The Impact of Obesity on Intraoperative Complications and Prolapse Recurrence After Minimally Invasive Sacrocolpopexy:

Effect of body mass index on surgical outcomes in patients undergoing laparoscopic sacrohysteropexy and sacrocolpopexy

INTRODUCTION

Laparoscopic promontofixation is often considered the preferred approach for the treatment of significant apical pelvic organ prolapse (POP). Obesity is an established risk factor for pelvic organ prolapse (POP), and obese patients may constitute a substantial portion of those seeking care for uterovaginal prolapse. Our aim was to evaluate the impact of body mass index on perioperative complications and long-term outcomes of this procedure.

METHODS

This is a single center retrospective cohort study. All patients who underwent laparoscopic sacrohysteropexy/sacrocolpopexy, between July 2011 and December 2021 were evaluated. The study population was divided into three groups, according to Body mass index (BMI) at time of surgery.

RESULTS

Altogether 246 patients were included: 145 in group 1 (mean BMI 21.9 ± 2), 88 patients in group 2 (mean BMI 27.1 ± 1), and 13 patients in group 3 (mean BMI 33.0 ± 3). LSH was more frequent than LSC in all groups. The overall perioperative complications rate was 6.3 %. There were no differences in operative details and rates of perioperative complications between the groups. During follow-up period, 30 patients (12.2 %) presented with prolapse recurrence (objective and/or subjective). The rates of prolapse recurrence, as well as long-term complications, were similar between the groups. Similarly, the groups did not differ in postoperative functional results except for postoperative constipation (group 1--14.5 %, group 2--23.8 %, group 3--25 %, p = 0.001).

CONCLUSION

Laparoscopic sacrohysteropexy/sacrocolpopexy is associated with low rates of perioperative and long- term complications. We did not find a difference in rates of complications and/ or long-term outcomes, between different weights groups.

Impact of Age and Body Mass Index on the Outcomes of Laparoscopic Mesh Sacrocolpopexy

Background: Pelvic organ prolapse (POP) is a benign condition that can adversely affect women's quality of life. Mesh sacrocolpopexy is an effective surgical treatment for POP, but is considered a complex and risky surgery for obese and elderly women. The objective of this study was to assess the impact of age and obesity on the outcomes of minimally invasive sacrocolpopexy. Methods: We performed a retrospective cohort study reviewing all minimally invasive sacrocolpopexy cases performed between 2003 and 2021. Data on operative time, hospital stay, conversion rate, perioperative injuries, early and late postoperative complications were collected. Surgical success was evaluated by gynecological examination at each follow-up visit. Results: One hundred seventy subjects were included, of whom 44% were older than 65 years and 58% had a body mass index (BMI) above 25 kg/m2. Seventy percent presented stage III uterovaginal prolapse. All patients achieved a good subjective outcome with no reported prolapse with a mean follow-up of 6 years. The rate of de novo stress urinary incontinence was 3.2%. Vaginal implant exposure was found in 4% of cases. A bivariate analysis studying the impact of older age (≥ 65 vs. < 65 years) and higher BMI (≥ 25 vs. < 25) on surgical and postoperative outcomes did not show any significant differences between the subgroups (p > 0.05). Conclusion: In experienced hands, laparoscopic sacrocolpopexy can be used as a safe and effective procedure for operable patients with POP, even when patients are between 65 and 80 years or have a BMI of 25 kg/m2 and above.

Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes.

DATA SOURCES

PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared.

METHODS OF STUDY SELECTION

In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted.

TABULATION, INTEGRATION, AND RESULTS

Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39).

CONCLUSION

Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022326255.

Obesity and Reconstructive Pelvic Surgery: An ACS NSQIP Study

IMPORTANCE

Obesity is steadily increasing in the United States and is a risk factor for many medical and surgical complications. Literature is limited regarding obesity as an independent risk factor for perioperative complications after reconstructive pelvic surgery (RPS).

OBJECTIVE

This study aimed to analyze the association of obesity on 30-day perioperative complications after RPS.

STUDY DESIGN

This was a database study comparing perioperative complications after RPS of obese versus nonobese patients using the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent surgery for uterovaginal or vaginal vault prolapse were selected, and perioperative outcomes were compared between obese and nonobese patients. Obesity was defined as a body mass index ≥30 (calculated as weight in kilograms divided by height in meters squared).

