A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments

Comparison of transvaginal natural orifice transluminal endoscopic surgery versus conventional surgery for uterosacral ligament suspension in patients who had concomitant vaginal hysterectomy for subtotal uterine prolapse

INTRODUCTION

The study aimed to compare the short-term outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for uterosacral ligament suspension (USLS) versus nonendoscopic USLS in patients with subtotal uterine prolapse who had a concomitant vaginal hysterectomy.

METHODS

There were 51 patients who underwent vNOTES USLS, whereas the nonendoscopic conventional USLS group had 49 patients. The information about patient demographics, and perioperative data including the operative duration, blood loss, intraoperative and postoperative complications, and length of postoperative hospital stay were determined from the patients' files. Postoperative follow-up visits were scheduled at the first week and 1 month after surgery.

RESULTS

The demographic variables including age, body mass index, menopausal status, and parity were comparable, and no significant differences were found. A total of 90.2% of the patients in the vNOTES group and 69.4% of the patients in the shull group were at menopause (p = .09). Operation time was significantly shorter in the shull group (p < .001), and the hospitalization period (p = .029) was significantly shorter in the vNOTES group. Ba, Bp, and D points and total vaginal length (TVL) were significantly behind the hymenal ring in patients who had vNOTES USLS procedure (p < .001). None of the patients who had intraoperative significant blood loss required transfusion. One patient in the vNOTES and two patients in the shull group had a postoperative cuff hematoma.

CONCLUSION

vNOTES USLS has a good safety profile, higher percentage of adnexal surgeries with better improvement on POP-Q points Ba, Bp, D, and TVL compared with classic USLS in patients with subtotal uterine prolapse. Studies evaluating short- and long-term results of vNOTES versus conventional USLS are needed.

Same-day Discharge Following Vaginal Hysterectomy and Native-tissue Apical Repair for Uterovaginal Prolapse: A Prospective Cohort Study

INTRODUCTION AND HYPOTHESIS

The safety and feasibility of same-day discharge (SDD) has been consistently reported across the benign and gynecologic oncology literature. However, outcomes of SDD in the urogynecology population are sparse. The objectives of this study were to describe the success of SDD following vaginal hysterectomy and native-tissue colpopexy, and to compare the incidence of postoperative adverse events in patients discharged same-day versus postoperative day 1 (POD1). Further objectives were to compare pain, quality of recovery (QoR), and satisfaction between the groups.

METHODS

This was a single-center, prospective cohort study of patients with planned SDD. A standardized ERAS protocol was utilized. The QoR-40 questionnaire was administered at baseline, POD2, and the 6-week postoperative visit. Pain scores were captured similarly, and a satisfaction survey was administered at 6 weeks. The primary outcome was composite adverse events defined as any postoperative adverse event and/or health care utilization, excluding telephone calls, and urinary tract infection.

RESULTS

A total of 101 patients were enrolled in the study; the primary outcome was available for 99. SDD was achieved for 76 patients (77.0%); 23 patients stayed overnight (23.2%). The overall incidence of composite adverse events was 20.2% (95% CI, 13.5-29.2), and was not different between the groups (26.1% vs 18.4%, p = 0.42). Additionally, there were no differences in the QoR-40 or pain scores on POD2 and at 6 weeks. Patient satisfaction was high and similar between the groups.

CONCLUSIONS

Successful SDD was achieved in 77.0% of the patients. SDD following vaginal hysterectomy and native-tissue colpopexy appears to be safe, feasible, and associated with good QoR and a high degree of patient satisfaction.

Mid-term outcomes of laparoscopic vaginal stump–round (Kakinuma method) and stump–uterosacral (Shull method) ligament fixation for pelvic organ prolapse: A retrospective comparative study

BACKGROUND

Laparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) using mesh are popular approaches for treating pelvic organ prolapse (POP). However, it is not uncommon that native tissue repair (NTR) should be presented as an option to patients who are expected to have extensive intraperitoneal adhesion or patients for whom LSC or RSC is difficult owing to various risk factors. Laparoscopic vaginal stump-uterosacral ligament fixation (Shull method) has been introduced as a method for NTR in case of POP. However, effective repair using this surgical procedure may not be possible in severe POPs. To solve the problems of the Shull method, we devised the laparoscopic vaginal stump-round ligament fixation (Kakinuma method) in which the vaginal stump is fixed to the uterine round ligament, a histologically strong tissue positioned anatomically higher than the uterosacral ligament. This study aimed to retrospectively and clinically compare the two methods.

METHODS

Of the 78 patients who underwent surgery for POP between January 2017 and June 2022 and postoperative follow-up for at least a year, 40 patients who underwent the Shull method (Shull group) and 38 who underwent the Kakinuma method (Kakinuma group) were retrospectively analyzed.

RESULTS

No significant differences were observed between the two groups in patient background variables such as mean age, parity, body mass index, and POP-Q stage. The mean operative duration and mean blood loss in the Shull group were 140.5 ± 31.7 min and 91.3 ± 96.3 ml, respectively, whereas the respective values in the Kakinuma group were 112.2 ± 25.3 min and 31.4 ± 47.7 ml, respectively. Thus, compared with the Shull group, the operative duration was significantly shorter (P < 0.001) and blood loss was significantly less (P = 0.003) in the Kakinuma group. Recurrence was observed in six patients (15.0%) in the Shull group and two patients (5.3%) in the Kakinuma group. Hence, compared with the Shull group, recurrence was significantly less in the Kakinuma group (P = 0.015). No patients experienced perioperative complications in either group.

CONCLUSIONS

The results suggest that the Kakinuma method can serve as a novel and viable NTR procedure for POP.

Three-year outcomes of a randomized clinical trial of perioperative vaginal estrogen as adjunct to native tissue vaginal apical prolapse repair

BACKGROUND

As the muscular and connective tissue components of the vagina are estrogen responsive, clinicians may recommend vaginal estrogen to optimize tissues preoperatively and as a possible means to reduce prolapse recurrence, but long-term effects of perioperative intravaginal estrogen on surgical prolapse management are uncertain.

OBJECTIVE

This study aimed to compare the efficacy of perioperative vaginal estrogen vs placebo cream in reducing composite surgical treatment failure 36 months after native tissue transvaginal prolapse repair.

STUDY DESIGN

This was an extended follow-up of a randomized superiority trial conducted at 3 tertiary US sites. Postmenopausal patients with bothersome anterior or apical vaginal prolapse were randomized 1:1 to 1-g conjugated estrogen cream (0.625 mg/g) or placebo, inserted vaginally twice weekly for ≥5 weeks preoperatively and continued twice weekly for 12 months postoperatively. All participants underwent vaginal hysterectomy (if the uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The primary report's outcome was time to failure by 12 months postoperatively, defined by a composite outcome of objective prolapse of the anterior or posterior walls beyond the hymen or the vaginal apex descending below one-third the total vaginal length, subjective bulge symptoms, and/or retreatment. After 12 months, participants could choose to use-or not use-vaginal estrogen for atrophy symptom bother. The secondary outcomes included Pelvic Organ Prolapse Quantification points, subjective prolapse symptom severity using the Patient Global Impression of Severity and the Patient Global Impression of Improvement, and prolapse-specific subscales of the 20-Item Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire-Short Form 7. Data were analyzed as intent to treat and "per protocol" (ie, ≥50% of expected cream use per medication diary).

RESULTS

Of 206 postmenopausal patients, 199 were randomized, and 186 underwent surgery. Moreover, 164 postmenopausal patients (88.2%) provided 36-month data. The mean age was 65.0 years (standard deviation, 6.7). The characteristics were similar at baseline between the groups. Composite surgical failure rates were not significantly different between the estrogen group and the placebo group through 36 months, with model-estimated failure rates of 32.6% (95% confidence interval, 21.6%-42.0%) and 26.8% (95% confidence interval, 15.8%-36.3%), respectively (adjusted hazard ratio, 1.55; 95% confidence interval, 0.90-2.66; P=.11). The results were similar for the per-protocol analysis. Objective failures were more common than subjective failures, combined objective and subjective failures, or retreatment. Using the Patient Global Impression of Improvement, 75 of 80 estrogen participants (94%) and 72 of 76 placebo participants (95%) providing 36-month data reported that they were much or very much better 36 months after surgery (P>.99). These data included reports from 51 of 55 "surgical failures." Pelvic Organ Prolapse Quantification measurements, Patient Global Impression of Severity scores, and prolapse subscale scores of the 20-Item Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire-Short Form 7 all significantly improved for both the estrogen and placebo groups from baseline to 36 months postoperatively without differences between the groups. Of the 160 participants providing data on vaginal estrogen usage at 36 months postoperatively, 40 of 82 participants (49%) originally assigned to the estrogen group were using prescribed vaginal estrogen, and 47 of 78 participants (60%) assigned to the placebo group were using vaginal estrogen (P=.15).

CONCLUSION

Adjunctive perioperative vaginal estrogen applied ≥5 weeks preoperatively and 12 months postoperatively did not improve surgical success rates 36 months after uterosacral or sacrospinous ligament suspension prolapse repair. Patient perception of improvement remained very high at 36 months.

