Surgery for pelvic organ prolapse

Capio slim suture capturing device for transvaginal apical pelvic organ prolapse

OBJECTIVE

Pelvic organ prolapse is an extremely common condition, with approximately 12% of women requiring surgical correction over their lifetime. This is the first study comparing standard technique with Capio device with a prolonged follow-up. The aim of this study was to describe a standardization technique and its efficacy to treat vaginal vault prolapse based on Capio device to sacrospinous ligament (SSL) suspension in comparison to the well-known and described "Capio-free" standard technique (ST).

MATERIALS AND METHODS

From January 2016 to January 2022, we retrospectively evaluated 163 women undergoing surgery to treat apical vaginal prolapse with ST and/or Capio technique (CT) at two high-volume centers.

RESULTS

ST mean operative time resulted to be longer in comparison to the CT (98 ± 22.6 m vs 86 ± 17.4 m, p < 0.001). Mean intraoperative bleeding, hospital stay, and indwelling catheter resulted to be comparable between the two groups (all p > 0.05).

CONCLUSION

The CT used to treat women with vaginal vault prolapse was effective, secure, easy to perform, and associated with low risks of bleeding, perineal pain, vessel injuries and recurrent prolapse. The shorter operative time observed in surgery performed with Capio device, could suggest an implementation of such technique due to the overlapping complications, prolapse recurrence and postoperative quality of life.

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.

The double-edged sword of mesh use in pelvic organ prolapse surgery: a case report

Introduction

Pelvic organ prolapse (POP) is a prevalent condition among parous women, often warranting surgical intervention. This case accentuates the complications associated with mesh in POP surgeries, iterating the imperative need for an evidence-based approach towards its utilization and exhaustive patient counselling.

Case presentation

A 60-year-old female, post-mesh-augmented POP repair, embarked on a 13-year journey characterized by persistent pelvic pain and multiple interventions. Despite undergoing several surgeries across different countries, involving mesh and stone removals, her symptoms, notably pelvic pain and dyspareunia, persisted. Clinical examinations revealed mesh erosion into the perivesical tissue, bladder, and associated stones, which were addressed through multiple interventions, albeit with transient success.

Discussion

The complex journey of this patient exemplifies the intricate challenges mesh poses in POP surgeries. While mesh application offers a minimally invasive approach and has proven successful in numerous cases, it simultaneously opens a Pandora's box of potential severe complications, necessitating thorough patient counselling and post-surgery management.

Conclusion

The case delineates the challenging path that clinicians and patients tread when navigating through mesh-associated complications post-POP repair. Although mesh has been heralded as a revolutionary approach in POP surgeries, its potential drawbacks necessitate judicious application, ensuring clinicians are well-versed with its associated risks and are adept in managing ensuing complications.

Multimodality Imaging of Anterior Compartment Pelvic Floor Repair

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are two common disorders that affect the anterior compartment of the pelvic floor in women. These can be treated conservatively or surgically. Among patients treated surgically, a substantial number present with pain, recurrent POP or SUI, or other conditions that warrant additional interventions. In many of these cases, imaging is key to identifying and characterizing the type of procedure performed, locating synthetic materials that may have been placed, and characterizing complications. Imaging may be particularly helpful when prior surgical records are not available or a comprehensive physical examination is not possible. US and MRI are the most commonly used modalities for such patients, although radiopaque surgical materials may be visible at voiding cystourethrography and CT. The authors summarize commonly used surgical treatment options for patients with SUI and POP, review imaging techniques for evaluation of such patients, and describe the normal imaging appearance and complications of pelvic floor surgical repair procedures in the anterior compartment of the pelvis. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Perioperative Pain Management With Opioid Analgesics in Colpopexy Increases Risk of New Persistent Opioid Usage

IMPORTANCE

Although the use of perioperative pain medications is highly investigated, limited studies have examined the usage of pain medication for post hysterectomy prolapse repair and the few that have have been restricted to smaller sample sizes.

OBJECTIVE

Our objective was to assess the association of perioperative opioid usage after posthysterectomy prolapse repairs with development of new persistent opioid usage.

STUDY DESIGN

The TriNetX Diamond Research Network was queried to create our cohorts of opioid-naive adult women with vaginal repair or laparoscopic sacrocolpopexy. The primary study outcomes were (1) the rate of perioperative opioid usage and (2) development of new persistent opioid usage. All cohorts were matched on age, race, ethnicity, chronic kidney disease, hypertensive diseases, ischemic heart disease, diseases of the liver, obstructive sleep apnea, affective mood disorders, pelvic and perineal pain, obesity, tobacco use, and utilization of office/outpatient, inpatient, or emergency department services.