RESULTS

A total of 13,302 patients met the inclusion criteria and were included in this study; 4,815 patients were obese, whereas 8,487 were nonobese. The overall rate of any 30-day postoperative complication was 6.8%, and the rate of complications did not differ between groups. Superficial and organ space surgical site infections were significantly higher in the obese cohort, whereas nonobese patients were more likely to receive a blood transfusion. A multivariable logistic regression model was performed with variables that were statistically significant on bivariate analysis and deemed clinically significant. Variables included obesity, age, American Society of Anesthesiologists class, current smoker, diabetes, hypertension, operative time, colpopexy, and obliterative procedure. After controlling for potential confounding factors, obesity was not associated with any 30-day postoperative complications after pelvic organ prolapse surgery.

CONCLUSION

Obesity was not associated with 30-day postoperative complications after RPS after controlling for possible confounding variables.

Impact of Severe Obesity on Major Perioperative Complications for Prolapse Surgery

IMPORTANCE

Obesity adds complexity to the decision of surgical approach for pelvic organ prolapse; data regarding perioperative complications are needed.

OBJECTIVE

The aim of the study was to evaluate associations of body mass index (BMI) and surgical approach (vaginal vs laparoscopic) on perioperative complications.

STUDY DESIGN

Patients who underwent prolapse surgery were identified via the Current Procedural Terminology codes from the American College of Surgeons National Surgical Quality Improvement Program database 2007-2018. Thirty-day major complications were compared across BMI to identify an inflection point, to create a dichotomous BMI variable. Multivariable logistic regression was used to assess the association between BMI and complications. An interaction term was introduced to evaluate for effect modification by operative approach.

RESULTS

A total of 26,940 patients were identified (25,933 BMI < 40, 1,007 BMI ≥ 40). The proportion of patients experiencing a major complication was higher in the BMI ≥ 40 group (2.0 vs 1.1%, P = 0.007). In multivariate analysis, the odds of a major complication was 1.8 times higher for women with a BMI ≥ 40 (95% confidence interval, 1.1-2.9, P = 0.04). There was a significant interaction between operative approach and BMI; therefore, further analyses were restricted to either vaginal or laparoscopic operative approaches. Among women who underwent vaginal prolapse repair, there was no difference in the odds of a major complication (adjusted odds ratio, 1.4; 0.8-2.4; P = 0.06). Among women who underwent laparoscopic repair, those with a BMI ≥ 40 were 6 times more likely to have a major complication (adjusted odds ratio, 6.0; 2.5-14.6; P < 0.001).

CONCLUSIONS

Body mass index ≥ 40 was associated with an increased odds of a 30-day major complication. This association was greatest in women who underwent a laparoscopic prolapse repair.

Risk factors for the recurrence of pelvic organ prolapse: a meta-analysis

Female pelvic organ prolapse (POP) is a common condition, which has a high recurrence rate after reconstructive surgery, and the risk factors for POP recurrence are unclear. The aim of this study was to perform a meta-analysis to determine risk factors for POP recurrence. A thorough search of PubMed, Medline, EMBASE, Cochrane Central Register of Controlled Trials, and China Academic Journal Network Publishing Database was conducted for relevant publications until 29 October 2022, without language restrictions. A total of 29 studies involving 6597 patients were included, and the recurrence rate of POP after surgery was 37.7%. Significant OR and CI were found for levator avulsion (OR: 2.46, 95% CI: 1.80-3.36), preoperative stage ≥ III (OR: 1.87, 95% CI: 1.53-2.27), hiatal area on Valsalva manoeuvre (OR: 1.08, 95% CI: 1.03-1.12) and previous pelvic floor surgery (OR: 1.60, 95% CI: 1.07-2.39). Levator avulsion, preoperative stage ≥ III, hiatal area on Valsalva manoeuvre and previous pelvic floor surgery are significant risk factors for POP recurrence.IMPACT STATEMENTWhat is already known on this subject? It has been reported that genetic factors, parity, obesity, birth-induced injury during delivery, etc. are risk factors for POP development and recurrence after operation.What do the results of this study add? There are few literatures about the risk factors of POP recurrence at present. Our research has increased the information regarding risk factors for POP recurrence.What are the implications of these findings for clinical practice and/or further research? Our study provides an overview of the risk factors affecting POP recurrence and their contribution (OR, CI) to POP recurrence, which provides valuable evidence-based basis for clinical decision-making in POP treatment and prevention of POP recurrence.

Comparison of outcomes of laparoscopic sacrocolpopexy with concomitant supracervical hysterectomy or uterine preservation

INTRODUCTION AND HYPOTHESIS

Sacrocolpopexy was traditionally performed for post-hysterectomy prolapse or during concurrent hysterectomy. Sacrocolpopexy outcome with uterine preservation is poorly investigated. This study compared outcomes of laparoscopic sacrocolpopexy with concurrent supracervical hysterectomy or uterine preservation.

