Anterior sacrospinous ligament fixation by the vaginal route in ten steps

Pelvic organ prolapse (POP) is a common condition affecting women, characterized by the descent of pelvic organs such as the vagina and uterus. While POP may not always cause symptoms, it can significantly impact a woman's quality of life. Diagnosis is typically made through clinical examination, and treatment options range from pelvic-floor physical therapy to surgery. Anterior sacrospinous ligament fixation (ASSLF) has emerged as a viable technique for treating apical prolapse vaginally. This procedure involves attaching the cervix or vaginal vault to the sacrospinous ligament, providing satisfactory results in the short term. Compared to the posterior approach, ASSLF shows similar efficacy, shorter operative time, and potentially fewer complications. Vaginal surgery offers advantages such as lower morbidity and cost, ability to address other pelvic conditions simultaneously, and suitability for managing recurrences. The presented case involves a 72-year-old woman with stage 3 cystocele, stage 3 hysterocele, stage 1 rectocele, and severe voiding dysfunction. After unsuccessful attempts with a pessary, surgical intervention becomes necessary. An instructive video article has been created to standardize the essential steps of ASSLF and facilitate resident education. The video demonstrates ten surgical steps, including installation/exposure, anterior vaginal wall infiltration, median anterior colpotomy, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture, cystocele correction, colpotomy and vaginal wall repair, uterine anterior isthmus suture and sacrospinous ligament fixation, and colporrhaphy final closure. In conclusion, POP is a prevalent condition that can be effectively managed through techniques like ASSLF. Vaginal surgery offers several advantages, and proper training and standardization of surgical steps contribute to successful outcomes and resident education.

All or nothing? A second look at partial levator avulsion

OBJECTIVE

To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP).

METHODS

This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression.

RESULTS

Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva.

CONCLUSION

Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Does Vaginal Parity Alter the Association Between Symptoms and Signs of Pelvic Organ Prolapse?

OBJECTIVES

This study aimed to investigate whether the number of vaginal births a woman has alters the association between symptoms and signs of pelvic organ prolapse.

METHODS

In this retrospective study, we investigated data on 1748 women seen between April 2012 and January 2016. To elucidate whether the number of vaginal births is a confounder of this relationship, we used receiver operating characteristic statistics to investigate the association between symptoms and signs of prolapse in women of different vaginal parity.

RESULTS

A higher number of vaginal births was associated with a higher likelihood of symptoms of prolapse for any given degree of prolapse. Multivariate modeling, however, showed this confounding effect to be due to higher vaginal parity in older women (P < .001). Receiver operating characteristic curves obtained for the association between symptoms and signs of prolapse were near identical regardless of whether vaginal parity was included in the modeling. This was true for both clinical and imaging assessments of prolapse.

CONCLUSIONS

Although vaginal childbirth is associated with symptoms of prolapse, the number of vaginal births does not alter the relationship between symptoms and signs of prolapse among individuals presenting to a tertiary care center for evaluation. Previously published limits for "normal" pelvic organ mobility can be used irrespective of vaginal parity.

Preoperative predictors and a prediction score for perception of improvement after mesh prolapse surgery

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) surgery using a mesh has a complication rate of 26%, and an estimated 10% of those operated on do not consider it brings improvement. The objective of this study was to identify preoperative predictors of improvement after POP repair with mesh to develop a predictive score.

METHODS

This is a secondary analysis of the randomized multicenter trial PROSPERE, which compared morbidity after prolapse repair with mesh according to the vaginal or laparoscopic approach. Improved women [PGI-I score at 1-year follow-up = 1 (much better) or 2 (better)] were compared with unimproved women. Two hundred fifty-five women were included to derive the prediction score based on multiple logistic regression. An internal validation by bootstrapping estimated the unbiased performance of the model.

RESULTS

Criteria independently related to improvement were: (1) cystocele stage > II [OR: 2.93 95% CI (1.22-7.04), p = 0.015]; (2) preoperative expectation related to bulge symptom improvement [OR: 2.57 95% CI (1.07-6.04), p = 0.031] and (3) absence of chronic pelvic pain [OR: 4.55 95% CI (1.77-11.46), p = 0.001]. A score (scored from 0 to 11) was constructed from the aOR of the predictive model: the ROC-AUC of the score was 0.75, and a score ≥ 9 predicted a 97% chance of improvement (95% CI 92-99), with a specificity of 85% (95% CI 68-94). The ROC-AUC corrected for optimism by the bootstrap procedure was 0.70.

CONCLUSIONS

This score could be used by surgeons in preoperative counseling of women.