Patient Impression of Improvement 1 year After Sacrospinous Hysteropexy Versus Vaginal Hysterectomy in Women with Pelvic Organ Prolapse Stage 2 or Higher

INTRODUCTION AND HYPOTHESIS

Patient-reported outcomes are relevant outcomes in studies on pelvic organ prolapse (POP) surgery, as anatomical recurrence alone does not have a significant correlation with perceived improvement. In the present study, the patient's impression of improvement after 1 year is studied after vaginal hysterectomy (VH) versus sacrospinous hysteropexy (SSH) in large cohorts from daily clinical practice. We hypothesize that there is no difference between the groups.

METHODS

This is a secondary analysis on prospectively collected data in a multicenter cohort of patients who underwent VH or SSH for symptomatic POP. All patients had a POP-Q stage ≥ 2 in at least one compartment at baseline and were treated with VH or SSH between 2002 and 2019. The primary outcome was the patient-reported score on the patient global impression of improvement index (PGI-I) 1 year after surgery. The secondary outcome was a composite outcome of surgical success, defined as the absence of recurrent POP beyond the hymen with bothersome bulge symptoms and/or repeat surgery.

RESULTS

A total of 378 women (196 VH and 182 SSH) were included. The median score on the PGI-I did not differ between VH and SSH. At 1 year post-operatively, 77 women after VH (73%) and 77 women after SSH (75%) considered their condition (very) much improved (p = 0.86). There was no difference in composite outcome of surgical success (126 out of 137 women [92%] after VH, 118 out of 125 women [94%] after SSH; p = 0.44).

CONCLUSIONS

Our study shows that there was no difference in the type of surgery, VH or SSH, with regard to the patient's impression of improvement 1 year postoperatively in a large cohort from daily clinical practice.

A Randomised Trial on the Effects of the Addition of Uterosacral Ligament Plication to Pectopexy Operation on Anatomical Restoration and Female Sexual Functions

INTRODUCTION AND HYPOTHESIS

The objective was to determine whether the addition of uterosacral ligament plication to pectopexy for pelvic organ prolapse increases anatomical improvement and female sexual functioning.

METHODS

This is a prospective randomised study. Forty patients who underwent laparoscopic pectopexy (LP) and laparoscopic pectopexy with uterosacral ligament plication (LPUSL) were included in the study. A total of 38 patients were evaluated in the study. Patients were assessed by the Pelvic Organ Prolapse Quantification (POP-Q) system and the patients who had symptomatic apical prolapse POP-Q ≥ II were included in the study. Patients were evaluated preoperatively and postoperatively at the 3rd, 6th and 12th month, with respect to anatomical changes as well as sexual function.

RESULTS

A statistically significant difference was found when the preoperative C points was compared with the C points postoperatively, at 3rd, 6th and 12th months in both the LP and LPUSL groups (p < 0.001). Additionally, there were statistically significant difference between the LP and LPUSL groups in terms of C and Aa points at the 6th and 12th postoperative months in favour of the LPUSL group (p = 0.007, p = 0.005 respectively). There was also a statistically significant difference when Ba points were compared between the two groups at the 12th postoperative month, in favour of the LPUSL group (p = 0.002). There were no statistically significant differences between the groups with respect to the variables of the Female Sexual Function Index. Additionally, all parameters were significantly better in both groups at the 3rd and 12th months than the preoperative values in post hoc analysis; only desire also had a significant improvement between the 3rd and 12th months in the LPUSL group in post hoc analysis.

CONCLUSION

Pectopexy operation seems to be a successful surgical approach as an alternative to sacrocolpopexy. The addition of uterosacral ligament plication to pectopexy operation improves the anatomical restoration more drastically than with LP on its own. Moreover, either LP or LPUSL has improved the majority of sexual function indices.

High Uterosacral Ligaments Suspension for Post-Hysterectomy Vaginal Vault Prolapse Repair

Background and Objectives: Uterosacral ligaments (USLs) suspension is a well-studied, safe, and long-lasting technique for central compartment correction. Preliminary clinical experiences showed encouraging data for this technique, also for post-hysterectomy vaginal vault prolapse surgical treatment. However, up-to-date evidence for post-hysterectomy vaginal vault prolapse repair through high uterosacral ligaments suspension is limited. Consequently, with this study, we aimed to assess the efficiency, complications frequency, and functional results of native-tissue repair through USLs in vaginal vault prolapse. Materials and Methods: This was a retrospective study. Women with symptomatic vaginal vault prolapse (≥stage 2) who underwent surgery with transvaginal native-tissue repair by high uterosacral ligaments were included. Patient characteristics, preoperative assessment, operative data, postoperative follow-up visits, and re-interventions were collected from the hospital's record files. High uterosacral ligament suspension was performed according to the technique previously described by Shull. A transverse apical colpotomy at the level of the post-hysterectomy scar was performed in order to enter the peritoneal cavity. USLs were identified and transfixed from ventral to dorsal with three absorbable sutures. Sutures were then passed through the vaginal apex and tightened to close the transverse colpotomy and suspend the vaginal cuff. At the end of the surgical time, a diagnostic cystoscopy was performed in order to evaluate ureteral bilateral patency. Using the POP-Q classification system, we considered an objective recurrence as the descensus of at least one compartment ≥ II stage, or the need for a subsequent surgery for POP. The complaint of bulging symptoms was considered the item to define a subjective recurrence. We employed PGI-I scores to assess patients' satisfaction. Results: Forty-seven consecutive patients corresponding to the given period were analyzed. No intraoperative complications were observed. We observed one postoperative hematoma that required surgical evacuation. Thirty-three patients completed a minimum of one-year follow-up (mean follow-up 21.7 ± 14.6 months). Objective cure rate was observed in 25 patients (75.8%). No patients required reintervention. The most frequent site of recurrence was the anterior compartment (21.2%), while apical compartment prolapse relapsed only in 6% of patients. An improvement in all POP-Q parameters was recorded except TVL which resulted in a mean 0.5 cm shorter. Subjective recurrence was referred by 4 (12.1%) patients. The mean satisfaction assessed by PGI-I score was 1.6 ± 0.8. Conclusion: This analysis demonstrated that native-tissue repair through high USL suspension is an effective and safe procedure for the treatment of post-hysterectomy vaginal vault prolapse. Objective, subjective, functional, and quality of life outcomes were satisfactory, with minimal complications.

Characteristics Associated With Surgical Failure After Native Tissue Apical Prolapse Repair

OBJECTIVE

To identify clinical and demographic characteristics associated with prolapse recurrence by 12 months after native tissue transvaginal repair.

METHODS

This was a planned secondary analysis of a randomized trial including postmenopausal participants with stage 2 or greater apical or anterior vaginal prolapse scheduled for surgical repair at three U.S. sites. Participants underwent vaginal hysterectomy (if uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The intervention was perioperative (5 weeks or more preoperatively and 12 months postoperatively) vaginal estrogen compared with placebo cream. The primary outcome was time to failure by 12 months after surgery, defined by objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, symptomatic vaginal bulge, or retreatment. For this analysis, participants were grouped according to failure compared with success, and multiple factors were compared, including age, time since menopause, race and ethnicity, parity, body mass index (BMI), baseline genital hiatus measurement, prolapse stage and point of maximal prolapse, surgery type (uterosacral or sacrospinous ligament suspension), and concomitant procedures. Factors were assessed for association with the hazard of surgical failure using Cox proportional hazards models, adjusted for site and treatment group. Factors with P <.50 from this analysis were considered for inclusion in the final multivariable model; site and treatment group were kept in this model.

RESULTS

One hundred eighty-six participants underwent surgery; 183 provided complete data. There were 30 failures (16.4%) and 153 successes (83.4%) at 12 months. On bivariate analysis, failure was associated with decreasing age, shorter duration since menopause, Latina ethnicity, and greater baseline genital hiatus. In the final multivariable model, which included age, BMI, and point of maximal prolapse, only age remained significantly associated with surgical failure (adjusted hazard ratio [per year] 0.92, 95% CI, 0.86-0.98, P =.016).

CONCLUSION

Among postmenopausal women, younger age was associated with increased frequency of prolapse recurrence by 12 months after native tissue repair.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT02431897.

Maintaining the apex: a novel technique for vault suspension during vaginal hysterectomy

INTRODUCTION AND HYPOTHESIS

Post-hysterectomy vault prolapse poses significant challenges to patients and surgeons alike. Despite numerous surgical interventions during initial vaginal hysterectomy to counteract this, a comparative analysis of their efficacy is limited. This study introduces a pioneering technique intended to avert vault prolapse during vaginal hysterectomy by harmoniously merging level 1 and level 2 support.

METHODS

After obtaining informed consent, we recorded a variation of the McCall technique performed during vaginal hysterectomy and anterior repair. Patient follow-ups were conducted up to 6 months post-operation to evaluate anatomical outcomes and quality of life.

RESULTS

A total of 46 women underwent the surgery. Anatomical evaluations at the 6-month mark were commendable, with no recurrence instances. Quality-of-life assessments, using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12), showcased substantial improvement.

CONCLUSION

Our novel approach to vault suspension provides an uncomplicated, easily impartible, surgical procedure utilizing standard sutures. We believe that this approach is both enduring and safe.