RESULTS

We identified 10,414 opioid-naive women who underwent laparoscopic sacrocolpopexy and 13,305 opioid-naive women who underwent vaginal reconstruction. Rates of perioperative opioid usage were higher after laparoscopic sacrocolpopexy. Rates of developing new opioid usage were higher in both surgical-approach populations that received perioperative opioids compared with those that did not. Rates of new and persistent opioid usage did not differ by surgical approach when stratified by perioperative opioid usage.

CONCLUSIONS

We identified that opioid dependence may occur after surgery if patients are given opioids within 7 days of either approach, associating opioid dependence with perioperative opioid usage rather than the approach taken.

Anatomical and symptomatic outcomes in patients with Le Fort colpocleisis with or without hysterectomy

BACKGROUND

We aimed to evaluate the short-term anatomical and clinical outcomes of elderly patients who underwent the Le Fort colpocleisis operation due to pelvic organ prolapse (POP) in our clinic.

METHODS

The medical records of fifty-nine sexually inactive females, with stage 2 or higher vaginal or uterine prolapse who underwent Le Fort colpocleisis operations were prospectively analysed. Preoperative and 12th month postoperative data were recorded. Lower urinary tract symptoms (LUTS) was also evaluated preoperatively and 12 months postoperatively in all patients. Anatomical success was determined as no prolapse of any POP-Q point at or below 1 cm above vaginal introitus.

RESULTS

A total of 59 patients were included in this study. The average age of the patients was 71.67 ± 7.01 (years). The mean BMI was 27.1 ± 9.52 kg/m2. POP-Q point, C (6.70 ± 2.44 vs. - 2.66 ± 1.21) measurements were significantly deeper, as well as Gh (4.83 ± 0.94 vs. 4.26 ± 0.94) and TVL (3.51 ± 1.24 vs. 8.93 ± 1.73) measurements were significantly higher after surgery than during the preoperative period (p < 0.01, p < 0.01, p < 0.01, respectively). There were no cases of recurrence. The evaluation of LUTS at the 12-months postoperative follow-up revealed significant differences for SUI, urinary frequency, nocturia, and pelvic pain symptoms (p = 0.007, p < 0.001, p = 0.01, p < 0.001, respectively).

CONCLUSIONS

Le Fort colpocleisis is a simple and effective procedure that provides successful anatomical and clinical outcomes in sexually inactive and elderly women with POP. However, the long-term results of this procedure need further investigation.

Reoperation rates for stress urinary incontinence and pelvic organ prolapse in women after undergoing Mid-Urethral sling with or without concomitant colporrhaphy in academic centers within the United States

In this study, the rates of reoperation for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women who underwent a mid-urethral sling (MUS) with or without concurrent colporrhaphy were evaluated. An academic faculty practice consortium database was used to identify a cohort of patients treated surgically for SUI with or without concurrent POP repair (apical, anterior, posterior, or a combination of the three) with or without hysterectomy between 2009 and 2011. A total of 20,484 patients matched the criteria. Of patients who underwent a MUS, 7.2% underwent secondary surgery, with a higher rate of 8.6% associated with those who underwent concurrent prolapse repair (Apical repair HR 1.84, p < .01; Anterior compartment repair HR 1.47, p < .01). Concurrent hysterectomy was associated with a lower hazard of secondary prolapse surgery (HR 0.48; p < .01) if the initial surgery involved a complete POP repair. Prolapse mesh repair resulted in a higher hazard of additional surgery (HR 1.43, p < .01). Medicaid insurance was also associated with an increased hazard ratio compared to commercial insurance for secondary surgery (HR 1.32, p < .01). For women undergoing MUS with complete prolapse repair, concurrent hysterectomy is associated with lower secondary surgery rates. Concurrent prolapse repair with mesh is associated with higher secondary surgery rates.Synopsis: For women undergoing MUS (mid-urethral sling) with complete prolapse repair, concurrent hysterectomy is associated with lower secondary surgery rates. Concurrent prolapse repair with mesh is associated with higher secondary surgery rates.Impact StatementWhat is already known on this subject? Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) can present at the same time and negatively impact patients' quality of life. There is little data regarding reoperation rates for patients who undergo both MUS and colporrhaphy in one setting.What do the results of this study add? This study found that patients who undergo concurrent MUS (mid-urethral sling) and complete POP repair with the addition of hysterectomy had a lower risk of secondary surgery.What are the implications of these findings for clinical practice and/or further research? Our data can be used by surgeons to counsel patients on the risks of re-operation for SUI for those who would like to undergo concurrent POP repair with or without hysterectomy.

