Concomitant Repair of Pelvic Floor Disorders in Women Undergoing Surgery for Gynecologic Malignancies

Pelvic floor dysfunction survivorship needs and referrals in the gynecologic oncology population: a narrative review

The population of survivors of gynecologic malignancies continues to grow. The population of gynecologic oncology survivors has a high prevalence of pelvic floor disorders. Gynecologic oncology patients identify several survivorship needs, including a need for more focused pelvic floor disorder sequelae care. The increasing focus on patient needs following cancer treatment has led to the development of survivorship care plans and other strategies for addressing post-treatment transitions and sequelae. Common themes in patient survivorship care are patient needs for flexible and integrated care, and it is unclear if survivorship care plans in their current state improve patient outcomes. Patient referrals, specifically to urogynecologists, may help address the gaps in survivorship care of pelvic floor dysfunction.The objective of this review is to discuss the burden of pelvic floor disorders in the gynecologic population and to contextualize these needs within broader survivorship needs. The review will then discuss current strategies of survivorship care, including a discussion of whether these methods meet survivorship pelvic floor disorder needs. This review addresses several gaps in the literature by contextualizing pelvic floor disorder needs within other survivorship needs and providing a critical discussion of current survivorship care strategies with a focus on pelvic floor disorders.

Pelvic floor dysfunction in gynecologic cancer survivors

Pelvic floor dysfunction (PFD) is a common complication in gynecologic cancer survivors (GCS) and is now a worldwide medical and public health problem because of its great impact on the quality of life of GCS. PFD after comprehensive gynecologic cancer treatment is mainly reflected in bladder function, rectal function, sexual dysfunction and pelvic organ prolapse (POP), of which different types of gynecologic cancer correspond to different disease incidence. The prevention strategies of PFD after comprehensive gynecologic cancer treatment mainly included surgical treatment, physical therapy and behavioral guidance, etc. At present, most of them still focus on physical therapy, mostly using Pelvic Floor Muscle Training (PFMT) and multi-modal PFMT treatment of biofeedback combined with electrical stimulation, which can reduce the possibility of PFD after surgery in GCS to some extent. This article reviews the clinical manifestations, causes and current research progress of prevention and treatment methods of PFD after comprehensive treatment for GCS.

Endometrial Cancer Surgery With or Without Concomitant Stress Urinary Incontinence Surgery

OBJECTIVE

To compare quality of life (QOL) among patients with endometrial intraepithelial neoplasia or early-stage endometrial cancer and stress urinary incontinence (SUI) who chose to have concomitant surgery with cancer surgery alone.

METHODS

A multicenter, prospective cohort study was conducted across eight U.S. sites. Potentially eligible patients were screened for SUI symptoms. Those who screened positive were offered referral to urogynecology and incontinence treatment, including concomitant surgery. Participants were categorized into two groups: 1) concomitant cancer and SUI surgery or 2) cancer surgery alone. The primary outcome was cancer-related QOL as measured by the FACT-En (Functional Assessment of Cancer Therapy-Endometrial) (range 0-100; higher score indicates better QOL). The FACT-En and questionnaires assessing urinary symptom-specific severity and effects were assessed before surgery and 6 weeks, 6 months, and 12 months after surgery. Adjusted median regression accounting for clustering was used to examine the relationship between SUI treatment group and FACT-En scores.

RESULTS

Of 1,322 (53.1%) patients, 702 screened positive for SUI with 532 analyzed; 110 (21%) chose concomitant cancer and SUI surgery, and 422 (79%) chose cancer surgery alone. FACT-En scores increased for both the concomitant SUI surgery and cancer surgery-only groups from the preoperative to the postoperative period. After adjustment for timepoint and preoperative covariates, the median change in FACT-En score (postoperative-preoperative) was 1.2 points higher (95% CI -1.3 to 3.6) for the concomitant SUI surgery group compared with the cancer surgery-only group across the postoperative period. Median time until surgery (22 days vs 16 days; P <.001), estimated blood loss (150 mL vs 72.5 mL; P <.001), and operative time (185.5 minutes vs 152 minutes; P <.001) were all greater for the concomitant cancer and SUI surgery group compared with the cancer-only group, respectively.