At the Scrub Sink: Uterosacral Ligament Suspension

ABSTRACT

Uterosacral ligament suspension for repair of prolapse has some challenges, such as visualization in the vagina, choice of suture, and avoidance of dangers such as ureteral kinking. This editorial offers some tips for performing a uterosacral suspension that are commonly discussed "at the scrub sink" before a case.

The effectiveness and safety of laparoscopic uterosacral ligament suspension: A systematic review and meta-analysis

BACKGROUND

Laparoscopic uterosacral ligament suspension (LUSLS) is a technique to correct apical pelvic organ prolapse (POP) by shortening the uterosacral ligaments with sutures.

OBJECTIVE

A systematic review with meta-analysis of the effectiveness and safety of LUSLS as treatment for apical POP.

SEARCH STRATEGY

PubMed and Cochrane search using 'pelvic organ prolapse', 'laparoscopy' and 'uterosacral', including synonyms.

SELECTION CRITERIA

All articles in English presenting outcome of an original series of women with LUSLS as treatment of apical POP. Case reports were excluded.

DATA COLLECTION AND ANALYSIS

Study enrollment was performed by two reviewers. Our primary outcome measures were objective and subjective effectiveness of the procedure. Secondary outcome measures regarded complications and recurrence. Bias was assessed with the Newcastle Ottawa Scale.

MAIN RESULTS

Of 138 hits, 13 studies were included with 933 LUSLS patients. The average follow-up was 22 months. All were nonrandomised cohort studies. The pooled anatomic success rate is 90% for all LUSLS procedures (95% confidence interval [CI] 83.3-95.5). LUSLS with hysterectomy resulted in an anatomic success rate of 96.6% (95% CI 87.5-100) and LUSLS with uterus preservation 83.4% (95% CI 67.7-94.6). The pooled subjective cure rate was 90.5% (95% CI 81.9-96.5). The rate of major complications was 1%.

CONCLUSIONS

Laparoscopic uterosacral ligament suspension (with or without uterus preservation) seems to be an effective and safe treatment for women with apical POP, but long-term prospective trials and randomised controlled trials are necessary to confirm these findings.

Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry

OBJECTIVE

The aim of the study was to compare 12-month subjective and objective outcomes between 3 approaches to apical pelvic organ prolapse (POP) surgery in patients presenting with uterovaginal or posthysterectomy vaginal prolapse enrolled in the Pelvic Floor Disorders Registry for Research.

STUDY DESIGN

This was an analysis of a multicenter, prospective registry that collected both patient- and physician-reported data for up to 3 years after conservative (pessary) and surgical treatment for POP. Twelve-month subjective and anatomic outcomes for patients who underwent surgical treatment were extracted from the registry for analysis. Pelvic organ prolapse recurrence was defined as a composite outcome and compared between the 3 apical surgery groups (native tissue repair, sacrocolpopexy, colpocleisis) as well as the 2 reconstructive surgery groups (native tissue repair and sacrocolpopexy).

RESULTS

A total of 1,153 women were enrolled in the registry and 777 (67%) opted for surgical treatment, of whom 641 underwent apical repair and were included in this analysis (404 native tissue repair, 187 sacrocolpopexy, and 50 colpocleisis). The overall incidence of recurrence was as follows: subjective 6.5%, anatomic 4.7%, retreatment 7.2%, and composite 13.6%. The incidence of recurrence was not different between the 3 surgical groups. When baseline patient characteristics were controlled for, composite POP recurrence between the native tissue and sacrocolpopexy groups remained statistically nonsignificant. Concurrent perineorrhaphy with any type of apical POP surgery was associated with a lower risk of recurrence (adjusted odds ratio, 0.43; 95% confidence interval, 0.25-0.74; P = 0.002) and prior hysterectomy was associated with a higher risk (adjusted odds ratio, 1.77, 95% confidence interval, 1.04-3.03; P = 0.036).

CONCLUSION

Pelvic Floor Disorders Registry for Research participants undergoing native tissue apical POP repair, sacrocolpopexy, and colpocleisis surgery had similar rates of POP recurrence 12 months after surgery.

Midterm comparison of laparoscopic high uterosacral ligament suspension and sacrocolpopexy in the treatment of moderate to severe apical prolapse

INTRODUCTION AND HYPOTHESIS

The objective was to retrospectively analyze the midterm efficacy of laparoscopic high uterosacral ligament suspension (HUS) and sacrocolpopexy (SC) in the treatment of moderate to severe apical prolapse.

METHODS

Patients who underwent laparoscopic HUS and SC in our center from 2013 to 2019 with follow-ups were included, consisting of laparoscopic HUS (group A, n=72) or SC (mesh added, group B, n=54). The general data of patients, pelvic organ prolapse quantitative examination (POP-Q) score, Pelvic Floor Distress Inventory short form 20 score (PFDI-20) before and after operation, perioperative conditions, Patient Global Impression of Improvement (PGI-I), and postoperative complications were collected for statistical analysis and comparison between groups.

RESULTS

There was no statistical difference in preoperative data between groups. The median follow-up time was 48 months. The objective recurrence rate of group A was higher than that of group B, without statistical significance. One patient in group B had a second operation owing to recurrence. The exposure rate of mesh in group B was 3.70%. There was no significant difference in deviation of POP-Q and PFDI-20 pre- and post-operation. The proportion of new defecation abnormalities in group A was lower. The total hospitalization expenses and surgical consumables in group B were significantly higher than those in group A.

CONCLUSIONS

The midterm curative effect of laparoscopic HUS is similar to that of SC in the treatment of moderate to severe apical prolapse. The former has the advantages of less intraoperative blood loss, shorter postoperative hospital stay, lower cost, fewer new defecation abnormalities, and there were no complications related to mesh.

Efficacy of Sacrospinous Fixation or Uterosacral Ligament Suspension for Pelvic Organ Prolapse in Stages III and IV: Randomized Clinical Trial

OBJECTIVE

 To evaluate the efficacy and outcomes of the surgical treatment for pelvic organ prolapse (POP) in stages III and IV by sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (USLS) by comparing anatomical and subjective cure rates and quality-of-life parameters (through the version validated for the Portuguese language of the Prolapse Quality of Life [P-QoL] questionnaire) under two definitions: genital prolapse Ba, Bp, and C < -1 (stage I) and Ba, Bp, and C ≤ 0 (stage II).

MATERIALS AND METHODS

 After we obtained approval from the Ethics Committee (under CAAE 0833/06) and registered the study in ClinicalTrials.gov (NCT01347021), 51 patients were randomized into two groups: the USLS group (N = 26) and the SSLF group (N = 25), with follow-up 6 and 12 months after the procedures.

RESULTS

 There was a significant improvement in the P-QoL score and anatomical measurements of all compartments in both groups after 12 months (p < 0.001). The anatomical cure rates in the USLS and SSLF groups, considering stage 1, were of 34.6% and 40% (anterior) respectively; of 100% both for groups (apical); and of 73.1% and 92% (posterior) respectively. The rates of adverse outcomes were of 42% (N = 11) and 36% (N = 11) for the USLS and SSLF groups respectively (p = 0.654), and those outcomes were excessive bleeding, bladder perforation (intraoperative) or gluteal pain, and urinary infection (postoperative), among others, without differences between the groups.

CONCLUSION

 High cure rates in all compartments were observed according to the anatomical criterion (stage I), without differences in P-QoL scores and complications either with USLS or SSLF for the surgical treatment of accentuated POP.

Variations in structural support site failure patterns by prolapse size on stress 3D MRI

INTRODUCTION AND HYPOTHESIS

Our objective was to develop a standardized measurement system to evaluate structural support site failures among women with anterior vaginal wall-predominant prolapse according to increasing prolapse size using stress three-dimensional (3D) magnetic resonance imaging (MRI).

METHODS

Ninety-one women with anterior vaginal wall-predominant prolapse and uterus in situ who had undergone research stress 3D MRI were included for analysis. The vaginal wall length and width, apex and paravaginal locations, urogenital hiatus diameter, and prolapse size were measured at maximal Valsalva on MRI. Subject measurements were compared to established measurements in 30 normal controls without prolapse using a standardized z-score measurement system. A z-score greater than 1.28, or the 90th percentile in controls, was considered abnormal. The frequency and severity of structural support site failure was analyzed based on tertiles of prolapse size.

RESULTS

Substantial variability in support site failure pattern and severity was identified, even between women with the same stage and similar size prolapse. Overall, the most common failed support sites were straining hiatal diameter (91%) and paravaginal location (92%), followed by apical location (82%). Impairment severity z-score was highest for hiatal diameter (3.56) and lowest for vaginal width (1.40). An increase in impairment severity z-score was observed with increasing prolapse size among all support sites across all three prolapse size tertiles (p < 0.01 for all).

CONCLUSIONS

We identified substantial variation in support site failure patterns among women with different degrees of anterior vaginal wall prolapse using a novel standardized framework that quantifies the number, severity, and location of structural support site failures.

New native tissue repair for pelvic organ prolapse: Medium-term outcomes of laparoscopic vaginal stump–round ligament fixation

BACKGROUND

Laparoscopic sacrocolpopexy for pelvic organ prolapse (POP) is a new and widely used approach; however, ever since the United States Food and Drug Administration warned against the use of surgical mesh, repairs performed using patients’ tissues [i.e. native tissue repair (NTR)] instead of mesh have attracted much attention. At our hospital, laparoscopic sacrocolpopexy (the Shull method) was introduced in 2017. However, patients with more severe POP who have a long vaginal canal and overextended uterosacral ligaments may not be candidates for this procedure.