Vaginal vault prolapse and recurrent surgery: A nationwide observational cohort study

INTRODUCTION

In surgical repair of pelvic organ prolapse the recurrence rate is about 30% and the importance of apical support was recently highlighted. In surgical randomized controlled studies, the external validity can be compromised because the surgical outcomes often depend on surgical volume. Therefore, we sought to study outcomes of surgical treatment in patients with vaginal vault prolapse in a nationwide setting with a variety of surgical volumes.

MATERIAL AND METHODS

This is a nationwide cohort study. All patients with a vaginal vault prolapse undergoing surgery, between January 1, 2015 and December 31, 2018, were identified from the Swedish National Quality Register of Gynecological Surgery, GynOp. The primary outcome was the frequency of recurrent pelvic organ prolapse surgery within 2 years postoperatively. Secondary outcomes included patient-reported vaginal bulging, operative time, estimated blood loss and 1-year postoperative complications.

RESULTS

In 1812 patients with vaginal vault prolapse, 538 (30%) had a sacrospinous ligament fixation (SSLF) with graft, 441 (24%) underwent SSLF without graft, and 200 (11%) underwent minimally invasive sacrocolpopexy (SCP) or sacrocervicopexy (SCerP). A significantly higher proportion of patients undergoing recurrent pelvic organ prolapse surgery was seen in SSLF without graft than in SSLF with graft (adjusted odds ratio [aOR] 2.2, 95% CI 1.4-3.6). Patient-reported sensation of vaginal bulging 1 year after surgery was higher in the SSLF group without graft than in the SSLF group with graft (aOR 1.9, 95% CI 1.3-2.8) and in the SCP/SCerP group (aOR 2.0, 95% CI 1.1-3.4). Finally, we found a significantly higher rate of complications 1 year after surgery in SSLF without graft (aOR 2.3, 95% CI 1.2-4.2) and in SSLF with graft (aOR 2.2, 95% CI 1.2-4.2) compared with SCP/SCerP.

CONCLUSIONS

In patients with vaginal vault prolapse, SSLF without graft was associated with a higher frequency of recurrent pelvic organ prolapse surgery compared with SSLF with graft, and a higher subjective relapse rate compared with SCP/SCerP and SSLF with graft. Additionally, the complication rate 1 year after primary surgery was higher in SSLF both with and without graft than in SCP/SCerP.

Challenges of Managing Lower Urinary Tract Symptoms in Women with Tamoxifen Use

Objective:

Tamoxifen complicates management of conditions such as urinary tract infections (UTIs), urinary incontinence (UI), and/or pelvic organ prolapse (POP) that traditionally benefit from hormonal intake; thus, we reviewed our experience in managing these hormonally deprived women.

Materials and Methods:

After IRB approval, electronic medical records from women with current use or history of tamoxifen use and referred to a tertiary care center with female pelvic medicine and reconstructive surgery expertise for UTI, UI, and/or POP were reviewed.

Results:

From 2015 to 2020, 32 women treated with tamoxifen 10–40 mg for a median of 4 years were referred for UTIs (9), UI (10), symptomatic POP (8), or for a combination of these (5). Participants with UTI treated with antibiotics, prophylactic supplements, and/or electrofulguration had satisfactory response at median follow-up of 1 year (interquartile range [IQR]: 0.5–1). Ten of 15 women with UI chose intervention, with no self-reported UI recurrence at median follow-up of 2.5 years (IQR: 1–3). All but one participant with POP underwent vaginal or open/robotic mesh repairs, with satisfactory outcomes at median follow-up of 3 years (IQR: 2–7).

Conclusions:

The management of UTIs, UI, and POP in women on tamoxifen or unable to benefit from hormonal intake is challenging, but traditional interventions can be considered with satisfactory results.