METHODS

This retrospective study compared data of patients with pelvic organ prolapse who underwent laparoscopic sacrocolpopexy with uterine preservation with the data of controls who underwent laparoscopic sacrocolpopexy with supracervical hysterectomy. We analyzed composite failure in uterine preservation versus concurrent supracervical hysterectomy (primary objective) and evaluated factors associated with the primary outcome of composite failure after laparoscopic sacrocolpopexy with preservation or supracervical hysterectomy (secondary objective). Composite failure was defined as subjective bulge symptoms, reoperation, or anatomical prolapse. Cox models indicated time to composite failure as an endpoint.

RESULTS

Of 274 patients, 232 underwent laparoscopic sacrocolpopexy with supracervical hysterectomy and 42 underwent laparoscopic uterine preservation. After propensity score matching (ratio: 2, for the laparoscopic sacrocolpopexy with supracervical hysterectomy group), 56 patients (24.1%) were in the supracervical hysterectomy group and 28 (66.7%) in the uterine preservation group. All patients underwent 24 months of follow-up. The composite failure rates were 10.7% for supracervical hysterectomy and 3.6% for preservation (p=0.87). The mean estimated blood loss was 10 ml (preservation, 10.0 ml [5.0-10.0] versus supracervical hysterectomy, 10.0 ml [10.0-15.0]; p=0.007). In the Cox proportional hazards model, higher preoperative body mass index and the point Ba increased composite failure risk.

CONCLUSIONS

Although not statistically significant, composite failure in the two techniques is likely clinically meaningful.

Impact of Obesity on Postoperative Complications after Lateral Skull Base Surgery: A Systematic Review

INTRODUCTION

The relationship between obesity and complications after lateral skull base tumor resection is not clear. There is conflicting evidence regarding the incidence of postoperative complications in this patient population. The purpose of this study is to examine the relationship between obesity and outcomes following lateral skull base tumor resection.

DATA SOURCES

Data were extracted from PubMed, Embase, CINAHL, and Cochrane CENTRAL.

METHODS

Included studies assessed the relationship between obesity and outcomes following lateral skull base tumor removal. Studies with ≤5 patients, pediatric patients, duplicate patient populations, or insufficient data were excluded. Two independent investigators reviewed each study for inclusion. A third reviewer served as a tie-breaker for any conflicts. Extracted data includes patient demographics, tumor pathology, surgical approach, and postoperative outcomes including incidence of cerebrospinal fluid (CSF) leak and other postoperative complications, length of stay (LOS), and readmission and reoperation rates. Descriptive statistics were used to compare postoperative outcomes for obese and nonobese controls.

RESULTS

14 studies met final inclusion criteria. Nine studies evaluated the relationship between obesity and CSF leaks. Four studies found a significant increase in postoperative CSF leak in obese patients compared to nonobese controls. The remaining studies trended toward an increased incidence of CSF leak in the obese population but did not reach statistical significance. One out of seven studies found that obesity increased postoperative LOS, and one out of five studies found that obesity increased reoperation rates following tumor resection.

CONCLUSIONS

Based on the results, obesity does not appear to increase LOS, readmission, or reoperation rates after lateral skull base tumor resection. The relationship between obesity and postoperative CSF leak, however, warrants further analysis.

Medium-term risk of recurrent pelvic organ prolapse within 2-year follow-up after laparoscopic sacrocolpopexy

Objective

The present study was performed to determine the risk of recurrent pelvic organ prolapse (POP) within 2 years after laparoscopic sacrocolpopexy (LSC) in patients with uterovaginal prolapse.

Materials and Methods

A retrospective comparative study was performed in a population of 204 patients over a 2-year follow-up period following LSC with concomitant supracervical hysterectomy or uterine preservation at a single urological clinic between 2015 and 2019. The primary outcome was surgical failure following LSC in cases of POP, focusing on failures occurring before the 2^ndyear of follow-up. Logistic regression analysis was used to determine the odds ratios (ORs) for surgical failure.

Results

The primary outcome, surgical failure in cases of POP, occurred 2 years after the initial surgery in 19 of the 204 patients (9.3%) (95% confidence interval [CI], 5.7% - 14.2%). Surgical failure was most common in the anterior compartment (n = 10, 4.9%), and further surgery was performed in seven of the patients with surgical failure (3.4%). The poor primary outcome was predicted by lysis of adhesions (OR, 7.5, 95% CI, 1.6-33.8, P = 0.008) and preoperative POP stage IV (OR, 3.5; 95% CI, 1.1-10.8, P = 0.03) on multivariable logistic regression analysis.

