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Abstract
OBJECTIVE The aim of this study was to describe the relationship of the uterosacral ligament (USL) to the ureter and rectum along a surgeon's target location for suture placement under conditions simulating live surgery. METHODS Dissections were performed in 11 unembalmed female cadavers. Steps were taken to identify the USL simulating USL colpopexy. Pins were placed in the midportion of the USL at the level of the IS, and at 1-cm, 2-cm, and 3-cm increments traveling proximally toward the sacrum (Fig. 1). We measured minimum distances from the USL to the ureter and rectum at each target location. RESULTS In general, the ureters range from 1.3 to 2.0 cm lateral to the USLs along the target length. The rectum ranges from 1.9 to 2.6 cm from the right USL and remains 1.5 cm from the left USL. The mean change in distance between the ureter and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% confidence interval [CI], 0.19-0.24) on the right and 0.2 cm (95% CI, 0.18-0.27) on the left. The mean change in distance between the rectum and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% CI, 0.19-0.24) on the right and 0.0 cm (95% CI, 0-0) on the left. CONCLUSIONS For every centimeter traveled along the bilateral USLs from the IS toward the sacrum, the ureter moves 0.2 cm laterally away from the ligament, the rectum moves 0.2 cm medially away from the right USL, but maintains its position from the left USL.
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Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 2017. [PMID: 28650894 DOI: 10.1097/spv.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chrysanthopoulou EL, Pergialiotis V, Perrea D, Κourkoulis S, Verikokos C, Doumouchtsis SK. Platelet rich plasma as a minimally invasive approach to uterine prolapse. Med Hypotheses 2017; 104:97-100. [PMID: 28673602 DOI: 10.1016/j.mehy.2017.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 05/24/2017] [Indexed: 12/19/2022]
Abstract
Pelvic organ prolapse (POP) is a major health problem that affects many women with potentially severe physical and psychological impact as well as impact on their daily activities, and quality of life. Several surgical techniques have been proposed for the treatment of POP. The FDA has published documents that refer to concerns about the use of synthetic meshes for the treatment of prolapse, in view of the severe complications that may occur. These led to hesitancy in use of these meshes and partial increase in use of other biological grafts such as allografts and xenografts. Although there seems to be an increasing tendency to use grafts in pelvic floor reconstructive procedures due to lower risks of erosion than synthetic meshes, there are inconclusive data to support the routine use of biological grafts in pelvic organ prolapse treatment. In light of these observations new strategies are needed for the treatment of prolapse. Platelet rich plasma (PRP) is extremely rich in growth factors and cytokines, which regulate tissue reconstruction and has been previously used in orthopaedics and plastic surgery. To date, however, it has never been used in urogynaecology and there is no evidence to support or oppose its use in women who suffer from POP, due to uterine ligament defects. PRP is a relatively inexpensive biological material and easily produced directly from patients' blood and is, thus, superior to synthetic materials in terms of potential adverse effects such as foreign body reaction. In the present article we summarize the existing evidence, which supports the conduct of animal experimental and clinical studies to elucidate the potential role of PRP in treating POP by restoring the anatomy and function of ligament support.
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Affiliation(s)
- E L Chrysanthopoulou
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Greece; Department of Obstetrics and Gynaecology, Queen's Hospital, Rom Valley Way, Romford, Essex, United Kingdom.
| | - V Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Greece
| | - D Perrea
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Greece
| | | | - C Verikokos
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Greece; 2nd Department of Surgery, Vascular Surgery Unit, Laiko General Hospital, Medical School of Athens, Greece
| | - S K Doumouchtsis
- Laboratory of Experimental Surgery and Surgical Research N.S. Christeas, National and Kapodistrian University of Athens, Greece; Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, United Kingdom; St George's University of London, London, United Kingdom
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Structural Failure Sites in Anterior Vaginal Wall Prolapse: Identification of a Collinear Triad. Obstet Gynecol 2017; 128:853-862. [PMID: 27607881 DOI: 10.1097/aog.0000000000001652] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test the null hypothesis that six factors representing potential fascial and muscular failure sites contribute equally to the presence and size of a cystocele: two vaginal attachment factors (apical support and paravaginal defects), two vaginal wall factors (vaginal length and width), and two levator ani factors (hiatus size and levator ani defects). METHODS Thirty women with anterior-predominant prolapse (women in a case group) and 30 women in a control group underwent three-dimensional stress magnetic resonance imaging. The location of the anterior vaginal wall at maximal Valsalva was identified with the modified Pelvic Inclination Coordinate System and the six factors measured. Analysis included repeated-measure analysis of variance, logistic regression, and stepwise linear regression. RESULTS We identified a collinear triad consisting of apical location, paravaginal location, and hiatus size that were not only the strongest predictors of cystocele size, but were also highly correlated with one another (r=0.84-0.89, P<.001) for the presence and size of the prolapse. Together they explain up to 83% of the variation in cystocele size. Among the less significant vaginal factors, vaginal length explained 19% of the variation in cystocele size, but no significant difference in vaginal width existed. Women in the case group were more likely to have abnormalities in collinear triad factors (up to 80%) than vaginal wall factors (up to 23.3%). Combining the strongest collinear triad with the vaginal factors, the model explained 92.5% of the variation in cystocele size. CONCLUSION Apical location, paravaginal location, and hiatus size are highly correlated and are strong predictors of cystocele presence and size.