Analysis of prevalence of selected anamnestic factors among women with pelvic organ prolapse

BACKGROUND

Pelvic organ prolapse is the most frequent medical condition in women in the postmenopausal age. The pathophysiology is multifactorial.

OBJECTIVES

The purpose of this paper was to analyze the prevalence of selected anamnestic factors in the population of women treated due to pelvic organ prolapse in the 2nd Department and Clinic of Obstetrics and Gynecology Wroclaw Medical University (Poland).

MATERIAL AND METHODS

A total of 104 medical histories of women treated in the 2nd Department and Clinic of Obstetrics and Gynecology in the years 2012-2013 due to pelvic organ prolapse were analyzed.

RESULTS

The most frequent type of defect was the complex defect concerning both cystocele and rectocele. Intensity of dysfunctions was determined by age, obstetric history (parity, newborn's body mass and process of labor), and woman's constitutional characteristic (her BMI and height). A comparison based on the type of defect revealed no differences between the groups except for BMI, which was the highest in the rectocele group (31.15 ±5.84; p = 0.0069).

CONCLUSIONS

The multifactorial ethology and differential clinical presentation including several types of this defect make this disorder difficult to prevent and treat. The obtained results confirm that there exists a relation between the data from the medical history and the prevalence of pelvic organ prolapse. Anamnesis can be useful when predicting prevalence and, in the future, may even help to decrease the prevalence of this type of disorder.

Anterior needle-guided mesh in advanced pelvic organ prolapse: apical fixation on sacrospinous ligaments

OBJECTIVE

To evaluate whether anterior-apical compartment mesh implants for pelvic floor reconstruction might be safely and effectively anchored to the sacro-spinous (SS) ligaments instead of the arcus tendineus fascia pelvis (ATFP). The SS ligaments as anchoring structures for centro-apical support mesh fixation are thought to be stronger than the ATFP and we presumed that anterior mesh fixation to the SS ligament might be feasible, safe and effective.

STUDY DESIGN

Patients with advanced anterior-apical pelvic floor prolapse, referred for mesh reconstruction and having poor ATFP were enrolled to this study. For these patients the posterior arms of the anterior mesh were fixed to the SS ligaments. Data regarding cure, complications and patient's satisfaction were collected prospectively: patients were interviewed and examined at the end of the first and third post-operative months, and interviewed again at the study conclusion.

RESULTS

Of 72 patients who were asked to participate in this study, 44 had rather un-palpable ATFP, and SS ligament fixation was performed. The mean follow-up duration was 12 months (range: 10-43). No significant intra- or post-operative complications were recorded. The POP-Q points measurements showed marked improvements: the average delta for the Ba point was 7.4cm, for the Bp point 4.7cm, and for the C point 7.9cm. These differences were all statistically significant. Bladder overactivity symptoms, namely urgency, frequency and nocturia, were all found to be reduced significantly, and so was the sexual discomfort rate. Fecal incontinence, pelvic pain and constipation rates were reduced as well, but these did not reach statistical significance.

CONCLUSIONS

This rather small study suggests that anterior pelvic floor meshes might be anchored safely and successfully to the SS ligament, aiming to achieve improved centro-apical support of the vaginal apex and the anterior wall by an anterior pelvic floor approach.

Gynecological aspects of obstetrical delivery

Parturition should be looked upon as a physiological exercise, and ideally the multiparous state should be one of asymptomatic change associated with comfortable function. However, because obstetrics is a field in which serious complications may suddenly occur, the ideal is not always possible. Among the delayed effects of delivery is a group of gynecological complications which may affect the well-being of the woman so involved in later life. Such complications as uterine prolapse, cystocele, rectocele, enterocele, and genital fistula may be the grim aftermath of poor obstetric practice.The article reviews some of the advances in the prevention of maternal mortality and morbidity and emphasizes the important place of intelligent conservative obstetrics in the hands of both general physicians and specialists.

Accidental injuries to women; obstetrical and gynecological problems associated with damage claims

Women who have been injured should be examined for possible gynecological injury within 24 hours of the accident. Injuries to pregnant women do not usually cause an obstetrical crisis. When such an event does occur, there is positive evidence which relates it to the accident if there was such relationship. Metrorrhagia and menorrhagia are common sequelae of physical and psychological injury, but they are of temporary nature in cases in which there is no demonstrable pathologic change upon pelvic examination. Uterine prolapse, cystocele and rectocele are not caused by a single injury except in extremely rare instances. When vaginal vault injury has occurred as a result of a single injury, there is plentiful evidence of severe tissue damage.