Conclusion

The overall rate of surgical failure following LSC in our cohort was 9.3% over the 2-year follow-up period after surgery, and preoperative prolapse stage IV was associated with a higher risk of recurrence.

Complications After Vaginal Vault Suspension Versus Minimally Invasive Sacrocolpopexy in Women With Elevated Body Mass Index: A Retrospective Cohort Study Using Data From the National Surgical Quality Improvement Program Database

IMPORTANCE

Overweight and obese women represent a growing share of pelvic floor reconstruction surgeons' practices. Determining perioperative risk specific to this population is essential to inform decision making regarding operative approach in this population.

OBJECTIVE

The aim of the study was to compare surgical complications among overweight and obese women undergoing apical compartment prolapse surgery by either minimally invasive abdominal or vaginal approach.

STUDY DESIGN

The American College of Surgeons National Surgical Quality Improvement Database was used to identify overweight and obese patients (body mass index ≥ 25) undergoing either minimally invasive sacrocolpopexy (MISC) or vaginal vault suspension (VVS) in the form of a sacrospinous vault fixation or uterosacral ligament fixation for pelvic organ prolapse from 2012 to 2019. Odds ratios for surgical complications, readmission, and reoperation were estimated using multivariable logistic regression.

RESULTS

Of 8,990 eligible patients, 5,851 underwent a VVS and 3,139 patients underwent MISC. There was a greater odds of any complication in the first 30 days following VVS (n = 608 [10.4%]) compared with MISC (n = 247 [7.9%]; odds ratio, 1.27; 95% confidence interval, 1.08-1.48) on multivariable analysis. Urinary tract infections (UTIs) were the most common complication and were more likely following VVS (112 (3.6%) versus 350 (6.0%), P < 0.001). When UTIs were excluded, there was no difference in complications between approaches (1.00; 95% CI, 0.82-1.22). There were no statistically significant odds of readmission, reoperation, or serious complications between approaches.

CONCLUSIONS

Vaginal vault suspension may be associated with a higher odds of any complication compared with MISC in overweight and obese women, but the rate of serious complications, readmission, and reoperation are low, and approaches were comparable when considering complications other than UTI.

Laparoscopic sacral hysteropexy versus laparoscopic sacral colpopexy plus supracervical hysterectomy in patients with pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The choice of whether or not to preserve the uterus in the case of patients with urogenital prolapse who undergo sacral colpopexy is still debated. We compared objective and subjective outcomes of laparoscopic sacral hysteropexy (LSHP) and laparoscopic sacral colpopexy with concomitant supracervical hysterectomy (LSCP/SCH) in patients with symptomatic pelvic organ prolapse.

METHODS

This is a multicenter retrospective cohort study conducted at the Urogynecology Department of the Fondazione Policlinico Universitario A. Gemelli IRCCS of Rome and at the Diaconesses Croix Saint Simon Hospital of Paris. We collected data of 136 patients; 78 underwent LSHP and 58 underwent LSCP/SCH for pelvic organ prolapse between January 2016 and December 2017.

RESULTS

Patients of the two groups had similar preoperative characteristics. All patients completed 24-month follow-up evaluation. Overall, anatomical cure rate was 84.6% and 87.9% in the LSHP group and LSCP/SCH group, respectively, without statistically significant differences. In particular, in the LSHP group the anatomical success rate was 94.9%, 92.3% and 92.3% for the apical, anterior and posterior vaginal compartment whereas in the LSHP group LSCP/SCH was 100%, 91.4% and 94.8%, respectively. Subjective success rate was 89.7% among patients who underwent LSHP and 93.1% among women who underwent LSCP/SCH (p = 0.494). The median operative time (OT) was significantly shorter in LSHP. There were no significant differences between the groups in terms of estimated blood loss, conversion to laparotomy and intra- and postoperative complications. Patients' satisfaction was high in both groups without statistical differences.

CONCLUSIONS

Both laparoscopic procedures are safe and effective in the treatment of pelvic organ prolapse. LSHP can be offered as an alternative in women who are strongly motivated to preserve the uterus in the absence of abnormal uterine findings.

Pelvic organ prolapse recurrence after apical prolapse repair: does obesity matter?