AIM

To validate a new NTR treatment for POP, we examined patients undergoing laparoscopic vaginal stump–round ligament fixation (the Kakinuma method).

METHODS

The study patients were 30 individuals with POP who underwent surgery using the Kakinuma method between January 2020 and December 2021 and who were followed up for > 12 mo after surgery. We retrospectively examined surgical outcomes for surgery duration, blood loss, intraoperative complications, and incidence of recurrence. The Kakinuma method involves round ligament suturing and fixation on both sides, effectively lifting the vaginal stump after laparoscopic hysterectomy.

RESULTS

The patients’ mean age was 66.5 ± 9.1 (45-82) years, gravidity was 3.1 ± 1.4 (2-7), parity was 2.5 ± 0.6 (2-4) times, and body mass index was 24.5 ± 3.3 (20.9-32.8) kg/m². According to the POP quantification stage classification, there were 8 patients with stage II, 11 with stage III, and 11 with stage IV. The mean surgery duration was 113.4 ± 22.6 (88-148) min, and the mean blood loss was 26.5 ± 39.7 (10-150) mL. There were no perioperative complications. None of the patients exhibited reduced activities of daily living or cognitive impairment after hospital discharge. No cases of POP recurrence were observed 12 mo after the operation.

CONCLUSION

The Kakinuma method, similar to conventional NTR, may be an effective treatment for POP.

Permanent or absorbable suture material for sacrospinous ligament fixation: Does it matter?

OBJECTIVE

To evaluate success and safety of sacrospinous ligament fixation (SSLF) using permanent versus absorbable suture materials 12 months following surgery.

STUDY DESIGN

Following IRB approval, the electronic medical records of women who underwent SSLF in the gynecology department of a university-affiliated medical center from November 2012 to September 2021 were retrospectively reviewed. SSLF was carried out using Capio®and Digitex™, with either absorbable (polyglactin-910 or polydioxanone) sutures (group 1), or permanent (polypropylene) sutures (group 2), Pre-operative and post-operative assessment included prolapse staging using the pelvic organ prolapse quantification system and validated quality of life questionnaires (Pelvic Floor Distress Inventory and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12). Patients with postoperative information on objective and subjective outcome at 12 months were included in final analysis. Anatomical success was defined as POP stage < 2 at 12-months following surgery. For statistical analysis, the Mann-Whitney test was used for continuous variables, Fisher's exact test for dichotomous variables, and Chi-squared test of independence for variables with>2 categories.

RESULTS

During the study period, 234 women underwent SSLF. One-hundred and forty-two patients (60.7 %) returned at the 12-month follow-up and were included in final analysis. Seventy-two (50.7 %) patients had absorbable suture and 70 patients (49.3 %) had permanent suture. Estimated blood loss was significantly higher in group 1 [100 (50-150) cc vs 50 (50-100) cc respectively, p =.016]. Moderate to severe pain on POD-1 was significantly higher in group 2 [VAS: 2.00 (0.00-4.00) vs 4.00 (3.00-5.75) respectively, p =.001]. Anatomical success, defined as POP ≤ stage 2 at 12 months, was similar between groups: 69 % in group 1 vs 67 % in group 2 (p =.77). Subjective cure was similar between groups, 97.2 % in group 1 vs 94.3 % in group 2 (p =.44). At the 12-month follow-up, none of the patients had gluteal pain. The rate of de-novo dyspareunia was similar between groups: 4 women (5.9 %) in the absorbable suture group versus 2 women (3.3 %) in the permanent suture group (p =.49).

CONCLUSIONS

Our findings suggest that absorbable or permanent suture material does not affect outcome of SSLF. Permanent sutures may be related to increased immediate postoperative pain.

The effect of hysteropreservation versus hysterectomy on the outcome of laparoscopic uterosacral suspension in pelvic organ prolapse surgery

OBJECTIVES

This study compares the recurrence rate, complication rate and subjective satisfaction with laparoscopic uterosacral suspension with or without hysterectomy.

STUDY DESIGN

This retrospective cohort study included 105 patients between June 2014 and December 2019. Recurrent pelvic organ prolapse was defined as any prolapse to or beyond the hymen with straining or needing retreatment. Student's t-test, the Mann-Whitney U test, the chi square test or Fisher's exact test, multivariate Cox proportional hazards regression and Kaplan-Meier survival analysis were used for the data analysis.

MAIN OUTCOME MEASURES

Whether the durability of laparoscopic uterosacral suspension surgery is affected by uterine preservation.

RESULTS

60 patients underwent laparoscopic uterosacral suspension with concomitant hysterectomy (Hysterectomy group), and 45 underwent laparoscopic uterosacral hysteropexy (Hysteropexy group). The median (interquartile range) duration of follow-up for all 105 patients was 31 (22.5-47.5) months. The results of multivariate Cox proportional hazards regression showed that no difference was found in the risk of overall recurrence between the hysterectomy and hysteropexy groups (25 % vs. 22 %; HR, 0.37; 95 % CI, 0.14-1.00). Kaplan-Meier survival analysis also demonstrated that there were no significant differences in the overall rates of recurrent prolapse between the two groups (P = 0.30). In addition, the subjective success rates were high in both groups (82 %).

CONCLUSIONS

Our study demonstrated equally satisfactory objective and subjective long-term outcomes after laparoscopic uterosacral suspension with or without hysterectomy. Laparoscopic uterosacral hysteropexy can be safely and effectively offered to patients with pelvic organ prolapse who wish to preserve their uterus and do not have contraindications.

Outcomes of Manchester procedure combined with high uterosacral ligament suspension for uterine prolapse

AIM

The objective of this study was to evaluate the outcomes of the Manchester procedure (MP) with or without concomitant high uterosacral ligament suspension (HUSLS) for treating uterine prolapse. The primary outcomes were to compare the two methods for differences in perioperative complications and recurrence rates, and to explore whether MP combined with concomitant HUSLS is beneficial in reducing recurrence rates.

METHODS

A total of 98 uterine prolapse patients underwent MP or MP-HUSLS during the study period. Demographic data, perioperative, and follow-up outcomes were analyzed retrospectively. Univariate and multivariate cox proportional hazards regression analysis was used to explore the effect of surgical methods on recurrence.

RESULTS

The MP-HUSLS group had a higher degree of apical compartment prolapse before the operation, but the pelvic organ prolapse quantification (POP-Q) values of points Ba and C in the MP-HUSLS group improved significantly compared with the MP group (p < 0.05). The operation time in the MP group was shorter than that in the MP-HUSLS group. There were no differences in baseline characteristics or perioperative complications between the two groups. Twelve patients had subjective recurrence during follow-up, although 20 developed anatomical recurrence. After controlling for confounding factors, the MP group had a higher risk of recurrence in the anterior compartment than the MP-HUSLS (adjusted hazard ratio: 4.191, confidence interval: 1.195-14.701, p = 0.025). There was no significant difference in the recurrence rate of the two groups' total, apical, and posterior compartments.

CONCLUSION

Compared with MP, MP-HUSLS seems more effective in treating uterine prolapse, with a higher location of the points C and Ba. However, further studies with large samples and long follow-up times need to confirm this result.

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.

Laparoscopic uterosacral ligament suspension: a comprehensive, systematic literature review

OBJECTIVES

Laparoscopic uterosacral ligament suspension (LUSLS) of the vaginal apex for the treatment of pelvic organ prolapse (POP) has gained popularity. The aim of this systematic review is to investigate perioperative outcomes and complications, subjective and objective success rates and recurrence rates in women undergoing this surgical procedure.

STUDY DESIGN

A systematic literature search was performed in December 2021. The critical appraisal skills program (CASP) was used to assess the methodological quality of the selected studies. The Clavien-Dindo (CD) scale and the Satava scale were used to classify periprocedural complications. Continuous variables were described as means and standard deviations while categorical were expressed as percentages of the whole group. Statistical significance was set at p < 0.05.

RESULTS

26 articles were selected and analysed, with a total population of 1401 patients. Anatomical and subjective success rates after LUSLS ranged from 79% and 100% and from 76.2% to 100% respectively. The re-operation rate varied from 2% to 4.5% in the largest cohorts. The overall complication rate was 13.6%, however grade III CD complications occurred only in 1% of patients. Ureteral complications were described in only 2 cases.

CONCLUSIONS

LUSLS represent a safe and effective technique for vaginal apex resuspension in women with POP. Further larger prospective randomized studies are required to confirm these data.

A preliminary clinical report of transvaginal natural orifice transluminal endoscopic Sacrospinous Ligament Fixation in the treatment of moderate and severe pelvic organ prolapse

Objective

To study the efficacy and safety of transvaginal natural orifice transluminal endoscopic Sacrospinous Ligament Fixation in the treatment of moderate and severe pelvic organ prolapse.

Design

Patients were selected into this study on a voluntary basis to evaluate the short-term efficacy of this surgery by comparing the OP-Q scores before the operation, three months after the operation, and six months after the operation.

