Ligament Fixation

OBJECTIVE

Our objective is to compare anatomic outcomes at medium term after mesh-augmented sacrospinous ligament fixation among women categorized by their preoperative and postoperative genital hiatus size.

METHODS

We performed a retrospective cohort study in women undergoing Uphold mesh-augmented sacrospinous ligament fixation between 2010 and 2017. We compared 3 groups: (1) women with a wide genital hiatus preoperatively and 6 weeks postoperatively ("Persistently Wide" cohort), (2) women with a wide genital hiatus preoperatively but normal hiatus 6 weeks postoperatively ("Improved" cohort), and (3) women with a normal genital hiatus preoperatively and 6 weeks postoperatively ("Stably Normal" cohort). We defined a wide hiatus as 4 cm or greater and a normal hiatus as less than 4 cm. The primary outcome was anatomic failure, defined as recurrent prolapse beyond the hymen or retreatment for prolapse with surgery or pessary.

RESULTS

Ninety-seven women were included in the study. Overall, mean age was 68 years (±7.15 years), mean body mass index was 28.36 kg/m2 (±5.34 kg/m2) and mean follow up time was 400 ± 216 days. Anatomic failure did not differ between groups (Persistently Wide, 15.4%; Improved, 11.1%; Stably Normal, 10.0%; P = 0.88). In logistic regression, the odds of anatomic failure remained similar among all groups (P = 0.93).

CONCLUSIONS

A persistently wide genital hiatus alone was not associated with anatomic failure in this small study cohort. Therefore, surgical reduction of the genital hiatus with level III support procedures may not affect prolapse recurrence at the time of mesh-augmented sacrospinous ligament fixation. Further studies are needed to confirm this relationship and investigate other potential mechanisms for these findings.

Laparoscopic minimally invasive sacrocolpopexy or hysteropexy and transobturator tape combined with native tissue repair of the vaginal compartments in patients with advanced pelvic organ prolapse and incontinence

INTRODUCTION AND HYPOTHESIS

The aim of the study was to evaluate hysterectomized and non-hysterectomized patients with prolapse and incontinence. Laparoscopic sacrohysteropexy (LSHP) and minimally invasive sacrocolpopexy (LMSCP) were done in combination with transobturator tape (TOT) and native tissue repair of the anterior and posterior vaginal compartments in patients with pelvic organ prolapse (POP) and occult, stress, or urinary incontinence (SUI). The hypothesis is that both methods are successful.

METHODS

A total of 81 patients with POP were evaluated: 44 had vaginal vault prolapse (POPQ points Ba, C, and Bp were 1.2, 2.6, and 0.4, respectively) and 37 had uterine prolapse (POPQ points Ba, C, and Bp were 1.8, 1.7, and 1.3, respectively). LMSCP (which means less dissection of the vagina in its upper third and avoiding possible collision with the ureters anteriorly or the rectum posteriorly) was performed in patients with vault prolapse, whereas patients with uterine prolapse underwent LSHP. Transobturator tape (TOT) was placed in all patients to treat symptomatic and occult urinary incontinence. Systematic anterior and posterior colporrhaphy was performed in both groups.

RESULTS

Both groups showed anatomic (p < 0.0001) and symptomatic improvement (p < 0.001-p < 0.05). Voiding was significantly improved after surgery without postoperative incontinence (p < 0.001). There was no significant difference between groups regarding duration of surgery (p = 0.06), hospital stay (p = 0.13), blood loss (0.83), Clavien-Dindo grade 3 (p = 0.87), and Clavien-Dindo grade 1-2 (p = 0.92) complications.

CONCLUSION

Minimally invasive LSCP or LSHP combined with TOT and native tissue repair of the anterior and posterior vaginal compartment is a successful treatment for POP.

Occult Uterine Malignancy at the Time of Sacrocolpopexy in the Context of the Safety Communication on Power Morcellation by the FDA

STUDY OBJECTIVE

The objective of this study was to determine the incidence of occult uterine malignancy at the time of sacrocolpopexy with concurrent hysterectomy, in the context of practice pattern changes as a result of the 2014 Food and Drug Administration (FDA) power morcellation safety communication.

DESIGN

Retrospective chart review.

SETTING

Tertiary care referral center in the United States.

PATIENTS

A total of 839 patients who underwent sacrocolpopexy from January 2004 to December 2018.

INTERVENTIONS

All patients received a concurrent hysterectomy without a diagnosis of suspected or confirmed gynecologic malignancy before surgery. Trends of surgeries were compared before and after the 2014 FDA power morcellation safety communication.

MEASUREMENTS AND MAIN RESULTS

Demographic and perioperative data were collected from the system-wide electronic medical record. Operative and pathology reports were reviewed to determine the method of specimen retrieval and specimen pathology results. A total of 238 patients (28.4%) had a hysterectomy at the time of sacrocolpopexy. There were no cases of occult uterine malignancy (0%, 95% CI 0%-1.6%). There was 1 case of borderline tumor of the ovary. The most common mode of hysterectomy over the 15-year period was laparoscopic hysterectomy (n = 84, 35.3%), followed by vaginal hysterectomy (n = 63, 26.5%). After the FDA communication, the most common form of hysterectomy changed significantly to vaginal hysterectomy (n = 35, 55.6%; p <.001). When comparing the first 2 years after the announcement (2014-2016) to the subsequent 2 years (2017-2018), there was again a significant increase in the use of laparoscopic hysterectomy in the latter time period (7.3% vs 40.9%; p <.001).

CONCLUSION

In this cohort of patients undergoing sacrocolpopexy with concurrent hysterectomy, the incidence of occult uterine malignancy was low. After the FDA safety communication, practice patterns with regard to the mode of hysterectomy changed, but the magnitude of these changes were transient.