Incidence of adverse events after uterosacral colpopexy for uterovaginal and posthysterectomy vault prolapse

OBJECTIVE

We sought to describe perioperative and postoperative adverse events associated with uterosacral colpopexy, to describe the rate of recurrent pelvic organ prolapse (POP) associated with uterosacral colpopexy, and to determine whether surgeon technique and suture choice are associated with these rates.

STUDY DESIGN

This was a retrospective chart review of women who underwent uterosacral colpopexy for POP from January 2006 through December 2011 at a single tertiary care center. The electronic medical record was queried for demographic, intraoperative, and postoperative data. Strict definitions were used for all clinically relevant adverse events. Recurrent POP was defined as the following: symptomatic vaginal bulge, prolapse to or beyond the hymen, or any retreatment for POP.

RESULTS

In all, 983 subjects met study inclusion criteria. The overall adverse event rate was 31.2% (95% confidence interval [CI], 29.2-38.6), which included 20.3% (95% CI, 17.9-23.6) of subjects with postoperative urinary tract infections. Of all adverse events, 3.4% were attributed to a preexisting medical condition, while all other events were ascribed to the surgical intervention. Vaginal hysterectomy, age, and operative time were not significantly associated with any adverse event. The intraoperative bladder injury rate was 1% (95% CI, 0.6-1.9) and there were no intraoperative ureteral injuries; 4.5% (95% CI, 3.4-6.0) of cases were complicated by ureteral kinking requiring suture removal. The rates of pulmonary and cardiac complications were 2.3% (95% CI, 1.6-3.5) and 0.8% (95% CI, 0.4-1.6); and the rates of postoperative ileus and small bowel obstruction were 0.1% (95% CI, 0.02-0.6) and 0.8% (95% CI, 0.4-1.6). The composite recurrent POP rate was 14.4% (95% CI, 12.4-16.8): 10.6% (95% CI, 8.8-12.7) of patients experienced vaginal bulge symptoms, 11% (95% CI, 9.2-13.1) presented with prolapse to or beyond the hymen, and 3.4% (95% CI, 2.4-4.7) required retreatment. Number and type of suture used were not associated with a higher rate of recurrence. Of the subjects who required unilateral removal of sutures to resolve ureteral kinking, 63.6% did not undergo suture replacement; this was not associated with a higher rate of POP recurrence.

CONCLUSION

Perioperative and postoperative complication rates associated with severe morbidity after uterosacral colpopexy appear to be low. Uterosacral colpopexy remains a safe option for the treatment of vaginal vault prolapse.

Resolution of Chronic Vulvar Pruritus With Replacement of a Neuromodulation Device

Vulvar pruritus is typically associated with fungal, bacterial, and/or dermatological conditions that routinely resolve with the use of topical medications. Pruritus rarely becomes chronic in nature without a definable pathological diagnosis. However, when this occurs, management is difficult and has limited treatment options. Few cases have reported resolution of vulvar pain or discomfort with sacral neuromodulation implantation. We report a case in which a patient experienced chronic vulvar pruritus that was refractory to medical treatments and did not have a pathological diagnosis. A neurological etiology was suspected, and upon replacement of the patient's sacral neuromodulation device, complete resolution of the vulvar symptoms occurred.

Perioperative adverse events after minimally invasive abdominal sacrocolpopexy

OBJECTIVE

Our first objective was to compare peri- and postoperative adverse events between robotic-assisted laparoscopic sacrocolpopexy (RSC) and conventional laparoscopic sacrocolpopexy (LSC) in a cohort of women who underwent these procedures at a tertiary care center. Our second objective was to explore whether hysterectomy and rectopexy at the time of sacrocolpopexy were associated with these adverse events.

STUDY DESIGN

This was a retrospective cohort study of women who underwent either RSC or LSC with or without concomitant hysterectomy and/or rectopexy from 2006-2012. Once patients were identified as either having undergone RSC or LSC, the electronic medical record was queried for demographic, peri-, and postoperative data.