Spondylodiscitis After Surgery for Pelvic Organ Prolapse: Description of a Rare Complication and Systematic Review of the Literature

Background: Spondylodiscitis can be a rare complication of gynecological surgery, typically of procedures involving the sacrum and the sacrospinous ligament. This report presents a case of spondylodiscitis arising after a laparoscopic sacrocolpopexy with a mesh. We also review the literature finding 52 cases of spondylodiscitis following sacrocolpopexy and (or) rectopexy with or without a mesh.

Methods: We performed a comprehensive search from the electronic databases MEDLINE (Pubmed), Scopus, Web of Science, Embase, CINAHL, and Google Scholar from 1990 to February 2021 in order to identify case reports or case series reporting on spondylodiscitis after rectopexy or sacrocolpopexy.

Results: We identified 52 total postoperative spondylodiscitis. We examined the mean age of patients, the surgical history, the time from initial surgery to spondylodiscitis, the presenting symptoms, the diagnostic tools, the medical and surgical treatment, the type of mesh used, the surgical access, and the possible causes of spondylodiscitis.

Conclusions: Diagnosis of spondylodiscitis may be challenging. From our review emerges that recurrent pelvic pain and lumbosciatalgia may be signals of lumbar spondylodiscitis. Magnetic resonance is the gold standard examination for spondylodiscitis. Surgical practice needs to be improved further in order to establish the best procedure to minimize the incidence of this complication. Awareness of symptoms, timely diagnosis, and treatment are fundamental to prevent irreversible complications.

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.

Short-term outcomes of anterior approach sacrospinous ligament fixation for apical vaginal prolapse - A retrospective study

Introduction

Vaginal sacrospinous fixation and sacrospinous hysteropexy (SSF/SSHP) are highly effective procedures for apical compartment prolapse. The established technique is the posterior vaginal approach. The alternative anterior approach through an anterior vaginal incision, although occasionally mentioned in the literature, is less well established. However, this approach is a more appropriate route if posterior vaginal surgery is not indicated. The aim of this paper is to review surgical outcomes of anterior approach in our centre and to compare outcomes of SSF vs SSHP.

Methods

Retrospective case note review of 60 patients who underwent anterior SSF for prolapse between 2009-2017 was performed. Preoperative and postoperative symptoms and findings were recorded. Anterior SSF involved an anterior vaginal incision and paravaginal access to the ligament for dissection and fixation to either the cervix or vault.

Results

SSF was performed in 39 patients, out of which 8 underwent vaginal hysterectomy concomitantly. SSHP for uterine prolapse was performed in 21 patients. There were no cases of recurrent apical prolapse in the cohort at mean follow-up of 1 year. No intra-operative visceral injuries were observed. Recurrence of anterior wall prolapse and postoperative voiding dysfunction was observed in 8.3% and short-term buttock pain in 6.6% of patients.

Conclusion

Anterior approach SSF and SSHP is a safe and effective technique for apical prolapse and is the recommended route when posterior vaginal surgery is not required.

Mesh-less laparoscopic treatment of apical prolapse

The pelvic organ prolapse (POP) is a common gynaecological problem, affecting nearly 50% of women over 40. The sacrocolpopexy using a synthetic mesh is now considered the “gold standard” for management of women with apical prolapse. In April 2019 the FDA placed a ban on the production of transvaginal meshes for prolapse due to late complications. The meshes for abdominal repair of POP are still used, but in future they may also be prohibited. The goal of the following video is to present a mesh-less modification of two techniques used for apical organ prolapse, the sacrocolpopexy and the pectopexy.

Safety and efficiency of modified sacrospinous ligament fixation for apical prolapse: Long-term studies and outcomes

OBJECTIVE

To explore the safety and efficiency of modified sacrospinous ligament fixation (MSSF) for apical prolapse.

METHODS

A retrospective cohort study. Patients diagnosed with apical prolapse from 2014 to 2019 were recruited and divided into three groups: sacrospinous ligament fixation (SSF), MSSF, and laparoscopic sacral hysteropexy (LSH). All surgical characteristics were obtained and information concerning complications was collected and compared among these three groups.