Setting and Patients

Evaluate the clinical efficacy and safety by a retrospective analysis of the clinical data of the 18 patients with POP-Q grade III–IV pelvic organ prolapse treated by the Department of Gynecology of Nanjing Medical University Affiliated Changzhou No.2 People's Hospital from April 2020 to November 2020, and their post-operation follow-ups.

Interventions

Patients with postoperative follow-ups found no obvious relapse without intervention measures.

Measurements and Main Results

The transvaginal natural orifice transluminal endoscopic Sacrospinous Ligament Fixation was performed successfully, and the anterior and posterior walls of vagina and/or trans-vaginal hysterectomy were repaired as appropriate. Except the total vaginal length (TVL), the P values of numerical analysis for all points before, three months after, and six months after the operation were all <0.05, being statistically significant.

Conclusion

This method is effective in the treatment of moderate and severe pelvic organ prolapse with few complications, but more cases and longer-term follow-up data are needed to determine the long-term effect of this procedure. For the selection of puncture sites, more anatomical data are needed to get more accurate result.

Surgical anatomy of the vaginal vault

Aim

Vaginal vault (VV) surgery should be a key part of surgery for a majority of pelvic organ prolapse (POP). The surgical anatomy of the VV, the upper most part of the vagina, has not been recently subject to a dedicated examination and description.

Methods

Cadaver studies were performed in (i) 10 unembalmed cadaveric pelves (observation); (ii) 2 unembalmed cadaveric pelves (dissection); (iii) 5 formalinized hemipelves (dissection). The structural outline and ligamentous supports of the VV were determined. Further confirmation of observations in post‐hysterectomy patients were from a separate study on 300 consecutive POP repairs, 46% of whom had undergone prior hysterectomy.

Results

The VV is equivalent to the Level I section of the vagina, measured posteriorly from the top of the posterior vaginal wall (apex or highest part of the vagina) to 2.5 cm below this point. It comprises the anterior fornix (through which cervix protrudes or is removed at hysterectomy), posterior fornix and two lateral fornices. Before hysterectomy, the posterior aspects of the cervix and upper vagina are supported by the uterosacral (USL) and cardinal ligaments (CL), the distal segments of which fuse together to form a cardinal‐uterosacral ligament complex (cardinal utero‐sacral complex), around 2–3 cm long. Post‐‐‐hysterectomy, there is some residual USL support to the anterior fornix but the posterior fornix has no ligamentous support and is thus more vulnerable to prolapse.

Conclusion

Effective management of VV prolapse will need to be part of most POP repairs. Enhanced understanding of the surgical anatomy of the vaginal vault allows more effective planning of those POP surgeries.

Influence of toileting behavior on the natural course of anterior vaginal wall prolapse

Background

Many risk factors for pelvic organ prolapse (POP) have been proposed, and the cause is most likely multifactorial. This study aimed to investigate the effect of toileting behaviors on the natural course of anterior vaginal wall prolapse (AVWP).

Methods

Data on 75 women who underwent surgery for symptomatic AVWP were collected. Patients with grade ≥ II AVWP were included in this study and were divided into two groups according to their voiding and defecation position. The volunteers who voided and defecated in a sitting position comprised Group 1, and those who voided and defecated in a squatting position comprised Group 2. The Colorectal-Anal Impact Questionnaire (CRAIQ), Pelvic Floor Impact Questionnaire (PFIQ), Pelvic Organ Prolapse Impact Questionnaire (POPIQ), Urinary Impact Questionnaire (UIQ) and visual analog scale (VAS) pain scores were used to evaluate the patients’ symptoms.

Results

Forty-four patients were included in Group 1 (sitting position), and 31 patients were included in Group 2 (squatting position). The groups were similar in terms of BMI, parity, menopause duration, topical estrogen use, comorbidities, the presence of constipation and urinary incontinence, and the pad count for incontinence. The time from initial symptoms to surgery was shorter in Group 2 than in Group 1 12 (3–73) and 24 (2–182) months (p = 0.001), respectively. The PFIQ, POPIQ and POP-related VAS scores were significantly higher in patients who voided and defecated in a squatting position.

Conclusion

In patients with symptomatic POP, increased IAP while performing the squat position during defecation and voiding may increase the severity of patients' symptoms related to prolapse more than that of sitting position. Therefore, questioning the toileting position of patients with AVWP may help inform management decisions, with changing to a sitting position encouraged.

Sexual and functional outcomes after prolapse surgery: a randomized prospective comparison of trocarless transvaginal mesh and pelvic organ prolapse suspension

PURPOSE

Stress urinary incontinence (SUI) related to pelvic organ prolapse represents a common condition that negatively impacts female sexual activity. Laparoscopic pelvic organ prolapse surgery (POPs) and the anterior repair with a trocar-less trans-vaginal mesh (TTMs) represent two different surgical techniques to treat SUI secondary to POP. This study aimed to report the results of these techniques comparing the sexual and functional outcome improvement.

MATERIALS AND METHODS

Fifty-nine sexually active female patients, complaining of urodynamic stress incontinence, were enrolled in this prospective study, and simply randomized in two groups: 29 POPs and 30 TTMs. All patients were studied at baseline and 6 months after surgery. Preoperative evaluation included medical history, urodynamic test, Female Sexual Function Index (FSFI), and pelvic magnetic resonance defecography. Six months after surgery, all patients completed the FSFI and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and were investigated with a uroflowmetry test with post-void residual volume (PVR).

RESULTS

At 6 months after surgery, 87% of POPs patients and 79% of TTMs subjects resulted dry. No statistically significant results were obtained in terms of urinary outcomes between the two surgical groups. Regarding sexual function, POPs group exhibited a significant greater improvement of global FSFI (mean: 27.4; SD: 4.31) compared to TTMs group (mean FSFI: 23.56; SD: 2.28; p-value ≤ 0.0001).

CONCLUSIONS

Our results indicated that POPs and TTMs lead to satisfactory and safe functional outcomes with a good recovery of urinary continence. Furthermore, POPs, when compared to TTMs, led to a greater improvement of sexual function.

Comparison of Surgical Results and Postoperative Recurrence Rates by Laparoscopic Sacrocolpopexy with Other Surgical Procedures for Managing Pelvic Organ Prolapse

Objectives:

Pelvic organ prolapse (POP) is relatively high for a gynecologic disease. Laparoscopic sacrocolpopexy (LSC) is currently the main surgical option for managing POP. The priority of the surgical treatment is preventing recurrence after the surgery. We presented the surgical outcome and recurrence rate of LSC and compared the data of LSC with that of other surgical procedures for managing POP to examine the effectiveness of LSC over other them.

Materials and Methods:

We compared the results of 138 cases of LSC with other conventional procedures, namely 30 cases of total vaginal hysterectomy (TVH) combined with colporrhaphy anterior and posterior, 66 cases of the Manchester operation, and 68 cases of colpocleisis. We compared the age, body mass index, operative time, blood loss volume, postoperative hospital stay duration, rate of complications, recurrence rate, reoperation rate, and the cumulative recurrence rate after 10 years.

Results:

The complication rate of LSC, TVH, the Manchester operation, and colpocleisis was 2.2%, 3.3%, 3.0%, and 4.4%; the recurrence rate 2.8%, 3.5%, 4.5%, and 8.7%; and the cumulative recurrence rate after 10 years 3.7%, 4.6%, 8.8%, and 18.2%. There was no significant difference between LSC and the other three groups.

Conclusion:

LSC seems to be an effective surgical option that requires a higher skill level than other surgical methods and has a longer operative time, lesser operative invasion, and a lower long-term recurrence rate. We will actively recommend LSC to those when appropriate.

Vaginal mesh hysteropexy: a review

PURPOSE OF REVIEW

Pelvic organ prolapse surgery is performed via native tissue or graft augmented repair. Graft augmentation with synthetic mesh was introduced to improve long-term surgical outcomes compared with vaginal native tissue repairs. Vaginal hysteropexy has recently become increasingly popular due to patient preference and an improved morbidity profile over hysterectomy, while maintaining comparable efficacy. As long-term outcomes remain unanswered, mesh augmentation to vaginal hysteropexy has sought to improve efficacy while minimizing complications.

RECENT FINDINGS

Recent studies have demonstrated superiority of vaginal mesh hysteropexy to vaginal hysterectomy with native tissue vault suspension. Short-term follow-up of vaginal mesh hysteropexy has also demonstrated lower blood loss and operative time with improved vaginal length compared with hysterectomy. Mesh exposure rates across studies were low and comparable to those of abdominally placed prolapse mesh.

SUMMARY

Vaginal mesh hysteropexy is a comparably well tolerated and effective surgical treatment option for women with uterovaginal prolapse. Although vaginal mesh kits are not commercially available, this procedure may be a viable treatment option in select patients.

Total Vaginal Hysterectomy With Uterosacral Ligament Suspension Compared With Supracervical Hysterectomy With Sacrocervicopexy for Uterovaginal Prolapse

OBJECTIVE

To compare prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension to recurrence after supracervical hysterectomy with mesh sacrocervicopexy for the primary management of uterovaginal prolapse.

METHODS

We conducted a retrospective cohort study of women undergoing uterovaginal prolapse repair at an academic center from 2009 to 2019. Women who underwent vaginal hysterectomy with uterosacral ligament suspension or laparoscopic supracervical hysterectomy with mesh sacrocervicopexy were included. The primary outcome was composite prolapse recurrence (prolapse beyond the hymen or retreatment with pessary or surgery). Secondary outcomes included mesh complications, time to recurrence, and overall reoperation for either prolapse recurrence or mesh complication. We used propensity scoring with a 2:1 ratio of sacrocervicopexy to uterosacral suspension.