CONCLUSION

Concomitant surgery did not result in improved QOL compared with cancer surgery alone for endometrial intraepithelial neoplasia and patients with early-stage endometrial cancer with SUI. However, FACT-En scores were improved in both groups.

Assessment of Adverse Events in a Matched Cohort of Women Undergoing Concurrent Midurethral Sling at the Time of Minimally Invasive Benign Gynecologic Surgery

IMPORTANCE

Procedures for stress urinary incontinence and benign gynecologic surgery are often performed concurrently, and associated complication rates have previously been unexplored.

OBJECTIVE

The aim of this study was to compare postoperative complication rates between women undergoing midurethral sling (MUS) placement at the time of benign gynecologic surgery and those undergoing MUS alone.

STUDY DESIGN

This was a retrospective matched cohort study of women undergoing MUS with or without concurrent minimally invasive benign gynecologic surgery from January 2010 through December 2020. Eligible women undergoing concurrent surgery were matched to a cohort of women undergoing MUS placement alone. The electronic medical record was queried for demographic and perioperative/postoperative data up to 12 months after surgery.

RESULTS

Thirty-eight women met inclusion criteria for the concurrent group, and 152 women were matched accordingly. The overall adverse event rate was 39.5% (95% confidence interval [CI], 0.25-0.55) for the concurrent group and 24.3% (95% CI, 0.18-0.32) for the MUS-only group ( P = 0.05). Adverse events with Clavien-Dindo grade ≤ 2 were higher in the concurrent group (Clavien-Dindo Grade 1: 5% vs 0%, P = 0.04; Clavien-Dindo Grade 2: 16% vs 6%, P = 0.04), as was composite postoperative resource utilization (76% vs 49%, P = 0.003). Mesh exposure ( P = 0.03) and sling lysis/excision rates ( P = 0.02) were higher in the concurrent group. On logistic regression, concurrent surgery cases remained significantly associated with sling mesh erosion (adjusted odds ratio, 12.6; 95% CI, 1.4-116.4).

CONCLUSIONS

Midurethral sling placement at the time of minimally invasive benign gynecologic surgery is safe but is associated with a higher incidence of postoperative hospital resource utilization and sling mesh extrusion, and a need for revision.

Surgeon Attitudes Toward Concurrent Urogynecologic and Gynecologic Oncology Procedures: A Cross-sectional Survey

IMPORTANCE

There is increasing overlap in the urogynecologic and gynecologic oncologic patient populations. To improve patient advocacy and access to care, a collaborative surgical approach may benefit this cohort.

OBJECTIVE

The aim of the study was to evaluate surgeon attitudes toward performing concurrent urogynecologic and gynecologic oncology procedures. We hypothesized that most surgeons are amenable to collaboration.

STUDY DESIGN

We conducted a cross-sectional questionnaire of members of the Society of Gynecologic Oncology and the American Urogynecologic Society from August to November 2020. A 23-item online survey was created to assess surgeon demographics, practice and screening patterns, and attitudes toward surgical collaboration. We also evaluated obstacles to performing joint procedures and assessed whether attitudes could be influenced by new information.

RESULTS

A total of 338 surveys were included in the analysis, including 158 urogynecologists and 226 gynecologic oncologists (GOs). Most surgeons (77.8%) will recommend concurrent procedures with another specialty, and 97.8% of urogynecologists and 95.7% of oncologists currently perform joint surgical procedures. Male surgeons, regardless of specialty, were more likely to recommend staged procedures (44% vs 31%, P < 0.001), as were GOs (28% vs 10.1%, P < 0.001). However, oncologists were more likely than urogynecologists to initiate referrals for surgical collaboration (33.3% vs 14.4%, P < 0.001).

CONCLUSIONS

A total of 22.2% of urogynecologists and oncologists prefer staging surgical procedures. The most common barrier to a combined procedure was logistics. Urogynecologists were more concerned about the effects of cancer treatments on healing, the use of mesh implants, and financial reimbursements as compared with GOs. Treatment delay was a significantly greater concern for the oncologists.

