Laparoscopic excision and re-attachment of sacrocolpopexy mesh

INTRODUCTION AND HYPOTHESIS

Two cases are described and surgical techniques for recurrent pelvic organ prolapse after minimally invasive sacrocolpopexy are demonstrated at an academic affiliated hospital in patients with recurrent pelvic organ prolapse after minimally invasive sacrocolpopexy.

METHODS

A laparoscopic approach was taken for surgical intervention, with excision of prior detached vaginal mesh and re-attachment of new sacrocolpopexy mesh.

RESULTS

Two patients presented with recurrent pelvic organ prolapse after failed surgical treatment. The first case is a 68-year-old vaginal multipara with recurrent pelvic organ prolapse status post laparoscopic supracervical hysterectomy, sacrocolpopexy, and mid-urethral sling performed at an outside institution. Preoperative physical examination revealed stage 3 prolapse. Mesh was loosely attached to the cervix. After surgical correction, postoperative physical examination revealed stage 1 prolapse at the 6-week postoperative visit. The second case is a 62-year old vaginal multipara with recurrent pelvic organ prolapse status post-total laparoscopic hysterectomy and sacrocolpopexy at an outside institution. Preoperative physical examination revealed stage 2 prolapse. The mesh was loosely attached to the vagina. After surgical correction, postoperative physical examination revealed stage 0 prolapse at the 6-week postoperative visit. Both patients reported improvement in symptoms and overall quality of life.

CONCLUSIONS

Surgical management of recurrent pelvic organ prolapse after failed initial sacrocolpopexy procedure can be safely accomplished laparoscopically through identification of points of mesh detachment, anatomical landmarks, removal of the prior vaginal portion of the mesh, and attachment of a new surgical mesh to either the sacrum or the sacral portion of the mesh.

A Case Series of Robot-assisted Rectus Abdominis Flap Harvest for Pelvic Reconstruction: A Single Institution Experience

STUDY OBJECTIVE

To analyze outcomes and postoperative complications in patients undergoing robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction.

DESIGN

Case series.

SETTING

Academic setting.

PATIENTS

Pelvic reconstruction surgery patients.

INTERVENTIONS

The rectus abdominis muscle flap can be used as a flap for pelvic reconstruction, providing a large volume of soft tissue that can be used in the treatment of many comorbid conditions, including genital fistulas, postradiation pelvic exenteration, and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall.

MEASUREMENTS AND MAIN RESULTS

A retrospective analysis of patient demographic and clinical characteristics was performed for all patients who underwent robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction at our institution from October 1, 2016, to October 31, 2018. The postoperative complications analyzed included bowel obstructions, surgical site infections, emergency room visits, and need for readmission. Six patients (4 women and 2 men), with a mean age of 69.2 years (range = 57-79 years) and median follow-up time of 9.2 months (range = 5-12 months), were included. Muscle flap harvest was performed on the right side in 4 patients and on the left in 2 patients. The indications for reconstructive surgery included vesicovaginal fistula, complex pelvic organ prolapse, anterior and posterior exenteration, partial and total vaginectomy, partial vulvectomy, and abdominoperineal resection. Two patients received neoadjuvant chemoradiation. One of the 6 cases was converted to laparotomy; however, this was not owing to the rectus harvest. Three patients experienced no complications after reconstruction; 1 patient reported occasional abdominal pain; 1 patient had intermittent bowel obstruction; and 1 patient developed a pelvic abscess, requiring readmission. All 6 patients achieved satisfactory healing of the pelvic wound after robot-assisted rectus abdominis flap inset.

CONCLUSION

Robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure, despite the presence of substantial comorbidities and risk factors in this patient cohort. Patient selection and counseling are crucial to optimize surgical outcomes in this complex population.

The impact of prior prolapse repairs on surgical outcomes with minimally invasive sacral colpopexy

INTRODUCTION AND HYPOTHESIS

To determine whether prior prolapse repair has an impact on operative time, surgical complications, and prolapse recurrence with minimally invasive sacral colpopexy (MISC).