RESULTS

A total of 710 patients were included: 108 in the SSF group, 260 in the LSH group, and 342 in the MSSF group. The MSSF and SSF groups took less surgical time (P < 0.001) and had shorter hospital stays (P < 0.001). All three methods can significantly change prolapses to point C on the POP quantification score (P < 0.001). Prevalence of vaginal and pelvic pain after surgery was higher in the SSF group (8/108; 7.41%) (P = 0.028), and urinary incontinence was higher in the LSH group (22/260; 8.46%) (P = 0.010). In the LSH group more patients experienced constipation and dyschezia after surgery (prevalence 18/260; 6.92%; P = 0.048). Recurrence of pelvic organ prolapse in the MSSF group (15/324; 4.39%) and LSH group (12/260; 4.62%) was much lower than in the SSF group (16/108; 14.81%) (P < 0.001).

CONCLUSION

The efficacy of MSSF is commendable with low recurrence of POP and few complications in long-term follow up.

Does ventral mesh rectopexy at the time of sacrocolpopexy prevent subsequent posterior wall prolapse?

Objective:

To determine whether ventral mesh rectopexy at the time of sacrocolpopexy reduces the rate of future posterior wall prolapse.

Material and Methods:

This was a retrospective cohort study of women with pelvic organ prolapse (POP) who underwent sacrocolpopexy or without concomitant rectopexy at a single community hospital from December 1, 2015 to June 30, 2019. Preoperative pelvic organ prolapse quantification (POP-Q) and urodynamic testing was used in evaluation of POP. Patients were followed for 12-weeks postoperatively and a 12-week postoperative POP-Q assessment was completed. The incidence of new or recurrent posterior prolapse was compared between cohorts.

Results:

Women with POP (n=150) were recruited, of whom 41 (27.3%) underwent sacrocolpopexy while the remainder (n=109, 72.7%) did not receive rectopexy. Patient demographics did not statistically differ between cohorts. Post-surgical posterior wall prolapse was reduced in the robotic assisted sacrocolpopexy (RASC) + rectopexy group compared to RASC alone, however this did not reach statistical significance. There were no patients who underwent concomitant rectopexy and RASC that needed recurrent posterior wall prolapse surgery, compared to eight-percent of patients that underwent isolated RASC procedures.

Conclusion:

Our findings suggest a reduction in the need for subsequent posterior wall surgery when rectopexy is performed at the time of sacrocolpopexy. In our study, no future surgery for POP was found in the concomitant sacrocolpopexy and rectopexy group, while a small proportion of the RASC only group required future POP surgery. Our study, however, was underpowered to elucidate a statistically significant difference between groups. Future larger studies are needed to confirm a reduced risk of posterior wall prolapse in patients who undergo concomitant RASC and rectopexy.

Robotic-assisted repair of pelvic organ prolapse: a scoping review of the literature

The purpose of this article is to perform a scoping review of the medical literature regarding the efficacy, safety, and cost of robotic-assisted procedures for repair of pelvic organ prolapse in females. Sacrocolpopexy is the "gold standard" repair for apical prolapse for those who desire to maintain their sexual function, and minimally-invasive approaches offer similar efficacy with fewer risks than open techniques. The introduction of robotic technology has significantly impacted the field, converting what would have been a large number of open abdominal sacrocolpopexy (ASC) procedures to a minimally-invasive approach in the United States. Newer techniques such as nerve-sparing dissection at the sacral promontory, use of the iliopectineal ligaments and natural orifice vaginal sacrocolpopexy may improve patient outcomes. Prolapse recurrence is consistently noted in at least 10% of patients regardless of route of mesh placement. Ancillary factors including pre-operative prolapse stage, retention of the cervix, type of mesh implant, and genital hiatus (GH) size all adversely affect surgical efficacy, while trainees do not. Minimally-invasive apical repair procedures are suited to early recovery after surgery protocols but may not be appropriate for all patients. Studies evaluating longer-term outcomes of robotic sacrocolpopexies are needed to understand the relative risk/benefit ratio of this technique. With several emerging robotic platforms with improved features and a focus on decreasing costs, the future of robotics seems bright.

Laparoscopic Pectopexy and Paravaginal Repair after Failed Recurrent Pelvic Organ Prolapse Surgery

Laparoscopic pectopexy has been described recently for pelvic organ prolapse (POP) and it could be an alternative surgery to sacrohysteropexy. A 36-year-old parity 3 women was operated cause of POP, and on her history, she had performed one sacrospinous ligament fixation with colporrhaphy anterior and one abdominal sacrohysteropexy because of POP. After 6-month follow-up, anatomic and functional cures were provided. Laparoscopic pectopexy could be an alternative procedure for recurrent POP surgery with promising results.