Vaginal symptoms in women who are affected by gynecologic cancer

PURPOSE OF REVIEW

Pelvic floor disorders are common among gynecologic cancer survivors. With improvements in survivorship, quality of life conditions in these women need greater attention and care. This review focuses specifically on vulvovaginal symptoms, which are common and have a negative impact on sexual health and quality of life in women affected by gynecologic cancer.

RECENT FINDINGS

We review publications on treatment-specific sexual health outcomes, screening and treatment of vulvovaginal symptoms and sexual pain, and surgical management options. Recent evidence regarding the safety of concomitant prolapse repair at the time of surgery for gynecologic malignancies and CO2 laser therapy is discussed and areas needing further research and innovation are highlighted.

SUMMARY

Pelvic floor disorders, including vaginal and sexual health concerns, are common in women affected by gynecologic cancer due to both common risk factors and as a side effects of cancer treatment. Gynecologists play a critical role in screening, treatment, and collaboration with other specialists to provide comprehensive care for these women throughout their lifetime.

Functional Changes of the Genitourinary and Gastrointestinal Systems before and after the Treatment of Endometrial Cancer-A Systematic Review

Simple Summary

Endometrial cancer is currently one of the most common gynecological cancer and accounts for around 5% of all female cancers. The treatment strategy most often includes surgery and adjuvant radiation therapy. Thanks to the high effectiveness of used treatment methods, the patients can live longer lives. Unfortunately their quality of life can be negatively affected by side effects resulting from weakening pelvic floor such as urinary incontinence, pelvic organ prolapse and fecal incontinence. In our paper we analyzed the studies published between 2010 and 2020 that touch upon the prevalence and management of pelvic floor dysfunction in endometrial cancer patients. Our results show increase in the incidence of pelvic floor disorders after various forms of endometrial cancer treatment and the need for more good quality research in the subject to be able to provide patients with holistic care focused on minimizing treatment side effects and prioritizing their quality of life.

Abstract

The incidence of endometrial cancer (EC), which coexists with such civilization diseases as diabetes, obesity or hypertension, is constantly increasing. Treatment includes surgery as well as brachytherapy, teletherapy, rarely chemotherapy or hormone therapy. Due to the good results of the treatment, the occurrence of side effects of therapy becomes a problem for the patients. One of the large groups of side effects includes the pelvic organ prolapse, urinary and fecal incontinence. The aim of this study was to present current knowledge on the occurrence of pelvic floor dysfunction in women treated for EC. A literature review was conducted in the PubMED and WoS databases, including articles on pelvic floor dysfunction in women with EC. PRISMA principles were followed in the research methodology. A total of 1361 publications were retrieved. Based on the inclusion and exclusion criteria, 24 papers were eligible for the review. Mostly retrospective studies based on different questionnaires were evaluated. No prospective studies were found in which, in addition to subjective assessment, clinical examination and objective assessment of urinary incontinence were used. Studies show a significant increase in the incidence of pelvic floor disorders, including urinary incontinence, after various forms of EC treatment. We believe that assessment of complications after endometrial cancer treatment is clinically relevant. The review emphasizes the importance of programming prospective studies to prevent and address these disorders at each stage of oncologic treatment.

Mesh Complication Rates Following Pelvic Radiation Therapy in Women With History of Synthetic Midurethral Sling Implantation

OBJECTIVE

To estimate the risk of mesh complications in women with and without subsequent pelvic and abdominal radiation therapy (RT).

METHODS

We identified women within a large health care organization who underwent mesh-augmented surgery for pelvic floor disorders between 2008 and 2014 and subsequently received RT prior to 2018. We compared them to a randomly selected group of women who underwent similar mesh-augmented pelvic reconstructive surgery without RT in a 1:4 ratio. Mesh complications were identified through chart review corroborated with the ninth and tenth revisions of the International Classification of Diseases and Current Procedural Terminology codes for mesh complications. Mesh complications between groups were compared using survival analysis and Cox proportional hazards models.

RESULTS

We identified 36 women with RT and compared them with 144 women without RT. Indications for mesh implantation and concomitant vaginal procedures were similar between the groups. The majority of mesh implants (94.4%) were midurethral slings. Twelve mesh complications (6.7%) were identified, with similar rates in the RT (8.3%) and no-RT (6.2%) groups (P = 0.65). The risk of mesh complications did not differ between groups when compared using the Cox proportional hazards model, controlling for age, body mass index, diabetes, menopausal status, and smoking (hazard ratio, 1.19; 95% confidence interval, 0.802-1.787).