METHODS

This was a retrospective study of all laparoscopic and robotic MISC procedures performed from January 2009 to July 2014 at the University of Pittsburgh Medical Center. Patient demographics, clinical and surgical data were compared in women who underwent MISC for initial repair versus those undergoing MISC for recurrence after prior prolapse surgery. Our primary outcome was operating room (OR) time (skin incision to closure) using linear regression. Logistic regression compared complications (a composite variable considered present if any major complication occurred) and prolapse recurrence (any POP-Q point ≥0 or retreatment).

RESULTS

Of 816 subjects, the mean age was 59.6 ± 8.7, with mean BMI 27.0 ± 3.0 in a primarily Caucasian population (97.8%). Subjects had predominantly POP-Q stage III prolapse (69.9%), and 21.3% reported prior prolapse repair. OR time was 205.0 ± 69.0 min. Prior prolapse repair did not impact OR time (p = 0.25) after adjusting for age, concomitant procedures, POP-Q measurements, changes in OR personnel, case order in the day, and preoperative stress incontinence. Complications occurred in 15.8% but were not impacted by prior prolapse repair (OR = 0.94, 95% CI = 0.53-1.67) after adjusting for potential confounders. During a median follow-up of 31 weeks, 7.8% had recurrence with no impact from prior prolapse surgery (OR = 1.557, 95% CI = 0.67-3.64) after adjusting for potential confounders.

CONCLUSIONS

We were unable to demonstrate increased OR time, complications, or prolapse recurrence for MISC based on history of prior prolapse repair. Longer follow-up is needed to confirm the lack of difference in prolapse recurrence rates.

Recurrent apical prolapse after high uterosacral ligament suspension - in a heterogenous cohort characterised by a high prevalence of previous pelvic operations

Background

The apical prolapse is probably the most complex form of pelvic organ prolapse (POP). Adequate apical support is essential in the treatment of POP, as it contributes to the support in all vaginal compartments. This study aimed to evaluate the rate of symptomatic recurrent apical prolapse after high uterosacral ligament suspension (HUSLS), in a cohort of women characterised by a high prevalence of previous pelvic operations and a significant degree of prolapse.

Methods

This is a retrospective chart review of 95 women who underwent HUSLS for symptomatic apical prolapse from 2002 to 2009 at Aarhus University Hospital, Denmark. Of these women, 97% attended a six-month clinical control. Recurrence was defined as symptomatic vaginal vault prolapse stage 2 or more (according to the International Continence Society (ICS) quantification system). Medical charts were reviewed for a mean period of 7.2 years. Any new contacts due to prolapse were noted.

Results

Before the operation, 73% of the women were hysterectomised, and 52% had previous prolapse surgery. Stage 2 apical prolapse was reported in 71% of the women, whereas 26% had stage 3 or 4.

At six-month follow-up, 19% of the women had recurrent symptomatic apical prolapse, and 9% of the women had symptomatic recurrent prolapse in other compartments 6 months after operation. In all, 35% of the women had a renewed prolapse operation during the long-term follow-up period.

Perioperative adverse events were seen in 7%.

Two women were re-operated due to postoperative complications.

Conclusions

This retrospective study of 95 women with a significant degree of prolapse and a high prevalence of previous pelvic operations demonstrates that the rate of recurrent prolapse associated with HUSLS might be higher than originally described. In conclusion, HUSLS may not be the optimal first choice of operation in this group of patients.

FPMRS challenges on behalf of the Collaborative Research in Pelvic Surgery Consortium (CoRPS): managing complicated cases : Series 3: Challenging recurrent prolapse in a medically complicated patient

This case presents the work-up and management of a spina bifida patient with recurrent prolapse. Four international experts also provide their evaluation of and approach to this complex case. According to the literature, little is known regarding the approach to the management of this specific patient population.