RESULTS

The cohort consisted of 654 patients, of whom 228 (34.9%) underwent uterosacral suspension and 426 (65.1%) underwent sacrocervicopexy. The median follow-up was longer for the sacrocervicopexy group (230 vs 126 days, P<.001) and less than 1 year for both groups. The uterosacral group had a greater proportion of composite prolapse recurrence (14.9% [34/228] vs 8.7% [37/426], P=.02) and retreatment for recurrent prolapse (7.5% [17/228] vs 2.8% [12/426], P=.02). The uterosacral group demonstrated a shorter time to prolapse recurrence on multivariable Cox regression (hazard ratio 3.14, 95% CI 1.90-5.16). There were 14 (3.3%) mesh complications in the sacrocervicopexy group. Overall reoperation was similar between groups (4.8% [11/228] vs 3.8% [16/426], P=.51).

CONCLUSION

Total vaginal hysterectomy with uterosacral ligament suspension was associated with higher rate of, and shorter time-to-prolapse recurrence compared with supracervical hysterectomy with mesh sacrocervicopexy.

Mechanics of Uterosacral Ligaments: Current Knowledge, Existing Gaps, and Future Directions

The uterosacral ligaments (USLs) are important anatomical structures that support the uterus and apical vagina within the pelvis. As these structures are over-stretched, become weak, and exhibit laxity, pelvic floor disorders such as pelvic organ prolapse occur. Although several surgical procedures to treat pelvic floor disorders are directed toward the USLs, there is still a lot that is unknown about their function. This manuscript presents a review of the current knowledge on the mechanical properties of the USLs. The anatomy, microstructure, and clinical significance of the USLs are first reviewed. Then, the results of published experimental studies on the in vivo and ex vivo, uniaxial and biaxial tensile tests are compiled. Based on the existing findings, research gaps are identified and future research directions are discussed. The purpose of this exhaustive review is to help new researchers navigate scientific literature on the mechanical properties of the USLs. The use of these structures remains very popular in reconstructive surgeries that restore and augment the support of pelvic organs, especially as synthetic surgical mesh implants continue to be highly controversial.

Regional Performance of Apical Support Procedures at Time of Hysterectomy for Benign Indications: What Is the Role of Surgeon Training?

OBJECTIVE

The objective of this study was to determine factors associated with performance of concomitant apical support procedures (ASPs) with benign hysterectomy at a regional medical system.

METHODS

Benign hysterectomies performed within 1 regional medical system from January 2011 to November 2017 were identified using International Classification of Diseases, Ninth and 10th Revision, and Current Procedural Terminology codes. Primary outcome was performance of concomitant ASP. χ2 Tests compared categorical variables. Multivariable logistic regression analysis was performed to determine factors associated with performance of concomitant ASP.

RESULTS

A total of 12,345 benign hysterectomies were performed during the study period. Uterovaginal prolapse was the primary diagnosis in 924 (7.48%) hysterectomies and an associated diagnosis in 1180 (9.56%) hysterectomies. A total of 686 patients (5.56%) had concurrent ASPs: 119 (17.3%) in patients without a diagnosis of prolapse and 567 (82.7%) with prolapse. Using multivariable logistic regression, controlling for age, race, insurance type, hospital type, procedure year, hysterectomy route, and surgeon training in patients with a diagnosis of prolapse, older age, supracervical hysterectomy, and surgeon training were associated with performance of ASPs.

CONCLUSIONS

Even in patients with a preoperative diagnosis of uterovaginal prolapse, ASPs are not routinely performed at time of hysterectomy. Fellowship-trained surgeons were more likely to perform ASPs. Ongoing educational efforts during training and postgraduate at the national and regional level on the importance of reestablishing apical vaginal support at time of hysterectomy is needed to prevent incident and recurrent post-hysterectomy vaginal vault prolapse.

Transvaginal Natural Orifice Transluminal Endoscopic Uterosacral Ligament Hysteropexy: An Innovative Approach for Treatment of Uterine Prolapse

STUDY OBJECTIVE

Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) was previously described as a feasible approach to perform several procedures including hysterectomy followed by uterosacral ligament suspension [1,2]. Approaching the cul-de-sac with vNOTES while the uterus is intact allowing access to the uterosacral ligaments. This enables attainment of apical support by placing sutures on the ligaments, shortening them, and reinforcing their attachment to the cervix. The objective of this video is to demonstrate a surgical technique for vNOTES uterosacral ligament hysteropexy (ULH).

DESIGN

Stepwise demonstration of the technique with narrated video footage. This video report is part of an institutional, investigational review board-approved study.

SETTING

Academic tertiary referral center.

INTERVENTIONS

This video presents our team's vNOTES technique for ULH in a woman aged 37 years (gravida 3 para 3) who presented with pelvic organ prolapse quantification stage 3 symptomatic uterine prolapse. The patient requested uterine prolapse repair surgery while retaining the uterus. After performing a posterior colpotomy and entering the posterior cul-de-sac, the alexis and then the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA) were placed into the vagina. Three trocars were inserted into the port. We used a 10-mm scope with a 30°-angle view. The instruments included a needle driver and a clinch grasper. The next step was to identify the uterosacral ligamentous structures. Once identified, 2 absorbable vicryl sutures and 1 nonabsorbable Ti-cron suture were placed on each ligament and then secured with large bites into the junctional portion of the uterosacral ligament with the posterior aspect of the cervix. The GelPOINT was then extracted, and the sutures locked in place to shorten the uterosacral ligaments and reinforce their attachment to the cervix. After all the suspensory sutures were tied, cystoscopy was performed to assess ureteral patency. The vaginal incision was then reapproximated in a horizontal manner, using continuous absorbable suture.

CONCLUSION

vNOTES ULH appears to be feasible in women with uterine prolapse when uterus conservative treatment is desired. Advantages of this technique include good exposure of the ureter, lowering the risk of ureteric injury. In addition, the absence of incisions on the abdomen eliminates the risk of abdominal wound infection and incisional pain and yields a better cosmetic outcome. Further studies are needed to appraise the long-term outcomes and demonstrate the ultimate use of this modality.

Transvaginal natural orifice transluminal endoscopic versus conventional vaginal hysterectomy with uterosacral ligament suspension for apical compartment prolapse

OBJECTIVE

The objective of this study was to compare surgical and short-term postoperative outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) versus conventional vaginal (CV) uterosacral ligament suspension (USLS) surgery.

STUDY DESIGN

A retrospective cohort study was conducted on 135 patients who underwent hysterectomy with USLS via CV (n = 70) or via vNOTES (n = 65). Patients' baseline characteristics, surgical characteristics, and surgical outcomes were retrieved. The primary outcome was total operative time. Secondary outcomes include intra- and post-operative complications.

RESULTS

Salpingectomy was performed in all vNOTES procedures and in only 27 % of conventional vaginal procedures (p < 0.005). Compared to the conventional vaginal procedures (n = 65), the vNOTES (n = 70) showed lower mean operative time and mean anesthesia time (101.4 ± 22.3 vs 125.5 ± 27.6 min and 141.4 ± 29.6 vs. 174.0 ± 32.9 min, respectively); and slightly longer median hospital stay (3 [range 2-4] vs. 2 [range 2-4] days, p < 0.05). Compared to women who underwent conventional vaginal hysterectomy with USLS, women who underwent vNOTES hysterectomy with USLS had lower incidences of intraoperative complications (6% vs. 18 %, p < 0.05) and intraoperative ureteral obstruction (0% vs. 8%, p < 0.05); and less estimated blood loss (58 ± 68 ml vs. 143 ± 87 ml, p < 0.05).

CONCLUSION

vNOTES hysterectomy with USLS is associated with reduced incidence of intraoperative complications, shorter surgical and anesthesia time, and slightly longer hospital stay, compared to the traditional vaginal surgical approach. Post-operative complications during hospital stay were similar and infrequent following the two procedures.

Association of Pelvic Organ Prolapse Quantification examination D point with uterosacral ligament suspension outcomes: the "OPTIMAL" D point

INTRODUCTION AND HYPOTHESIS

The objective was to determine the relationship between the preoperative D-point and apical outcomes at 24 months, using the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) dataset.

METHODS

This was a secondary analysis of the OPTIMAL trial, a randomized multi-centered study comparing outcomes of sacrospinous ligament fixation and transvaginal uterosacral ligament suspension (USLS). The 2-year dataset utilized included women undergoing USLS with concomitant hysterectomy. The primary outcome was the relationship between preoperative D-point and apical outcomes at 24 months. Secondary objectives were to determine the relationship between preoperative D-point and anatomical, composite and subjective outcomes, and to determine a D-point cut-off that could be used to predict success in each of these categories.

RESULTS

Of the 186 women in the USLS arm, 120 were available for analysis of anatomical failure at 24 months. A higher preoperative D-point correlated with improved apical outcome (C-point) at 24 months (r = 0.34; p value = 0.0002). Using ROC curves, a moderate association was found between the preoperative D-point and apical and anatomical success, (AUC 0.689 and 0.662). There was no relationship between preoperative D-point and composite or subjective success (AUC 0.577 and 0.458). Based on the ROC curves, a "cut-off" D-point value of -4.25 cm (sensitivity = 0.58, specificity = 0.67) was determined to be a predictor of postoperative anatomical success at 2 years.