The underutilization of obliterative and constrictive surgery in the surgical treatment of pelvic organ prolapse

Vaginal length and caliber are necessary for satisfactory vaginal coitus. Surgical treatment of pelvic organ prolapse (POP) can include preservation of vaginal length and caliber, or shortening and narrowing of the vagina (constrictive and obliterative surgery). The latter option is proven to have fewer complications and a lower risk of recurrence of POP. Women undergoing surgical intervention for POP who are not coitally active and choose not to be coitally active for the rest of their lives should be offered constrictive and obliterative surgery.

A Prospective Study of Minimally Invasive Paravaginal Repair of Cystocele and Associated Pelvic Floor Defects: Our Experience

Aims and objectives

To assess the outcome of minimally invasive paravaginal repair of symptomatic cystocele and to correlate postoperative outcome with preoperative presentation. The primary outcome was the anatomical outcome measured by postoperative physical examination and the functional outcome was assessed by subjective symptoms and questionnaires. The secondary outcomes were perioperative and postoperative complications.

Materials and methods

In this longitudinal prospective observational study, 44 women underwent laparoscopic or robotic paravaginal cystocele repair from January 2016 to July 2016 and they were followed up to 1 year after surgery in a tertiary advanced laparoscopic center. All patients had a symptomatic lateral cystocele ≥ grade 2 according to Baden-Walker classification. Other coexisting defects like apical cystocele or combined defects were corrected concomitantly. The anatomical outcome was measured by physical examination and functional outcome was assessed by questionnaires-Pelvic Organ Prolapse Distress Inventory 6 and Urinary Distress Inventory 6 preoperatively and during postoperative follow-up.

Results

All 44 patients were followed up to 12 months after surgery. The anatomical cure rate for cystocele was 97.7%. There were no major complications. All subjective symptoms and quality of life scores improved significantly during postoperative follow-up. The anatomical recurrence rate in our study was 2.3%.

Conclusion

Minimally invasive paravaginal repair of cystocele is an effective advanced laparoscopic procedure. It can be concomitantly performed with other surgical procedures to correct coexisting defects. The anatomical and functional results were outstanding with minimum perioperative morbidity and encouraging long-term outcome.

[The gynecological pessary: Is it really a device of another age, a fig leaf?]

OBJECTIVES

The use of pessary to put back up prolapsed organs to their normal position dates back prior to several millennia. This work aims to discuss its place in our clinical practice through an updated bibliographic review and emphasizes a hands-on approach to pessary fitting and management in terms of indication, pessary type selection, device' size, insertion, removal, follow-up visits and care.

METHODS

A review of the literature, in the light of the latest publications and recommendations of French and international learned societies, as well as our own experience, were analyzed.

RESULTS

This device appears to be as effective as surgical management to relieve symptoms related to urogenital prolapse and restore body image. It can be used temporarily, awaiting a surgical solution or as a therapeutic test (mimicking the effect of a surgical procedure to predict its functional outcome or identifying a masked urinary incontinence). It can also represent an alternative to surgery (patient choice, women who wish to complete childbearing or who are unsuitable for surgery because of medical comorbidities) and thus can be used in first intention. However, despite its moderate cost and its harmlessness, this device remains somewhat little known as regards the practical modalities of its use, which, moreover, appear not consensual.

CONCLUSION

A guide intended for the attention of the patients as well as a film relating to the practical modalities of the device' use were elaborated to improve the knowledge of both professionals and users in order to optimize and secure the care pathway.

Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate

BACKGROUND

Apical vaginal support is considered the keystone of pelvic organ support. Level I evidence supports reestablishment of apical support at time of hysterectomy, regardless of whether the hysterectomy is performed for prolapse. National rates of apical support procedure performance at time of inpatient hysterectomy have not been well described.

OBJECTIVE

We sought to estimate trends and factors associated with use of apical support procedures at time of inpatient hysterectomy for benign indications in a large national database.

STUDY DESIGN

The National (Nationwide) Inpatient Sample was used to identify hysterectomies performed from 2004 through 2013 for benign indications. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to select both procedures and diagnoses. The primary outcome was performance of an apical support procedure at time of hysterectomy. Descriptive and multivariable analyses were performed.