CONCLUSIONS

There was no difference in the occurrence of mesh-related complications between women with and without RT. Abdominopelvic RT may not substantially increase the risk of mesh complications following placement of a synthetic sling for stress urinary incontinence. The need for future RT may only be a minor factor in counseling patients on the risks of mesh implants for pelvic floor disorders.

Transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh: experiences of 93 cases

INTRODUCTION AND HYPOTHESIS

To demonstrate the outcomes of pelvic reconstruction using Y-shaped mesh in patients with multiple-compartment pelvic organ prolapse via transvaginal single-port laparoscopy.

METHODS

We conducted a retrospective case series study. Patients diagnosed with severe multiple-compartment prolapse were enrolled between July 1, 2017, and March 31, 2020. Patients underwent transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh. Baseline data and perioperative results were collected. Patients were followed up with the POP-Q score, Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12). T-test was used for statistical analysis.

RESULTS

Operations were successful in all 93 patients without conversion or serious complications. Mean operative time was 132.70 ± 28.02 min and estimated blood loss was 110.65 ± 56.31 ml. VAS pain score was 2.91 ± 1.16 and cosmetic score was 9.20 ± 0.60. During 1-33 months of follow-up, no recurrence or mesh exposure was observed. Five patients suffered from de novo SUI, six had constipation, two had dyspareunia, and one had persistent pelvic pain. The pre- and postoperative Aa point was +2.13 ± 1.23 vs. -2.91 ± 0.28 (P < 0.05), C point was 2.63 ± 2.41 vs. -6.86 ± 0.69 (P < 0.05), and Ap point was -0.26 ± 1.79 vs. -2.97 ± 0.16 (P < 0.05). The PFDI-20 score was 76.81 ± 32.06 vs. 18.18 ± 20.25 (P < 0.05), while the PISQ-12 score was 34.30 ± 4.17 vs. 37.20 ± 2.60 (P < 0.05), which suggested significant improvements in both physical prolapse and quality of life after surgery.

CONCLUSION

Transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh is a feasible, effective and safe treatment option for severe multiple-compartment prolapse. Patients may benefit from its mild pain level and good cosmetic effect as well as only minor mesh-related complications.

Perioperative adverse events in women undergoing concurrent urogynecologic and gynecologic oncology surgeries for suspected malignancy

INTRODUCTION AND HYPOTHESIS

This study's objectives were to compare the incidence of adverse events after concurrent urogynecologic and gynecologic oncology surgery to gynecologic oncology surgery alone and to describe the frequency of modification in planned urogynecologic procedures. The authors hypothesized there would be no difference in major complications.

METHODS

This was a retrospective matched cohort study of women who underwent concurrent surgery at a large tertiary care center between January 2004 and June 2017. Cohorts were matched by surgeon, surgery route, date, and final pathologic diagnosis. Perioperative data and postoperative adverse events classified by Clavien-Dindo grade were compared.

RESULTS

One hundred and eight patients underwent concurrent surgeries, with 216 matched cohorts. Concurrent-case patients were more likely to be older, postmenopausal, have greater vaginal parity, have had preoperative chemotherapy, and have preoperative cardiac or pulmonary disease. There were no differences in intraoperative complications or Dindo grade ≥ 3 adverse events between groups, but there were more grade 2 adverse events in the concurrent cohort (44 vs 19%, p < 0.0001) including postoperative urinary tract infection (UTI) (26 vs 7%, p < 0.0001). Concurrent surgery remained associated with a higher incidence of grade ≥ 2 events on multivariate analysis [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.5-4.2, p = 0.0004). Discharge with a urinary catheter was more frequent after concurrent cases (35 vs 2%, p < 0.0001). Planned urogynecologic procedures were modified in 10% (n = 11) of cases.

CONCLUSIONS

Concurrent surgeries have an increased incidence of minor but not serious perioperative adverse events. One in ten planned urogynecologic procedures is either modified or abandoned during combined surgeries.