Apical prolapse

Introducing a true minimally invasive meshless and dissectionless anchoring system for pelvic organ prolapse repair

INTRODUCTION AND HYPOTHESIS

The objective was to demonstrate the biomechanical properties, feasibility, and potential advantages over conventional techniques of this new anchoring device, NeuGuide™.

METHODS

We evaluated the pull-out forces required to pull the NeuGuide™ anchor elements from a uniform porcine ligament and a cadaver ligament. We also evaluated the function of the NeuGuide™ and the characteristics of the device for the establishment of verification evidence ensuring the reliability and feasibility of the device. We also evaluated the safety and performance of the NeuGuide™ procedure in female cadavers by palpating the sacro-spinous ligament in real time. We assessed the ability to deploy and fixate the anchor to the sacro-spinous ligament and to stitch the sutures from both sides of the vaginal apex to the cervix, without damaging the surrounding structures.

RESULTS

All 12 anchors were inserted into the porcine ligament and the cadaver sacro-spinous ligaments successfully (mean pull-out force 34.13 ± 4.32 and 35.68 ± 9.28 respectively). None of the measured forces were below 20 N. No statistically significant difference was noted in the pull-out forces between the porcine and the cadavers (p = 0.60), between the two cadavers (p = 0.19) and between the right and left sacro-spinous ligaments. No abnormalities or malfunctions were noted in the functional performance of the device. Upon laparotomy, dissection of the cadavers revealed that the sacro-spinous ligaments were reached safely with no damage to the surrounding organs and tissues.

CONCLUSIONS

This novel anchoring device (NeuGuide™) is aimed at facilitating a durable, easy, and short procedure for sacro-spinous ligament fixation with hypothetically fewer operative complications.

Apical prolapse repair: weighing the risks and benefits

PURPOSE OF REVIEW

This article reviews the current literature regarding surgical repair of vaginal apical prolapse and discusses the risks and benefits of various surgical approaches.

RECENT FINDINGS

Vaginal uterosacral ligament suspension has similar anatomic and subjective outcomes to sacrospinous ligament fixation at 1 year. Native tissue vaginal repairs offer decreased morbidity compared with mesh-augmented sacrocolpopexy; however, sacrocolpopexy has greater anatomic success. Minimally invasive sacrocolpopexy appears to be equivalent to open abdominal sacrocolpopexy. Native tissue repairs and transvaginal mesh kits support the vaginal apex with similar results; however, long-term follow-up is needed. Robotic and laparoscopic sacrocolpopexy are equally effective in restoring the vaginal apex.

SUMMARY

Surgical restoration of the vaginal apex can be accomplished via a variety of approaches and techniques. When deciding on the proper surgical intervention, the surgeon must carefully calculate the risks and benefits of each procedure while incorporating the patient's individual medical and surgical risk factors. Lastly, a discussion regarding the patient's overall goals of care is paramount to the decision-making process.

Abdominal sacral colpopexy versus sacrospinous ligament fixation: a cost-effectiveness analysis

INTRODUCTION AND HYPOTHESIS

For the surgical correction of apical prolapse the abdominal approach is associated with better outcomes; however, it is more expensive than the transvaginal approach. This cost-effectiveness analysis compares abdominal sacral colpopexy (ASC) with sacrospinous ligament fixation (SSLF) to determine if the improved outcomes of ASC justify the increased expense.

METHODS

A decision-analytic model was created comparing ASC with SSLF using data-modeling software, TreeAge Pro (2013), which included the following outcomes: post-operative stress urinary incontinence (SUI) with possible mid-urethral sling (MUS) placement, prolapse recurrence with possible re-operation, and post-operative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) of less than $50,000 per quality-associated life year (QALY). Base-case, threshold, and one-way sensitivity analyses were performed.

RESULTS

At the baseline, ASC is more expensive than SSLF ($13,988 vs $11,950), but is more effective (QALY 1.53 vs 1.45) and is cost-effective (ICER $24,574/QALY) at 2 years. ASC was not cost-effective if the following four thresholds were met: the rate of post-operative SUI was above 36 % after ASC or below 28 % after SSLF; the rate of MUS placement for post-operative SUI was above 60 % after ASC or below 13 % after SSLF; the rate of recurrent prolapse was above 15 % after ASC or below 4 % after SSLF; the rate of post-operative dyspareunia was above 59 % after ASC or below 19 % after SSLF.