CONCLUSIONS

Preoperative D-point correlates with postoperative anatomical and apical support, but is less successful at predicting subjective outcomes. The strongest predictive D-point cut-off for anatomical and apical success at 24 months was -4.25 cm.

Vaginal Colposuspension Using the Uphold Lite Mesh System versus Transvaginal Hysterectomy with Uterosacral Ligament Suspension for Treatment of Apical Prolapse: A Comparative Study

STUDY OBJECTIVE

To compare clinical and anatomic outcomes as well as patient satisfaction in women undergoing vaginal colposuspension using the Uphold Lite system (Boston Scientific Corporation, Marlborough, MA) and transvaginal hysterectomy with uterosacral ligament suspension (VUSLS) for the treatment of apical prolapse.

DESIGN

Retrospective cohort study.

SETTING

Female pelvic medicine and reconstructive surgery unit at a university-affiliated tertiary medical center.

PATIENTS

Women with apical prolapse who underwent either vaginal colposuspension using the Uphold Lite system (uterine-preserving as well as after previous hysterectomy) or VUSLS from 2010 to 2019. Excluded were women with 1 month or less of follow-up.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 164 women were included in the study: 112 women underwent VUSLS, and 52 underwent colposuspension using the Uphold Lite mesh system. Age, body mass index, maximal birth weight, comorbidity rates, and pelvic organ prolapse severity were similar between the groups. The clinical cure rate was similarly high in both groups, with 91.1% in the women who underwent VUSLS and 88.5% in those in the Uphold Lite group (p = .60). No differences were noted between the groups with regard to anatomic cure rate or composite outcome success rate (73.9% vs 76.0%, p = .77 and 70.3% vs 74.0%, p = .63, in the VUSLS and Uphold Lite groups, respectively). An advantage was noted in the VUSLS group with regard to patient satisfaction with 98.1% of the women stating that their condition was very much better (Patient Global Impression of Improvement questionnaire: A) or much better (Patient Global Impression of Improvement questionnaire: B) compared with 83.9% of the women in the Uphold Lite group (p = .023). In an attempt to assess the association between different variables and the composite outcome, a multivariate analysis was performed in which increased body mass index, menopausal status, and increased preoperative genital hiatus were found to decrease composite outcome success.

CONCLUSION

Vaginal colposuspension using the Uphold Lite system and VUSLS for the treatment of apical prolapse have comparable results with high clinical success rates.

Perioperative Adverse Events in Women Undergoing Vaginal Prolapse Repair With Uterine Preservation Versus Concurrent Hysterectomy: A Matched Cohort Study

OBJECTIVE

The objective of this study is to compare the incidence of perioperative adverse events (AEs) in women undergoing vaginal prolapse repair with uterine preservation (hysteropexy) versus concurrent hysterectomy.

METHODS

This was a retrospective matched cohort study between 2012 and 2019. Patients who received a sacrospinous or uterosacral hysteropexy or colpopexy with hysterectomy were matched by surgeon, surgical year, and age. The electronic medical record was queried for demographic and perioperative data. Strict definitions were used for all clinically relevant AEs.

RESULTS

One hundred and thirty hysteropexy (89 sacrospinous, 41 uterosacral) patients were matched to 260 concurrent hysterectomy (6 sacrospinous, 253 uterosacral, 1 both) patients. Mean age and body mass index were 58 years (±13 years) and 27.9 kg/m2 (±6 kg/m2). Compared with hysteropexy, cases with hysterectomy were longer, had higher blood loss, and a longer hospital stay. The overall incidence of AEs was 29.0% for concurrent hysterectomy versus 10.5% in hysteropexy cases (P = 0.02); on logistic regression, concurrent hysterectomy remained a statistically significant predictor of AEs, with an adjusted odds ratio of 4.03 (95% confidence interval, 1.48-11.01). There was no difference in Dindo grade 3 complications between concurrent hysterectomy and hysteropexy procedures (0.8% vs 1.3%, P = 0.12). In a subanalysis examining the 2 hysteropexy types, there were no significant differences in AEs.

CONCLUSIONS

The overall incidence of serious AEs is low in women with uterovaginal prolapse undergoing vaginal native tissue repair with or without hysterectomy. Vaginal hysteropexy is associated with lower odds of experiencing AEs, shorter operating times, a shorter length of stay, and less blood loss.

Risk factors for ureteral obstruction and the diagnostic value of the "cysto-under-tension" technique at the time of uterosacral colpopexy

INTRODUCTION AND HYPOTHESIS

The objective is to determine the incidence of ureteral obstruction and delayed ureteral injury and to identify risk factors for ureteral obstruction following uterosacral colpopexy. The secondary objective is to evaluate the diagnostic value of the "cysto-under-tension" technique, when a cystoscopy is performed prior to vaginal cuff closure with the uterosacral sutures on tension.

METHODS

This was a retrospective review of patients undergoing uterosacral ligament colpopexy between 2007 and 2012 with a nested case-control analysis. Patients with documented ureteral obstruction on cystoscopy or a delayed ureteral injury were identified. Cases were defined as patients with a ureteral obstruction on cystoscopy and controls as those who did not; a multivariable regression analysis was performed.

RESULTS

A total of 551 patients underwent uterosacral ligament colpopexy. Twenty-four (4.3% [95% CI = 2.94-6.40]) patients had a ureteral obstruction on cystoscopy, and two (0.4% [95% CI = 0.09-1.31]) patients experienced a delayed ureteral injury. The "cysto-under-tension" technique was used in 40 (7.3%) cases, with a sensitivity of 50.0% (CI = 1.26-98.74) and specificity of 97.4% (CI = 86.2-99.9) to detect ureteral obstruction. On logistic regression for the case-control analysis, increased age remained associated with increased odds of ureteral obstruction (adjOR 1.06, 95% CI = 1.02-1.11) and a higher BMI had lower odds (adjOR 0.89, 95% CI = 0.79-0.98).

CONCLUSIONS

In this large cohort study, older age was associated with higher odds of obstruction at the time of colpopexy while a higher BMI might have been protective. The "cysto-under-tension" technique overall may not be that useful in detecting ureteral obstructions but has high negative predictive value.

Extraperitoneal high vaginal cuff suspension at the time of vaginal hysterectomy for advanced uterovaginal prolapse: Results of a modified McCall technique from a longitudinal clinical study

BACKGROUND

Women with high-grade uterovaginal prolapse have a greater risk of recurrent prolapse after pelvic organ prolapse surgery. Royal College of Obstetricians and Gynaecologists guidelines have recommended sacrospinous suspension (sacrospinous fixation) at the time of vaginal hysterectomy, whenever there is a marked uterovaginal prolapse. We have modified the McCall culdoplasty by placing sutures extraperitoneally, higher and more lateral into the uterosacral/cardinal ligaments to re-support the vaginal cuff at the time of a vaginal hysterectomy.

AIMS

To evaluate the results of a modified technique of McCall high culdoplasty and native tissue repair at time of vaginal hysterectomy in women with advanced uterovaginal prolapse.

MATERIAL AND METHODS

Longitudinal clinical follow-up conducted between 2000-2018, in a tertiary urogynaecology centre for patients presenting with stage 3-4 uterovaginal prolapse, who underwent vaginal hysterectomy and modified McCall vault suspension.

RESULTS

There were 176 cases meeting the inclusion criteria. Mean follow-up was 19.35 months. There were 25 recurrences (14%) of ≥ stage 2 (76% not symptomatic). Twelve of these recurrences (48%) occurred in anterior compartment, six (25%) posterior, three (12%) combined anterior/posterior, two (8%) combined posterior/central and one case had recurrence in all compartments. Only six cases (3%) required another surgical procedure for symptomatic prolapse, all with an enterocele recurrence.

CONCLUSIONS

Our described modified McCall technique incorporates high extraperitoneal approach to apical resuspension along with closure of any existing large hiatal defects of the levator plate at the time of vaginal hysterectomy for advanced uterine prolapse has excellent outcomes and extremely low complication rates and avoids the need for sacrospinous fixation.

Suture Complication Rates and Surgical Outcomes According to the Nonabsorbable Suture Materials Used in Vaginal Uterosacral Ligament Suspension: Polyester versus Polypropylene

STUDY OBJECTIVE

To evaluate suture complication rates and surgical outcomes according to the nonabsorbable suture materials used in vaginal uterosacral ligament suspension (USLS) surgery. Multifilament polyester (polyethylene terephthalate [PET]) and monofilament polypropylene (PP) sutures were compared.

DESIGN

Retrospective cohort study.

SETTING

Single teaching hospital.

PATIENTS

Total of 229 patients who underwent transvaginal USLS and completed a 1-year follow-up.

INTERVENTIONS

Use of PET and PP sutures for transvaginal USLS procedures.

