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

Is Posterior Transvaginal Mesh Surgery Using PTFE Mesh ORIHIME Effective and Safe for Advanced Posterior Vaginal Prolapse?

OBJECTIVES

To examine the efficacy and safety of posterior tension-free vaginal mesh (TVM-P) surgery using polytetrafluoroethylene (PTFE) mesh (ORIHIME) for advanced posterior vaginal prolapse.

METHODS

A retrospective cohort study was conducted involving patients who underwent TVM-P surgery with PTFE mesh for pelvic organ prolapse quantification stage III or IV posterior vaginal prolapse between December 2018 and March 2023. All patients were followed for a minimum of 1 year postoperatively. The primary outcome was the recurrence rate in the operated compartment. Secondary outcomes comprised recurrence in other pelvic compartments, mesh-related complications, and an analysis of risk factors for recurrence.

RESULTS

Seventy-one patients underwent TVM-P surgery during the study period. The recurrence rate in the operated compartment was 4.2%, while the overall recurrence rate was 18.3%. Eleven cases of recurrence occurred within the first year; 13 cases were observed within 3 years postsurgery. Patients who experienced recurrence in other compartments had a significantly higher incidence of preoperative Ba point score ≥ -1 versus the nonrecurrence group. Preoperative Ba point score ≥ -1 was associated with a higher risk of recurrence in other compartments (crude odds ratio: 4.17, 95% confidence interval: 1.03-26.7; adjusted odds ratio: 2.58, 95% confidence interval: 0.56-11.8).

CONCLUSIONS

The recurrence rate in the operated compartment following TVM-P surgery for advanced rectoceles or enteroceles was 4.2%. These findings suggest that TVM-P surgery using PTFE mesh may be an effective surgical option for treating severe posterior vaginal pelvic organ prolapse.

Dynamic Changes of the Genital Hiatus at the Time of Prolapse Surgery: 1-Year Follow-Up Study

IMPORTANCE

The genital hiatus (GH) has been identified as a predictor of pelvic organ prolapse. An enlarged preoperative GH is a risk factor for recurrent prolapse after surgery.

OBJECTIVE

The objective of this study was to determine the changes in preoperative and postoperative GH size compared with the intraoperative resting GH at 6 weeks and 12 months after native-tissue pelvic organ prolapse surgery.

STUDY DESIGN

This was a descriptive analysis of a prospective cohort study of women undergoing native-tissue prolapse repair with apical suspension. Resting GH was obtained at the start and conclusion of surgery. Measurements were obtained preoperatively, and 6 weeks and 12 months postoperatively under Valsalva maneuver. Comparisons were made using paired t tests for the following time points: (1) preoperative measurements under Valsalva maneuver to resting presurgery measurements under anesthesia, and (2) resting postsurgery measurements under anesthesia to 6 weeks and 12 months postoperatively under Valsalva maneuver.

RESULTS

Sixty-seven patients were included, with a median age of 66 years and median body mass index (calculated as weight in kilograms divided by height in meters squared) of 29.1. There was no significant difference in GH when measured preoperatively to resting presurgical measurements under anesthesia (P = 0.60). For all, the median GH was 3.0 cm at the conclusion of surgery and remained at 3.0 cm at 6 weeks and 12 months postoperatively. In patients who had a concurrent posterior colporrhaphy, the median resting postsurgery GH was 3.0 cm, then decreased to 2.5 cm at 6 weeks then 3.5 cm at 12 months under Valsalva.

CONCLUSIONS

Preoperative GH size under Valsalva maneuver and resting under anesthesia were comparable. For all patients undergoing native-tissue pelvic organ prolapse repair, the genital hiatus size remains the same from the intraoperative final resting measurements to the 6-week and 12-month measurements under Valsalva maneuver.

Diagnostic Value of Dynamic Magnetic Resonance Imaging (dMRI) of the Pelvic Floor in Genital Prolapses

Pelvic organ prolapse is a chronic disease resulting from a weakening of the musculoskeletal apparatus of the pelvic organs. For the diagnosis of this pathology, it is insufficient to conduct only a clinical examination. An effective diagnostic tool is the method of dynamic magnetic resonance imaging (MRI) of the pelvic floor, which allows a comprehensive assessment of the anatomical and functional characteristics of the walls of the pelvis and pelvic organs. The aim of the study was to analyze the literature data on the possibilities and limitations of using dynamic MRI in pelvic organ prolapse. The widespread use of the dynamic MRI method is due to the high quality of the resulting image, good reproducibility, and the maximum ability to display the characteristics of the pelvic floor. Dynamic MRI of the small pelvis allows a comprehensive assessment of the anatomical and functional features of the pelvis, excluding the effect of ionizing radiation on the body. The method is characterized by good visualization with high resolution and excellent soft tissue contrast. The method allows for assessing the state of the evacuation function of visualized structures in dynamics. Simultaneous imaging of all three parts of the pelvic floor using dynamic MRI makes it possible to assess multicompartment disorders. The anatomical characteristics of the state of the pelvic organs in the norm and in the event of prolapse are considered. The technique for performing the method and the procedure for analyzing the resulting images are described. The possibilities of diagnosing a multicomponent lesion are considered, while it is noted that dynamic MRI of the pelvic organs provides visualization and functional analysis of all three parts of the pelvis and often allows the choice and correction of tactics for the surgical treatment of pelvic organ prolapse. It is noted that dynamic MRI is characterized by a high resolution of the obtained images, and the advantage of the method is the ability to detect functional changes accompanying the pathology of the pelvic floor.

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.