RESULTS

Four hundred six women met study inclusion criteria. Mean age and body mass index of all the women were 58 ± 10 years and 27.9 ± 4.9 kg/m(2). The women who underwent RSC were older (60 ± 9 vs 57 ± 10 years, respectively; P = .009) and more likely to be postmenopausal (90.9% vs 79.1%, respectively; P = .05). RSC cases were associated with a higher intraoperative bladder injury rate (3.3% vs 0.4%, respectively; P = .04), a higher rate of estimated blood loss of ≥500 mL (2.5% vs 0, respectively; P = .01), and reoperation rate for pelvic organ prolapse (4.9% vs 1.1%, respectively; P = .02) compared with LSC. Concomitant rectopexy was associated with a higher risk of transfusion (2.8% vs 0.3%, respectively; P = .04), pelvic/abdominal abscess formation (11.1% vs 0.8%, respectively; P < .001), and osteomyelitis (5.6% vs 0, respectively; P < .001). The mesh erosion rate for all the women was 2.7% and was not statistically different between LSC and RSC and for patients who underwent concomitant hysterectomy and those who did not.

CONCLUSION

Peri- and postoperative outcomes after RSC and LSC are favorable, with few adverse outcomes. RSC is associated with a higher rate of bladder injury, estimated blood loss ≥500 mL, and reoperation for recurrent pelvic organ prolapse; otherwise, the rate of adverse events is similar between the 2 modalities. Concomitant rectopexy is associated with a higher rate of postoperative abscess and osteomyelitis complications.

Laparoscopic repair of recurrent lateral enterocele and rectocele

It is difficult to determine what types of procedures should be attempted in patients who have recurrent prolapse. We present a case of recurrent lateral enterocele and rectocele after the patient had undergone multiple surgeries for pelvic organ prolapse (POP), including a vaginal hysterectomy, bladder-neck suspension, anterior colporrhaphy, site-specific rectocele repair, apical mesh implant, iliococcygeus vault suspension, and transobturator suburethral sling procedure. With recurrence, the patient underwent robot-assisted laparoscopic sacral colpopexy, tension-free vaginal tape transobturator sling insertion, rectocele repair, and perineorrhaphy with cystoscopy. She then presented with defecatory outlet obstruction and constipation and subsequently was treated with a stapled transanal rectal resection. The patient returned with continued defecatory dysfunction and a recurrent lateral enterocele and rectocele. The recurrence was treated laparoscopically using a lightweight polypropylene mesh. The postoperative period was uneventful. Two years later, the patient reported decreased defecatory symptoms and no further symptomatic prolapse.

Animal models of female pelvic organ prolapse: lessons learned

Pelvic organ prolapse is a vaginal protrusion of female pelvic organs. It has high prevalence worldwide and represents a great burden to the economy. The pathophysiology of pelvic organ prolapse is multifactorial and includes genetic predisposition, aberrant connective tissue, obesity, advancing age, vaginal delivery and other risk factors. Owing to the long course prior to patients becoming symptomatic and ethical questions surrounding human studies, animal models are necessary and useful. These models can mimic different human characteristics - histological, anatomical or hormonal, but none present all of the characteristics at the same time. Major animal models include knockout mice, rats, sheep, rabbits and nonhuman primates. In this article we discuss different animal models and their utility for investigating the natural progression of pelvic organ prolapse pathophysiology and novel treatment approaches.

Surgical preparation: are patients "ready" for stress urinary incontinence surgery?

INTRODUCTION AND HYPOTHESIS

Patient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life.

METHODS

The ValUE trial compared the effect of pre-operative urodynamic studies with a standardized office evaluation of outcomes of SUI surgery at 1 year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured using a five-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment's effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ).

RESULTS

Based on PPQ question 11, 4 out of 5 (81 %) of women reported they "agreed" or "strongly agreed" that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ; Spearman's r = 0.13, p = 0.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (r s = 0.11, p = 0.02) and larger PGI-S improvement (increase; p = 0.008).