INTRODUCTION AND HYPOTHESIS

We hypothesized obesity increases the risk of pelvic organ prolapse recurrence (POP-R) after primary apical prolapse repair.

METHODS

We conducted a retrospective cohort study of 353 women who underwent primary apical prolapse surgery from 2011 to 2016. Demographic and clinical data were abstracted from medical records. Multivariable Cox proportional hazard models were used to generate hazard ratios (HR) for association between obesity (BMI ≥ 30 kg/m²) and POP-R (leading edge > 0), adjusting for potential confounders. Given the potential for outcome ascertainment bias due to differential loss to follow-up, a sensitivity analysis was performed assuming all patients with < 6 months of follow-up developed POP-R.

RESULTS

Ten percent of women developed POP-R. The median follow-up time was 7 months (range 1.4, 63.9). Twenty-four percent of patients were Black and 70% were White; 37% were obese. After controlling for confounders, obese women did not have an increased risk of POP-R (aHR 1.39; 95% CI 0.67, 2.86, p = 0.38). Although only marginally statistically significant, patients who developed POP-R were more likely to be current smokers (aHR 3.48, 95% CI 1.14, 10.67; p = 0.06) or previous smokers (aHR 1.86, 95% CI 0.82, 4.24, p = 0.06) in comparison to non-smokers. Sensitivity analysis showed loss to follow-up had the potential to influence our results.

CONCLUSIONS

Obesity was not a risk factor for POP-R in our cohort. Larger, prospective studies with longer postoperative follow-up time are needed to fully elucidate the relationship between obesity and POP-R.

Assessing pelvic organ prolapse recurrence after minimally invasive sacrocolpopexy: does mesh weight matter?

INTRODUCTION AND HYPOTHESIS

There has been a trend toward the use of ultra-lightweight mesh types for minimally invasive sacrocolpopexy. We hypothesized that ultra-lightweight mesh would have a greater proportion of composite anatomical pelvic organ prolapse recurrence than lightweight mesh.

METHODS

Retrospective cohort study of minimally invasive sacrocolpopexies at two academic institutions from 2009 to 2016. Our primary outcome was composite anatomical prolapse recurrence, defined as prolapse beyond the hymen or retreatment with pessary or surgery, compared between ultra-lightweight (≤21 g/m² [range 19-21]) and lightweight (>21 g/m² [range 35-50]) mesh types. We assessed time to prolapse recurrence using Kaplan-Meier and Cox regression.

RESULTS

The cohort consisted of 1,272 laparoscopic (n = 530, 41.7%) and robotic-assisted sacrocolpopexies (n = 742, 58.4%). Lightweight mesh was used in 745 procedures (58.6%) and ultra-lightweight mesh in 527 (41.4%). The lightweight mesh had longer median follow-up than the ultra-lightweight group (344 [IQR 50-670] vs 143 days [IQR 44-379], p < 0.01). There was no difference in composite anatomical prolapse recurrence between lightweight and ultra-lightweight mesh (54 [7.2%] vs 35 [6.6%], p = 0.68). Ultra-lightweight mesh demonstrated a shorter time to prolapse recurrence (p < 0.01), which remained significant on multivariate Cox regression (HR 2.38 [95% CI 1.47-3.87]). The lightweight mesh had significantly more mesh complications (43 [5.8%] vs 7 [1.3%], p < 0.01).

CONCLUSIONS

Ultra-lightweight mesh for minimally invasive sacrocolpopexy was not associated with a higher proportion of composite anatomical prolapse recurrence; however, it was associated with a shorter time to recurrence. Longer follow-up is needed to assess the clinical importance of this finding, particularly given the trade-off of more complications with lightweight mesh.

Impact of obesity on operative complications and outcome after sacrocolpopexy: A systematic review and meta-analysis

OBJECTIVE

Surgery is required by many obese women with pelvic organ prolapse, and sacrocolpopexy is considered to be an effective method to correct apical prolapse. However, to the authors' knowledge, epidemiological studies have not been summarized formally.

STUDY DESIGN

A systematic literature search of Pubmed, Medline (Ovid) and Embase databases was undertaken for articles written in English. Statistical analysis was performed using Revman 5.3.