RESULTS

There were 3,509,230 inpatient hysterectomies performed for benign disease from 2004 through 2013. In both nonprolapse and prolapse groups, there was a significant decrease in total number of annual hysterectomies performed over the study period (P < .0001). There were 2,790,652 (79.5%) hysterectomies performed without a diagnosis of prolapse, and an apical support procedure was performed in only 85,879 (3.1%). There was a significant decrease in the proportion of hysterectomies with concurrent apical support procedure (high of 4.0% in 2004 to 2.5% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (large and medium), and hysterectomy type (vaginal and laparoscopically assisted vaginal) were associated with performance of an apical support procedure. During the study period, 718,578 (20.5%) inpatient hysterectomies were performed for prolapse diagnoses and 266,743 (37.1%) included an apical support procedure. There was a significant increase in the proportion of hysterectomies with concurrent apical support procedure (low of 31.3% in 2005 to 49.3% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (medium and large), and hysterectomy type (total laparoscopic and laparoscopic supracervical) were associated with performance of an apical support procedure.

CONCLUSION

This national database study demonstrates that apical support procedures are not routinely performed at time of inpatient hysterectomy regardless of presence of prolapse diagnosis. Educational efforts are needed to increase awareness of the importance of reestablishing apical vaginal support at time of hysterectomy regardless of indication.

Does traction on the cervix under anaesthesia tell us when to perform a concomitant hysterectomy? A 2-year follow-up of a prospective cohort study

INTRODUCTION AND HYPOTHESIS

Variations exist in urogynaecological practice to decide on hysterectomy in managing prolapse. This study evaluates the outcomes of uterine preservation during anterior colporrhaphy with apparent uterine descent with cervical traction under anaesthesia. We hypothesize that cervical traction should not be used to assess uterine prolapse.

METHODS

Thirty-five women opting for surgery for symptomatic anterior prolapse (≥ stage 2) with no uterine prolapse (point C at -3 or above) were recruited. "Validated cervical traction" was applied under anaesthesia. Only an anterior repair was performed. Incontinence Modular Questionnaire Vaginal Symptoms (ICIQ-VS) questionnaires were used for follow-up. Wilcoxon test was used for statistical analysis.

RESULTS

Stage 2 uterine prolapse (POPQ) was demonstrated in all women with traction under anaesthesia. Follow-up was possible in 29 women, 5 did not respond and 1 needed a hysterectomy at 6 months (2.86 %, 95 % CI 0.07-14.91 %). The mean follow-up time was 23 months (range: 13-34 months). There was a significant reduction in the ICIQ-VS scores from 22.7 (pre-operative) to 7.97 at 23 months (p < 0.001) and a significant improvement in the quality of life scores (4.3 to 1.86; p < 0.0001). There was also a significant reduction in the complaint of a bulge in the vagina (question 5a-ICIQ-VS; 2.91 to 0.89; p < 0.0001).

CONCLUSIONS

The "cervical traction" test seems unnecessary, and the decision for a hysterectomy should be based on examination findings in the clinic. Larger RCTs are needed to evaluate cervical traction in the assessment of prolapse.

Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement?

OBJECTIVE

Levator avulsion has been shown to be a predictor of cystocele recurrence following anterior colporrhaphy. The aim of this study was to determine if levator avulsion is a risk factor for prolapse recurrence following anterior colporrhaphy with mesh.

METHODS

This was a retrospective analysis of data obtained from three surgical audits for subjective and objective outcomes following anterior colporrhaphy with mesh. Recurrence was defined as cystocele ≥ Stage 2 on the prolapse quantification system of the International Continence Society; symptoms of vaginal lump/bulge; or cystocele on ultrasound, defined as maximum bladder descent to ≥ 10 mm below the symphysis pubis. Levator avulsion was diagnosed using tomographic ultrasound imaging.

RESULTS

Two hundred and nine patients were followed up at a mean of 2.2 years (range, 3 months to 5.6 years) after anterior vaginal mesh placement. 24% (51/209) had recurrent prolapse symptoms, 33% (68/209) clinical cystocele recurrence ≥ Stage 2, and 26% (54/209) a recurrent cystocele on ultrasound. Twenty-eight out of 80 (35%) women with levator avulsion had significant sonographic cystocele recurrence (odds ratio (OR), 2.24 (95% confidence interval (CI), 1.13-4.43)). This finding was confirmed after adjusting for potential predictors of prolapse recurrence on multivariate logistic regression (OR, 2.13 (95% CI, 1.04-4.39); P = 0.04).

CONCLUSION

Levator avulsion doubles the risk of cystocele recurrence after anterior colporrhaphy with transobturator mesh.