CONCLUSIONS

Approximately half (48 %) of women "strongly agreed" that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied, although surgical outcomes did not differ.

A randomized trial comparing conventional and robotically assisted total laparoscopic hysterectomy

OBJECTIVE

The purpose of this study was to compare operative time and intra- and postoperative complications between total laparoscopic hysterectomy and robotic-assisted total laparoscopic hysterectomy.

STUDY DESIGN

This study was a blinded, prospective randomized controlled trial conducted at 2 institutions. Subjects consisted of women who planned laparoscopic hysterectomy for benign indications. Preoperative randomization to total laparoscopic hysterectomy or robotic-assisted total laparoscopic hysterectomy was stratified by surgeon and uterine size (> or ≤12 weeks). Validated questionnaires, activity assessment scales, and visual analogue scales were administered at baseline and during follow-up evaluation.

RESULTS

Sixty-two women gave consent and were enrolled and randomly assigned; 53 women underwent surgery (laparoscopic, 27 women; robot-assisted, 26 women). There were no demographic differences between groups. Compared with laparoscopic hysterectomy, total case time (skin incision to skin closure) was significantly longer in the robot-assisted group (mean difference, +77 minutes; 95% confidence interval, 33-121; P < .001] as was total operating room time (entry into operating room to exit; mean difference, +72 minutes; 95% confidence interval, 14-130; P = .016). Mean docking time was 6 ± 4 minutes. There were no significant differences between groups in estimated blood loss, pre- and postoperative hematocrit change, and length of stay. There were very few complications, with no difference in individual complication types or total complications between groups. Postoperative pain and return to daily activities were no different between groups.

CONCLUSION

Although laparoscopic and robotic-assisted hysterectomies are safe approaches to hysterectomy, robotic-assisted hysterectomy requires a significantly longer operative time.

Anticholinergic therapy vs. onabotulinumtoxina for urgency urinary incontinence

BACKGROUND

Anticholinergic medications and onabotulinumtoxinA are used to treat urgency urinary incontinence, but data directly comparing the two types of therapy are needed.

METHODS

We performed a double-blind, double-placebo-controlled, randomized trial involving women with idiopathic urgency urinary incontinence who had five or more episodes of urgency urinary incontinence per 3-day period, as recorded in a diary. For a 6-month period, participants were randomly assigned to daily oral anticholinergic medication (solifenacin, 5 mg initially, with possible escalation to 10 mg and, if necessary, subsequent switch to trospium XR, 60 mg) plus one intradetrusor injection of saline or one intradetrusor injection of 100 U of onabotulinumtoxinA plus daily oral placebo. The primary outcome was the reduction from baseline in mean episodes of urgency urinary incontinence per day over the 6-month period, as recorded in 3-day diaries submitted monthly. Secondary outcomes included complete resolution of urgency urinary incontinence, quality of life, use of catheters, and adverse events.

RESULTS

Of 249 women who underwent randomization, 247 were treated, and 241 had data available for the primary outcome analyses. The mean reduction in episodes of urgency urinary incontinence per day over the course of 6 months, from a baseline average of 5.0 per day, was 3.4 in the anticholinergic group and 3.3 in the onabotulinumtoxinA group (P=0.81). Complete resolution of urgency urinary incontinence was reported by 13% and 27% of the women, respectively (P=0.003). Quality of life improved in both groups, without significant between-group differences. The anticholinergic group had a higher rate of dry mouth (46% vs. 31%, P=0.02) but lower rates of catheter use at 2 months (0% vs. 5%, P=0.01) and urinary tract infections (13% vs. 33%, P<0.001).

CONCLUSIONS

Oral anticholinergic therapy and onabotulinumtoxinA by injection were associated with similar reductions in the frequency of daily episodes of urgency urinary incontinence. The group receiving onabotulinumtoxinA was less likely to have dry mouth and more likely to have complete resolution of urgency urinary incontinence but had higher rates of transient urinary retention and urinary tract infections. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health; ClinicalTrials.gov number, NCT01166438.).