RESULTS

In total, 7315 patients in 12 studies were included in this meta-analysis. No significant differences were found between obese women and non-obese women in terms of re-operation rate [risk ratio (RR) 1.19, 95 % confidence interval (CI) 0.88-1.59; p = 0.25], postoperative Pelvic Organ Prolapse Quantification System stage ≥2 (RR 0.86, 95 % CI 0.64-1.16; p = 0.33), transfusion rate (RR 0.91, 95 % CI 0.57-1.44; p = 0.68), mesh erosion rate (RR 1.62, 95 % CI 0.74-3.51; p = 0.23), overall rate of surgical complications (RR 1.17, 95 % CI 0.91-1.50; p = 0.23) and length of hospital stay [mean difference (MD) 0.13 days, 95 % CI -0.05 to 0.31; p = 0.15). Additionally, no differences were found in the rates of bladder injury, ileus and urinary incontinence between obese women and non-obese women. However, obese women were associated with a higher laparoconversion rate (RR 3.00, 95 % CI 1.71-5.31; p = 0.0002), higher rate of infection (RR 1.65, 95 % CI 1.25-2.20; p = 0.0005), longer operative duration (MD 14.93 min, 95 % CI 10.14-19.73; p < 0.00001) and higher estimated blood loss (MD 18.01 ml, 95 % CI 8.22-27.80; p = 0.0003) compared with non-obese women.

CONCLUSIONS

The complications and curative effects of sacrocolpopexy for obese women are similar to those of non-obese women, except for the higher laparoconversion rate, higher rate of infection, longer operative duration and higher estimated blood loss in obese women. Obesity increases the operational difficulty of sacrocolpopexy to a certain extent, although it does not increase the mesh erosion rate or prolapse recurrence rate. Gynaecologists need to be aware of the possibility of the abovementioned risks when choosing sacrocolpopexy for obese patients with middle pelvic defects.

Outcomes of nerve-sparing laparoscopic sacropexy on one hundred fifteen cases

STUDY OBJECTIVE

To evaluate the postoperative anatomic and functional outcomes of patients who underwent laparoscopic nerve-sparing sacrocolpopexy or sacrocervicopexy for pelvic organ prolapse (POP) POP-Q stage III and IV apical prolapse, and to delineate the contributing factors for recurrence.

STUDY DESIGN AND CLASSIFICATION

The file records of patients who underwent sacropexy in the last five years were reviewed retrospectively and compared in terms of preoperative and postoperative anatomic findings and symptoms.

PATIENTS

Patients who underwent laparoscopic nerve-sparing surgery for treatment of POP-Q Stage III and IV/prolapse of uterine or vaginal cuff were included.

INTERVENTIONS

Postoperative anatomic and functional outcomes were evaluated using POP-Q classification and urinary/anal function by questioning during visits.

RESULTS

The mean follow-up duration was 24.2 ± 17.6 months. Anatomic recovery was achieved in 104 (90.4 %) cases. Advanced age (≥70 years), longer duration of symptoms, and low body mass index were determined as parameters related to recurrence risk.

Effect of BMI on clinical outcomes following minimally invasive sacrocolpopexy

Our objective was to compare success and complication rates following minimally invasive sacrocolpopexy (SCP) based on body mass index (BMI). This is a retrospective cohort study of women who underwent laparoscopic or robotic SCP at one academic center from 2006 to 2016. Women were included if they had a postoperative pelvic organ prolapse quantification (POPQ) exam and subjective success documented. For our primary outcome, we compared composite success (POPQ stage ≤ I and report of no bulge symptoms) amongst three groups: normal weight (BMI ≤ 25), overweight (BMI 25-30) and obese (BMI ≥ 30) women. Secondary outcomes included intraoperative complications, 6 week postoperative complications, and sacrocolpopexy mesh exposure. Of the 431 women who met inclusion criteria, 140 (32%) had normal BMI (23 kg/m²; IQR 22, 24), 177 (41%) were overweight (27 kg/m²; IQR 26, 28), and 114 (26%) were obese (32 kg/m²; IQR 31, 36). Mean age was 60 ± 11 years, and most were Caucasian, with no differences in demographics or Charlson Comorbidity Index (CCI). Median length of follow-up was 49 weeks (IQR 9, 104), with similar follow-up for all groups. For our primary outcome, composite success was 72% overall, with no significant differences in composite success rates between groups. For secondary outcomes, there were no differences in the rates of perioperative complications but obese women had a 2.8 increased risk of mesh exposure (p = 0.02). Obesity was not associated with differences in the success or peri-operative complication rates for SCP in our population, but was associated with mesh exposure.

Obesity and its long-term impact on sacrocolpopexy key outcomes (OBELISK)

INTRODUCTION AND HYPOTHESIS

Sacrocolpopexy is the preferred contemporary approach to managing significant apical pelvic organ prolapse. Obesity is an established risk factor for several surgical procedures and can have a negative impact on outcomes. Our goal was to evaluate the impact of BMI on the safety and efficacy of laparoscopic sacrocolpopexy in women with pelvic organ prolapse.