MEASUREMENTS AND MAIN RESULTS

PP sutures were used in 149 patients, and PET sutures were used in 80 patients. The suture-related complication rates, including granulation tissue and suture erosion at the vaginal apex, were significantly higher in the PET suture group than in the PP suture group (46.3% vs 20.1%, p <.01). However, there was no significant difference in the rates of surgical failure (defined as the presence of vaginal bulging symptoms, apical descent ≥ half of the total vaginal length, anterior or posterior vaginal wall descent beyond the hymen, or retreatment for prolapse) between the 2 groups (p = .84).

CONCLUSION

Compared with the use of multifilament PET sutures, the use of monofilament PP sutures in transvaginal USLS may reduce suture-related complications without increasing surgical failure rates.

Practice Patterns Regarding Apical Support Procedures at Time of Hysterectomy for Pelvic Organ Prolapse

OBJECTIVES

We sought to understand practice patterns of non-female pelvic medicine and reconstructive surgery (FPMRS) clinicians regarding concurrent apical support procedures during hysterectomies when primarily performed for the treatment of pelvic organ prolapse. We also sought to describe differences between those receiving and not receiving apical support.

METHODS

This retrospective study analyzed medical records of individuals undergoing hysterectomy for the primary indication of pelvic organ prolapse between 2012 and 2017 at all locations within the TriHealth system. Surgeries performed by board-certified FPMRS physicians were excluded. Comparisons were drawn between those who did and did not receive apical support.

RESULTS

A total of 236 charts met the inclusion criteria. Of these, 66 (28%) received concurrent apical suspension, and 94 (39.8%) underwent no reconstructive procedures. The annual proportion of those receiving apical suspension did not differ over the course of the study period. On average, the addition of apical support added 39.9 minutes (P < 0.001) to the length of surgery. There was, however, no difference noted in estimated blood loss. Risk factors for recurrent prolapse including chronic constipation, pulmonary disease, and connective tissue disorders were similar between groups.

CONCLUSION

When excluding FPMRS surgeons, data from our institution showed that most patients undergoing hysterectomy for prolapse did not receive concurrent apical support. This suggests areas of potential improvement for adopting into clinical practice the new American College of Obstetricians and Gynecologists recommendations regarding the treatment of prolapse. Furthermore, this may represent an important opportunity for peer outreach and education by FPMRS surgeons.

Long-term efficacy of transvaginal high uterosacral ligament suspension for middle-compartment defect-based pelvic organ prolapse

Background

We aim to assess the long-term efficacy of transvaginal high uterosacral ligament suspension (HUS) procedure for middle compartment defect-based pelvic organ prolapse (POP).

Methods

We performed a retrospective review of 84 women with middle-compartment defect-based POP who underwent transvaginal HUS as the primary surgical treatment without mesh augmentation from January 2007 to January 2019. All 84 patients manifested ≥ grade-II middle-compartment defect-based POP. Follow-up visits were performed 2, 6 and 12 months after surgery and then annually, including questionnaires and clinical examination using pelvic organ prolapse quantitation system (POP-Q). Surgical success required to fulfill all three of these criteria: (I) anterior or posterior vaginal wall prolapsed the leading edge of 0 cm or less and apex of 1/2 total vaginal length or less; (II) the absence of POP symptoms as reported on the PFDI-20 question No. 3 (“do you usually have a bulge or something falling out that you can see or feel in your vaginal area?”); and (III) no prolapse re-operations or pessary use during the study period.

Results

Of 84 women, 56 cases (66.7%, 56/84) were evaluated at a ≥5-year follow-up. The 5-year recurrence rates for patients with prolapse of either the anterior vaginal wall, vaginal vault, or posterior vaginal wall, or prolapses in multiple sites, were 7.1% (4/56), 0, 1.8% (1/56), and 3.6% (2/56), respectively. The surgery success rate was 87.5% (49/56). None of the recurrent women underwent retreatment. The satisfaction rate was 91.1% (51/56).

Conclusions

Transvaginal HUS without mesh augmentation is a safe and effective procedure in the surgical treatment of patients with middle-compartment defects. Anatomical, functional, and subjective outcomes were very satisfactory.

Risk Factors for Surgical Failure and Worsening Pelvic Floor Symptoms Within 5 Years After Vaginal Prolapse Repair

OBJECTIVE

To assess independent risk factors for surgical failure and worsening pelvic floor symptoms within 5 years after vaginal prolapse surgery.

METHODS

This secondary analysis includes OPTIMAL (Operations and Pelvic Muscle Training in the Management of Apical Support Loss) (n=374) and E-OPTIMAL (Extended) (n=285) trial participants. Surgical failure was defined as apical descent greater than one third of the total vaginal length, anterior or posterior vaginal wall past the hymen, subsequent surgery or bothersome vaginal bulge. Worsening pelvic floor symptoms were defined as increases from baseline as large as the minimally important difference for subscale scores of the Pelvic Floor Distress Inventory: 11 for the Urinary Distress Inventory and Colorectal-Anal Distress Inventory and 34.3 for the Pelvic Organ Prolapse Distress Inventory. Outcomes were measured at 6 months then 1, 2, 3, 4, and 5 years. Chi-square and t test results from bivariate models and clinical relevance were used to inform final models.

RESULTS

Baseline risk factors for surgical failure were Hispanic ethnicity (adjusted odds ratio [aOR] 1.92, 95% CI 1.17-3.15), perineal body (aOR 1.34, 95% CI 1.09-1.63), and pretreatment Pelvic Organ Prolapse Distress Inventory score (aOR 1.16, 95% CI 1.05-1.28). Risk factors for worsening of pelvic floor symptoms were pretreatment Pelvic Organ Prolapse Distress Inventory score (aOR 0.75, 95% CI 0.60-0.94) for worsening Pelvic Organ Prolapse Distress Inventory score, vaginal deliveries (aOR 1.26, 95% CI 1.10-1.44) and pretreatment Urinary Distress Inventory score (aOR 0.86, 95% CI 0.80-0.93) for worsening Urinary Distress Inventory score, and age (aOR 1.03, 95% CI 1.01-1.05) and pretreatment Colorectal-Anal Distress Inventory score (aOR 0.95, 95% CI 0.92-0.98) for worsening Colorectal-Anal Distress Inventory score.

CONCLUSIONS

Hispanic ethnicity, larger preoperative perineal body, and higher pretreatment Pelvic Organ Prolapse Distress Inventory scores were risk factors for surgical failure up to 5 years after vaginal prolapse repair. Participants with higher baseline Pelvic Floor Distress Inventory scores were less likely to worsen. Risk factors for worsening Urinary Distress Inventory and Colorectal-Anal Distress Inventory scores included more vaginal deliveries and increased age, respectively.

CLINICAL TRIAL REGISTRATION

NCT00597935, NCT01166373.

Comparison of two natural tissue repair-based surgical techniques; sacrospinous fixation and uterosacral ligament suspension for pelvic organ prolapse treatment

INTRODUCTION AND PURPOSE

The present study aims to compare the effectiveness and perioperative results of the natural tissue repair-based treatments sacrospinous fixation (SSF) and uterosacral ligament suspension (USLS) based on the preoperative Pelvic Organ Prolapse Quantification system (POP-Q).

MATERIALS AND METHODS

Medical records of patients with stage ≥2 uterine prolapse between January 2011 and December 2016 were retrospectively examined. Preoperative POP-Q stages, demographic characteristics, perioperative results, and recurrence ratios in mid-term follow-up for patients were compared.

RESULTS

Overall, 235 patients were determined according to our study's inclusion criteria. A total of 155 patients underwent vaginal hysterectomy and USLS (VH/USLS), whereas 80 patients underwent vaginal hysterectomy and SSF (VH/SSF). There were no significant differences between groups in terms of body mass index (BMI), age, and parity as well as cardiovascular disease and diabetes mellitus. There was no significant difference in terms of anatomical success and clinical success rates in the postoperative follow-up period between both groups. (p = 0.588 and 0.692, respectively). However, the assessment of results based on preoperative stages of patients revealed that recurrence and anatomical failure were higher in the stage 4 group (p < 0.001).

CONCLUSION

Our findings indicate that the main determinant factor in evaluating recurrence rates is preoperative POP-Q staging of the patient. Recurrence rates significantly increase with disease stage. Consistent with studies that do not report a clear superiority for USLS or SSF, we observed no significant differences between both procedures in terms of recurrence. The effectiveness of these procedures is similar. We believe that prospective, long-term follow-up studies with larger populations are required to accurately identify preoperative risk factors and compare them with mesh techniques.

Total laparoscopic multi-compartment native tissue repair of pelvic organ prolapse and stress urinary incontinence

AIM OF THE VIDEO

In this video we present the surgical management of a 59-year-old woman with stress urinary incontinece (SUI) and pelvic organ prolapse (POP) who had a history of rheumatoid arthritis and endometrial hyperplasia with atypia.

METHODS

A concomitant laparoscopic hysterectomy with bilateral oophorectomy and a multi-compartment laparoscopic native tissue repair of the POP, combined with a Burch urethropexy, was performed to restore pelvic floor defects and treat the underlying endometrial pathology.

CONCLUSION

Total laparoscopic multi-compartment repair of POP and/or SUI using native tissue appears to be a viable alternative to both laparoscopic procedures using synthetic meshes and vaginal native tissue repairs. Although not a routine option for the majority of patients with POP and SUI, this procedure may be offered in selected cases, where native tissue repair of the pelvic floor is preferred.