Accuracy of the digital anal examination in women with fecal incontinence

INTRODUCTION AND HYPOTHESIS

This study aims to determine the accuracy of digital rectal examination (DRE) to detect anal sphincter defects when compared to endoanal ultrasound (US) in women with fecal incontinence (FI).

METHODS

Seventy-four patients identified by retrospective chart review who presented with complaints of bothersome FI who underwent endoanal US are the subjects of this analysis. Sensitivity, specificity, and positive and negative likelihood ratios were calculated for the ability of the DRE to detect anal sphincter defects.

RESULTS

Anal sphincter defect was suspected on DRE in 75%. At endoanal US, external sphincter defects were noted in all three segments in 41% (complete defect) while partial defects were noted in 30%. DRE demonstrated a sensitivity of 82%, specificity of 32%, +likelihood ratio 1.2 (95% confidence interval (CI), 0.95-1.16) and -likelihood ratio of 0.6 (95% CI, 0.2-1.24) for detecting a complete EAS defect on endoanal US.

CONCLUSION

DRE has poor specificity for detecting anal sphincter defects seen on endoanal US.

Lower abdominal and pelvic pain with advanced pelvic organ prolapse: a case-control study

OBJECTIVE

The objective of the study was to compare the relative frequencies of pain in women with and without pelvic organ prolapse (POP).

STUDY DESIGN

This was an ancillary analysis of a case-control study investigating functional bowel disorders in women with and without POP. Cases were defined as subjects with stage 3 or 4 POP and controls were subjects with normal pelvic support.

RESULTS

Women with POP were more likely to experience lower abdominal or pelvic pain that was significantly bothersome and interfered with daily activities (odds ratio [OR], 9.7; 95% confidence interval [CI], 4.7-20.4). After controlling for confounders, women with prolapse were more likely to report pressure in the lower abdomen (OR, 2.3; 95% CI, 1.6-3.2), heaviness in the pelvic region (OR, 3.3; 95% CI, 2.3-4.3), and pain in the lower abdomen (OR, 2.6; 95% CI, 1.8-4.1).

CONCLUSION

Women with prolapse are more likely to report pain, pressure, or heaviness in the lower abdomen or pelvis compared with women with normal support.

Risk of deep venous thrombosis and pulmonary embolism in urogynecologic surgical patients

OBJECTIVE

We sought to determine the incidence of symptomatic deep venous thrombosis and pulmonary embolism, collectively referred to as venous thromboembolic events (VTE), in patients undergoing urogynecologic surgery to guide development of a VTE prophylaxis policy for this patient population.

STUDY DESIGN

We conducted a retrospective analysis of VTE incidence among women undergoing urogynecologic surgery over a 3-year period. All patients wore sequential compression devices intraoperatively through hospital discharge.

RESULTS

Forty of 1104 patients (3.6%) undergoing urogynecologic surgery were evaluated with chest computed tomography, lower extremity ultrasound, or both for suspicion of VTE postoperatively. The overall rate of venous thromboembolism in this population was 0.3% (95% confidence interval, 0.1-0.8).

CONCLUSION

Most women undergoing incontinence and reconstructive pelvic surgery are at a low risk for VTE. Sequential compression devices appear to provide adequate VTE prophylaxis in this patient population.

Lumbosacral osteomyelitis after robot-assisted total laparoscopic hysterectomy and sacral colpopexy

We report on the transabdominal resection of infected lumbosacral bone, synthetic mesh, and sinus tract following sacral colpopexy. A 45-year-old nulliparous patient who had undergone transvaginal mesh followed by robot-assisted sacral colpopexy presented with increasing back pain and foul-smelling vaginal drainage. An epidural abscess required surgical intervention, including diskectomy, sacral debridement, and mesh removal to drain the abscess and vaginal sinus tract. Recognized complications of open prolapse procedures also manifest following minimally invasive approaches. Osteomyelitis of the sacral promontory following sacral colpopexy may require gynecologic and neurosurgical management.