METHODS

A single-center retrospective observational study of women undergoing laparoscopic sacrocolpopexy between January 1, 2015, and December 31, 2017.

RESULTS

We found 299 procedures: 82 (27.4%), 147 (49.2%) and 70 (23.4%) in women with BMI <25 (normal weight), BMI ≥ 25 - < 30 (overweight) and BMI ≥ 30 (obese), respectively. Perioperative and early postoperative complications were generally low and not statistically significantly different between the groups. At 12 months postoperatively, 81 (98.8%), 136 (92.5%) and 62 (88.6%) normal-weight, overweight and obese women attended their follow-up, respectively. All obese women attending the follow-up scored an overall Patient Global Impression of Improvement (PGI-I) of ≤ 3. The Pelvic Floor Distress Inventory (PFDI) scores showed a significant improvement in all domains and were similar between the study groups. In total, there was one (0.4%) anatomical apical compartment failure, three (1.1%) anterior compartment failures and two (0.7%) posterior compartment failures with no significant differences between the groups. Similarly, there were no differences in functional outcomes or mesh position as assessed by ultrasound.

CONCLUSIONS

There were no differences in surgical, short- and long-term outcomes of laparoscopic sacrocolpopexy for pelvic organ prolapse in obese compared with non-obese women.

Laparoscopic sacrocolpopexy posthysterectomy: intraoperative feasibility and safety in obese women compared with women of normal weight

Introduction and hypothesis

Our aim was to determine the intraoperative feasibility and complication rate of laparoscopic sacrocolpopexy (LSC) in overweight and obese women compared with women of normal weight.

Methods

This was a retrospective observational cohort study (Canadian Task Force classification II-2) conducted at a tertiary urogyaenocology unit evaluating 119 women who underwent LSC between March 2005 and January 2013.

Results

Body mass index (BMI) was classified as normal (22.89 ± 1.55), overweight (27.12 ± 1.40) and obese (33.47 ± 3.26) according to the World Health Organisation (WHO) classification. There was no difference in intraoperative complication rates for bladder, bowel, ureteric or vascular injury; haemorrhage; conversion to laparotomy; or anaesthetic complications for normal weight, overweight or obese women. Similarly there was no difference in operating time, duration of anaesthetic or hospital stay between BMI class (p = 0.070, p = 0.464, p = 0.898, respectively) postoperative or mesh complication rates. At 6-months’ follow-up, there was no difference in Patient Global Impression of Improvement scale (PGI-I) (defined as very much better or much better) between normal weight, overweight and obese women (76.9, 72 and 65.4%, p = .669) or objective cure using the Pelvic Organ Prolapse Quantification (POP-Q) examination (p = 0.402).

Conclusions

LSC is feasible, with equivalent intraoperative complication rates for normal weight, overweight and obese women when performed by experienced laparoscopic urogynaecologists. Given the benefits of a laparoscopic approach in obese women, the authors suggest they should be offered LSC as an option to treat vault prolapse when surgical management is being considered.

Perioperative adverse events associated with pelvic organ prolapse repair by nerve-preserving sacropexy: an analysis of 768 cases over a 10-year period

OBJECTIVE

To report the perioperative adverse events associated with nerve-preserving sacropexy for pelvic organ prolapse (POP) repair and to identify risk factors that could predict possible adverse events.

MATERIALS AND METHODS

A total of 768 women who underwent sacropexy for POP repair performed by one surgeon using the same technique, beyond the learning curve, over a 10-year period, between January 1st 2007 and December 31st 2016.

METHODS

The medical records of 768 women were reviewed for age, body mass index (BMI), tobacco use, previous surgeries (for POP and incontinence, abdominal surgeries in general), operating time, duration of hospitalization and perioperative events at time of surgery and 6 weeks postoperatively. Additionally, the complications were classified according to the Clavien-Dindo grading system and the Charlson Age Comorbidity Index (CACI) was evaluated for the patients.

RESULTS

Between January 1st 2007 and December 31st 2016, 768 patients underwent sacropexy for POP. 27 (3.5%) adverse events occurred intra- and post-operative within 6 weeks after surgery. In univariate and multivariate analyses, only comorbidity and concomitant posterior colporrhaphy are significantly associated with complications.

CONCLUSIONS

Surgeon's experience and a standardized technique minimize the risk of perioperative adverse events. The data on complications we found can be used to guide effective consent.