CONCLUSIONS

Abdominal sacral colpopexy can be cost-effective compared with sacrospinous ligament fixation; however, as the post-operative outcomes of SSLF improve, SSLF can be considered a cost-effective alternative.

The investigation and treatment of female pelvic floor dysfunction

BACKGROUND

25% of all women report involuntary loss of urine, and 7% may require treatment.

METHODS

This review is based on a selection of pertinent literature, including guidelines and Cochrane reviews.

RESULTS

The assessment of pelvic floor dysfunction in women begins with a basic evaluation that is followed by special diagnostic tests if indicated. The physician taking the clinical history should inquire about the patient's behavior, personality, social and other stressors, and eating and drinking habits, as well as any mental disorders that may be present, including anxiety disorders, depression, somatization disorders, and disorders of adaptation. Conservative treatment consists mainly of lifestyle changes, physiotherapy, and medication. Stress incontinence is most commonly treated with pelvic floor exercises, with a documented success rate of 56.1% vs. 6% without such treatment (relative risk 8.38, 95% confidence interval 3.67-19.07). If incontinence persists, surgery may be indicated ( implantation of suburethral tension-free slings, or colposuspension). Feedback and biofeedback training can be used to treat an overactive bladder. If these techniques and drug therapy are unsuccessful, botulinum toxin injections can be considered.

CONCLUSION

Well-validated treatments for pelvic floor dysfunction are available. Psychosomatic factors must be taken into account and can have a major effect on treatment outcomes.

Vaginally assisted laparoscopic sacrocolpopexy for the treatment of complete uterovaginal prolapse

INTRODUCTION AND HYPOTHESIS

Women with complete uterovaginal prolapse (UVP) present multicompartmental pelvic defects. The vaginally assisted laparoscopic sacrocolpopexy (VALS) has been introduced to address such defects by combining a vaginal and a laparoscopic approach.

METHOD

This is a video demonstration of a VALS procedure performed on a 60-year-old patient with a complete UVP. The presented procedure comprises two steps: an initial vaginal surgery, followed by a laparoscopic approach. The vaginal surgery initially includes a vaginal hysterectomy and full-thickness dissection of the vaginal walls. The meshes are then sutured on the fascias and the free ends are placed in the pelvic cavity. The vaginal vault is closed transvaginally and then suspended laparoscopically on the sacral promontory.

CONCLUSIONS

The VALS procedure is a valid minimally invasive surgical alternative for patients with severe or complete UVP. This combined procedure facilitates the surgical steps and minimizes the need to perform difficult pelvic laparoscopic dissections.

Functional outcome after pelvic floor reconstructive surgery with or without concomitant hysterectomy

PURPOSE

When counseling patients about surgical alternatives for pelvic organ prolapse (POP) repair, numerous things have to be considered. Uterine preservation vs. hysterectomy is one relevant issue. Hysterectomy has been traditionally performed for POP, but its benefit regarding outcome has never been proven. Furthermore, a growing number of women ask for uterine preservation.

METHODS

In this retrospective cohort study, 384 patients who had undergone surgery for POP between 2000 and 2012 at Freiburg University Medical Center were included. Using a standardized questionnaire, further surgeries, urinary incontinence, recurrent POP, pessary use, and satisfaction with the surgical outcome were evaluated. The functional results after uterine preservation vs. concomitant hysterectomy were compared using t test.

RESULTS

196 (51.04%) women were available for follow-up and agreed to participate (n = 122 with hysterectomy, n = 72 with uterine-preserving surgery, respectively). After a mean follow-up time of 67 months, vaginal bulge symptoms and urinary incontinence did not differ between treatment groups. We observed higher success rates and satisfaction scores in the uterine-preserving group. Regarding satisfaction with surgery and whether the patients thought it had been successful, we observed a trend toward better results in the uterine-preserving group (mean satisfaction score: 8.45 ± 2.15 vs. 7.76 ± 2.91, range 0-10, p = 0.061; success: 91.4 vs. 81.7 %, p = 0.087).

CONCLUSIONS

There was no difference with regard to functional outcome between patients with or without concomitant hysterectomy. Satisfaction with the operation was slightly higher after uterus preserving surgery. Therefore, uterine-preserving surgery is a valuable option unless there are contraindications.