Primary stress urinary incontinence: what to do and why

Stress urinary incontinence (SUI) is defined as the involuntary leakage of urine on effort, exertion, sneezing, or coughing. SUI is the most common cause of urinary incontinence in younger women and the second most common cause in older women. Surgery offers high cure rates and is considered by many to be the first-line therapy for uncomplicated SUI in women. Currently, a variety of surgical procedures are available to treat symptomatic SUI. This article reviews the process of choosing a primary surgical procedure for women with SUI.

Surgical management of uterine prolapse

The surgical management of uterine prolapse requires an apical suspension procedure, with or without uterine removal. Options in the surgical treatment of uterine prolapse encompass the open, laparoscopic, or vaginal approaches. Vaginal apical suspension procedures include the uterosacral vaginal vault suspension, sacrospinous ligament fixation, iliococcygeus fascia suspension, and the McCall or Mayo culdoplasty. The abdominal sacral colpopexy may be performed via laparotomy or laparoscopy. Uterine preservation techniques include the Manchester procedure, sacrospinous hysteropexy, laparoscopic sacral hysteropexy and laparoscopic uterosacral vault suspension. Most of the data for subjective and objective outcomes for these prolapse procedures are from uncontrolled retrospective case series. Currently there is no definitive gold standard procedure to favor a particular route in the treatment of uterine prolapse. Thus, the optimal procedure to treat uterine prolapse depends on the specific defects that are present, as well as considerations such as the patient's age, comorbidities, activity level, desire for future fertility, history of prior prolapse surgery in other compartments, patient preference, as well as the skill and comfort level of the surgeon with the particular surgery.

Risk factors associated with failure 1 year after retropubic or transobturator midurethral slings

OBJECTIVE

The objective of the study was to identify predictors of recurrent urinary incontinence (UI) 1 year after treatment with tension-free vaginal tape (TVT) and transobturator tape (TOT).

STUDY DESIGN

One hundred sixty-two women with urodynamic stress urinary incontinence (SUI) were included in a clinical trial comparing TVT with TOT with at least 1 year of follow-up were included in this analysis. Potential clinical and urodynamic predictors for development of "any recurrent UI" or "recurrent SUI" 1 year after surgery were evaluated using logistic regression models.

RESULTS

Subjects who received concurrent prolapse surgery and those taking anticholinergic medications preoperatively were more likely to develop any recurrent UI. Increasing age was independently associated with recurrent SUI. Risk factors were similar for TVT and TOT for both definitions of treatment failure.

CONCLUSION

Concurrent prolapse surgery and preoperative anticholinergic medication use are associated with increased risk of developing recurrent UI 1 year after TVT or TOT. Increasing age is specifically associated with the recurrence of SUI symptoms.

Early experience with mesh excision for adverse outcomes after transvaginal mesh placement using prolapse kits

OBJECTIVE

The purpose of this study was to determine the complications, treatments, and outcomes in patients choosing to undergo removal of mesh previously placed with a mesh procedural kit.

STUDY DESIGN

This was a retrospective review of all patients who underwent surgical removal of transvaginal mesh for mesh-related complications during a 3-year period at Cleveland Clinic. At last follow-up, patients reported degree of pain, level of improvement, sexual activity, and continued symptoms.

RESULTS

Nineteen patients underwent removal of mesh during the study period. Indications for removal included chronic pain (6/19), dyspareunia (6/19), recurrent pelvic organ prolapse (8/19), mesh erosion (12/19), and vesicovaginal fistula (3/19), with most patients (16/19) citing more than 1 reason. There were few complications related to the mesh removal. Most patients reported significant relief of symptoms.

