ACOG Practice Bulletin No. 79: Pelvic Organ Prolapse:

Extraperitoneal uterosacral suspension technique for post hysterectomy apical prolapse in 472 women: results from a longitudinal clinical study

OBJECTIVES

The study aims to evaluate the long-term results of the extraperitoneal uterosacral ligament suspension (bilateral) technique in women with apical prolapse following hysterectomy.

DESIGN

Longitudinal clinical follow up conducted between June 2002 and December 2017.

SETTING

Tertiary urogynaecology centre in Melbourne, Australia.

POPULATION

A total of 472 women with symptomatic vault prolapse who underwent bilateral extraperitoneal uterosacral ligament suspension (EPUSLS). Of these patients, 61% (287/472) had previously had a procedure for pelvic organ prolapse (POP).

METHODS

Follow up using structured, standardised questionnaires and examination by POP-Q and Baden-Walker system pre- and postoperatively.

MAIN OUTCOME MEASURES

Functional and anatomical results and surgical complications.

RESULTS

Mean follow-up duration was approximately 5 years. The objective success rate at vaginal cuff support was 89% (420/472). Only 4% needed revision surgery for vault recurrence. There was improvement in bladder, bowel, and sexual symptoms after the procedure. Mesh exposure rate was 17% (of the 138 having mesh augmentation), with the majority of cases managed conservatively or with minor interventions. The ureteric injury rate was 1% and mainly occurred in patients operated early on in the series. No women had buttock pain.

CONCLUSION

EPUSLS is an effective, suture-based procedure for vault prolapse with few complications even on long-term follow up. This technique avoids the need to open the peritoneum vaginally and has a low risk of ureteric injury and gluteal pain.

TWEETABLE ABSTRACT

Bilateral extraperitoneal USL suspension of vault is effective with low morbidity and a high success rate.

Post-hysterectomy vaginal vault prolapse

Post-hysterectomy vaginal vault prolapse (PHVP) is a recognised although rare complication following both abdominal and vaginal hysterectomy and the risk is increased in women following vaginal surgery for urogenital prolapse. The management of PHVP remains challenging and whilst many women will initially benefit from conservative measures, the majority will ultimately require surgery. The purpose of this paper is to review the prevalence and risk factors associated with PHVP as well to give an overview of the clinical management of this often complicated problem. The role of prophylactic primary prevention procedures at the time of hysterectomy will be discussed as well as initial conservative management. Surgery, however, remains integral in managing these complex patients and the vaginal and abdominal approach to managing PHVP will be reviewed in detail, in addition to both laparoscopic and robotic approaches.

Demands and properties of alloplastic implants for the treatment of stress urinary incontinence

Surgical treatment of stress urinary incontinence changed dramatically with the introduction of the tension-free vaginal tape. Owing to its high efficacy and minimal patient discomfort this new minimally invasive procedure quickly obtained widespread acceptance and superseded the abdominal colposuspension as the gold standard. In the course of success of the original method a number of tension-free vaginal tapes flooded the market, varying in approach and material. These variations may strongly influence the safety, efficacy and long-term results of tension-free vaginal tape and its major modification, the transobturator technique. Therefore, it is the aim of this review to closely illuminate available materials and complications associated with this procedure. An extensive Medline search of the published literature up until 2006 on the subject of stress urinary incontinence was carried out. All sources identified were reviewed with particular attention to the method applied, the properties of the mesh materials and clinical complications. Apart from several technical variations, there are marked differences between the different vaginal sling materials, ranging from absorbable collagens over polypropylene to allografts. Although performed globally in substantial and increasing numbers, minimally invasive techniques for the surgical treatment of stress urinary incontinence are lacking sufficient safety data.

Tissue fixation system (TFS) to repair uterovaginal prolapse with uterine preservation: a preliminary report on perioperative complications and safety

OBJECTIVES

To assess the effectiveness, perioperative safety and invasiveness of the Tissue Fixation System (TFS) sling operation when used for repair of uterovaginal prolapse with uterine preservation.

METHODS

Operations using the TFS anchor system were performed on 25 women aged between 44 and 84 years (average 65) for grade 3 or 4 uterine prolapse with or without urinary incontinence. Details of the procedures were as follows: midurethral sling (n=2); posterior sling of the uterosacral ligaments (n=25); U-sling for lateral/central anterior vaginal wall defects (n=24). The defect of the perineal body and rectovaginal fascia were repaired in all cases.

RESULTS

All patients were followed up for a minimum of 3 months. The mean +/- standard deviation of the operating time and loss of blood were 94.2 (+/-19.3) minutes and 98.1 (+/-129.6) mL, respectively. Twelve patients (48%) were discharged on the same day of surgery and 13 patients (52%) on the following day, with a return to normal activities within 1-7 days. There were no intra- or postoperative complications. At the 3-month follow up, cure rates of symptoms due to pelvic laxity were: urinary frequency 85.7% (n=14); nocturia 66.6% (n=12); urgency 93.3% (n=15); and dragging pain 100% (n=6). There was one recurrent uterovaginal prolapse and one recurrent cystocele.

CONCLUSION

The TFS procedure delivers satisfactory results for uterine prolapse repair with uterine preservation. The procedure is useful because of the short duration of the operation, the short term of recovery, its safety profile and minimal invasiveness. There is a significant improvement in the quality of life, especially for older women. However, long-term results are currently unknown.