Risk factors for prolapse recurrence: systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Female pelvic organ prolapse (POP) is a common condition, with a lifetime risk for surgery of 10-20%. Prolapse procedures are known to have a high reoperation rate. It is assumed that etiological factors for POP may also be risk factors for POP recurrence after surgery. There are few reviews available evaluating risk factors for prolapse and recurrence or recently updated meta-analysis on this topic. Our aim was to perform a systematic review and quantitative meta-analysis to determine risk factors for prolapse recurrence after reconstructive surgery.

METHODS

Four electronic databases (MEDLINE, PubMed, EMBASE, and Google Scholar) were searched between 1995 and 1 January 2017, with no language restrictions.

RESULTS

Twenty-five studies met inclusion criteria for a total of 5082 patients with an average recurrence rate of 36%. Variables on which a meta-analysis could be performed were body mass index (BMI) (n = 12), age (n = 11), preoperative stage (n = 9), levator avulsion (n = 8), parity (n = 8), constipation/straining (n = 6), number of compartments involved (n = 4), prior hysterectomy (n = 4), familiy history (n = 3), and several other predictors evaluated in only three studies. The following meta- analyses identified significant predictors: levator avulsion [odds ratio (OR) 2.76, P < 0.01], preoperative stage 3-4 (OR 2.11, P < 0.001), family history (OR 1.84, P = 0.006), and hiatal area (OR 1.06/cm2, P = 0.003).

CONCLUSIONS

Levator avulsion, prolapse stage, and family history are significant risk factors for prolapse recurrence.

The impact of fellowship surgical training on operative time and patient morbidity during robotics-assisted sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Abdominal sacrocolpopexy is commonly performed for the surgical correction of pelvic organ prolapse (POP) in the USA. Over the last decade, fellowship programs have increased the number of these procedures performed robotically. Currently, there is a paucity of literature exploring the impact of fellowship training on outcomes of robotic-assisted sacrocolpopexy (RASC). We sought to explore the impact of an expert surgeon operating alone versus with a fellow on operative time and perioperative morbidity associated with RASC.

METHODS

This is an analysis of a retrospectively collected cohort of all RASCs performed to treat POP from June 2010 to August 2015 by a single attending surgeon. Outcomes were compared by expert surgeon alone and with a fellow.

RESULTS

We identified 208 RASCs, of which 124 (59.6%) were performed by an expert surgeon alone and 84 (40.4%) with a fellow. Eight fellows were included, with a median of 7 cases (interquartile range 5-13.5). Cases with fellows were 31.1 min longer than an expert surgeon alone (155.6 vs 124.5 min, p < 0.001), a 25% increase. Increased operative time for fellows remained significant on multivariate regression (34.2 min, p < 0.001) after adjusting for case order postmenopausal status, hysterectomy, mid-urethral sling, and bowel injury. Years in fellowship did not have an impact on operative time (p = 0.80). Complications were seen in 34 women (16.4%). On univariate regression, fellows did not have an impact on complications (OR 1.49, 95% CI [0.65-3.43]), which was unchanged on multivariate regression (OR 0.628, 95% CI [0.26-1.54]). Prolapse recurrence was seen in 19 women (9.5%). Fellows had no impact on prolapse recurrence (OR 0.478, 95% CI [0.17-1.38]), which was unchanged on multivariate regression (OR 0.266, 95% CI [0.17-1.49]).

CONCLUSION

When an expert surgeon operated together with a fellow, operative time increased by 34 min without increasing prolapse recurrence or complications.

Minimally Invasive Sacrocolpopexy: How to Avoid Short- and Long-Term Complications

Sacrocolpopexy remains the "gold standard" procedure for management of posthysterectomy vaginal vault prolapse with improved anatomic outcomes compared to native tissue vaginal repair. Despite absence of clinical data, sacrocolpopexy is increasingly being offered to women as a primary treatment intervention for uterine prolapse. While reoperation rates remain low, recurrent prolapse and vaginal mesh exposure appear to increase over time. The potential morbidity associated with sacrocolpopexy is higher than for native tissue vaginal repair with complications including sacral hemorrhage, discitis, small bowel obstruction, port site herniation, and mesh erosion. Complications are more common during the learning curve of minimally invasive sacrocolpopexy. Appropriate case selection is paramount to balancing the potential for prolapse recurrence with the risk of surgical complications. Use of ultra-lightweight polypropylene mesh and vaginal mesh attachment with delayed absorbable suture may reduce the risks of vaginal mesh exposure.