CONCLUSION

Mesh removal can be technically difficult but appears to be safe with few complications and high relief of symptoms, although some symptoms can persist.

A comprehensive review of suburethral sling procedure complications

The study objective was to review the existing literature regarding complications of anti-incontinence sling procedures. PubMed listings using keywords related to slings and associated complications with no date or language restrictions through May 2007 and the Manufacturer and User Facility Device Experience Database were searched for specific device- and procedure-related complications. Where no information was available, published abstracts were cited. Published reports of complications for all types of anti-incontinence sling procedures are analyzed and reported. Sling-related complications are multiple but can be summarized from studies on 13737 cumulative patients as involving: voiding dysfunction (8 studies, 881 patients, 16.3% average overall incidence [OI]); detrusor overactivity (20 studies, 1950 patients, 15.4% OI); urinary retention (14 studies, 943 patients, 14.2% OI); erosion/extrusion (19 studies, 2197 patients, 6.03% OI); impact on quality of life-dyspareunia (2 studies, 175 patients, 4.3% OI); infections-most often urinary tract infections but severe infections such as abscess are reported (19 studies, 1487 patients, 5.5% OI); hematoma-most often pelvic or vaginal (4 studies, 3691 patients, 2% OI); pain (6 studies, 597 patients, 7.3% OI); abdominal and pelvic organ injury-bladder, urethra, vagina, and intestines (10 studies, 1816 patients, 3.3% OI); systemic complications-deep vein thrombosis, sepsis (case reports); and death (case reports). Cure rates for all slings are as follows: subjective (16 studies, 1541 patients, 95% OI, range 63%-99%), objective (15 studies, 1203 patients, 82% OI, range 51%-97%), and failure (8 studies, 599 patients, 11.5% OI, range 4%-37%). It is likely that sling-related complications are under-reported in the published medical literature and in the Manufacturer and User Facility Device Experience Database. This review reports on the incidence of known complications for all types of slings. Some complications are common to all sling techniques; however, with development of minimally invasive slings, device-related complications are reported and compared.

Anatomic relationships of the tension-free vaginal mesh trocars

OBJECTIVE

The objective of the study was to describe the distances between the major anatomic structures to the path of the tension-free vaginal mesh (TVM) trocars.

STUDY DESIGN

Four anterior transobturator and 2 posterior ischiorectal TVM trocars were inserted bilaterally into 8 fresh frozen cadavers. Dissections were performed and mean distances (95% confidence interval) were measured between the closest points along the trocar's path and significant anatomic structures.

RESULTS

The mean distances between both anterior transobturator trocars and the medial branch of the obturator vessels were 0.8 cm (range, 0.6 to 1.0) and 0.7 cm (range, 0.4 to 1.1), and bladder were 0.7 cm (range, 0.5 to 0.9) and 1.3 cm (range, 0.8 to 1.9), respectively. The mean distances between the posterior trocar and the rectum and inferior rectal vessels were 0.8 cm (range, 0.6 to 1.0) and 0.9 cm (range, 0.7 to 1.1), respectively.

CONCLUSION

The bladder and medial branch of the obturator vessel may be at risk of injury during the passage of the anterior trocars, whereas the rectum and inferior rectal vessels may be at risk during the passage of the posterior trocar.

Vesicovaginal fistula due to an unreported foreign body in an adolescent

BACKGROUND

In the United States, vesico-vaginal fistula formation is most commonly associated with prior gynecologic surgery, and only rarely with severe pressure necrosis.

CASE

A 16-year-old girl presented with continuous urinary leakage and malodorous discharge. Examination revealed an incarcerated plastic cup in the vagina with a 5 cm vesico-vaginal fistula at the bladder neck. After trans-vaginal repair, the patient underwent full recovery with an intact continence mechanism.

CONCLUSION

Evaluation of unusual urinary symptoms in an adolescent should include pelvic examination and/or imaging. An undisclosed vaginal foreign body is a rare, but well described entity, contributing to vesico-vaginal fistula formation.