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Long-Term Effectiveness of Uterosacral Colpopexy and Minimally Invasive Sacral Colpopexy for Treatment of Pelvic Organ Prolapse. Female Pelvic Med Reconstr Surg 2017; 23:188-194. [DOI: 10.1097/spv.0000000000000313] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Pelvic organ prolapse affects approximately 8% of women, and the demand for pelvic organ prolapse surgery is expected to increase by nearly 50% over the next 40 years. The surgical techniques used to correct pelvic organ prolapse have evolved over the last 10 years, with multiple well-designed studies addressing the risks, outcomes, reoperation rates, and optimal surgical approaches. Here we review the most recent evidence on the route of access, concomitant procedures, and synthetic materials for augmenting the repair. Ultimately, this review highlights that there is no optimal method for correcting pelvic organ prolapse and that the risks, benefits, and approaches should be discussed in a patient-centered, goal-oriented approach to decision-making.
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Affiliation(s)
- Julia Geynisman-Tan
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, Illinois, USA
| | - Kimberly Kenton
- Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, Illinois, USA
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Schiavi MC, Perniola G, Di Donato V, Visentin VS, Vena F, Di Pinto A, Zullo MA, Monti M, Benedetti Panici P. Severe pelvic organ prolapse treated by vaginal native tissue repair: long-term analysis of outcomes in 146 patients. Arch Gynecol Obstet 2017; 295:917-922. [DOI: 10.1007/s00404-017-4307-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 01/27/2017] [Indexed: 02/03/2023]
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Transvaginal uterosacral ligament suspension for posthysterectomy vaginal vault prolapse repair. Int Urogynecol J 2017; 28:1421-1423. [DOI: 10.1007/s00192-017-3277-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/16/2017] [Indexed: 02/03/2023]
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Bonde L, Noer MC, Møller LA, Ottesen B, Gimbel H. Vaginal vault suspension during hysterectomy for benign indications: a prospective register study of agreement on terminology and surgical procedure. Int Urogynecol J 2016; 28:1067-1075. [PMID: 27999933 DOI: 10.1007/s00192-016-3229-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Several suspension methods are used to try to prevent pelvic organ prolapse (POP) after hysterectomy. We aimed to evaluate agreement on terminology and surgical procedure of these methods. METHODS We randomly chose 532 medical records of women with a history of hysterectomy from the Danish Hysterectomy and Hysteroscopy Database (DHHD). Additionally, we video-recorded 36 randomly chosen hysterectomies. The hysterectomies were registered in the DHHD. The material was categorized according to predefined suspension methods. Agreement compared suspension codes in DHHD (gynecologists' registrations) with medical records (gynecologists' descriptions) and with videos (reviewers' categorizations) respectively. Whether the vaginal vault was suspended (pooled suspension) or not (no suspension method + not described) was analyzed, in addition to each suspension method. RESULTS Regarding medical records, agreement on terminology was good among patients undergoing pooled suspension in cases of hysterectomy via the abdominal and vaginal route (agreement 78.7, 92.3%). Regarding videos, agreement on surgical procedure was good among pooled suspension patients in cases of hysterectomy via the abdominal, laparoscopic, and vaginal routes (agreement 88.9, 97.8, 100%). Agreement on individual suspension methods differed regarding both medical records (agreement 0-90.1%) and videos (agreement 0-100%). CONCLUSIONS Agreement on terminology and surgical procedure regarding suspension method was good in respect of pooled suspension. However, disagreement was observed when individual suspension methods and operative details were scrutinized. Better consensus of terminology and surgical procedure is warranted to enable further research aimed at preventing POP among women undergoing hysterectomy.
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Affiliation(s)
- Lisbeth Bonde
- Department of Obstetrics and Gynecology, Nykoebing Falster Hospital, Nykoebing Falster, Denmark. .,University of Southern Denmark, Odense, Denmark. .,Department of Gynecology, Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Mette Calundann Noer
- Department of Gynecology, Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Alling Møller
- Department of Obstetrics and Gynecology, Zealand University Hospital, Zealand, Denmark
| | - Bent Ottesen
- Department of Gynecology, Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helga Gimbel
- Department of Obstetrics and Gynecology, Nykoebing Falster Hospital, Nykoebing Falster, Denmark.,University of Southern Denmark, Odense, Denmark
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Ligament shortening compared to vaginal colpopexy at the time of hysterectomy for pelvic organ prolapse. Int Urogynecol J 2016; 28:899-905. [PMID: 27858132 DOI: 10.1007/s00192-016-3201-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 10/30/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The performance of a colpopexy at the time of hysterectomy for pelvic organ prolapse is a potential indicator of surgical quality. However, vaginal colpopexy has not been directly compared with the classic technique of ligament shortening and reattachment. We sought to test the null hypothesis that there is no difference in prolapse recurrence between the techniques. METHODS We performed a retrospective chart review of 330 vaginal hysterectomies performed for prolapse, comparing symptomatic and/or anatomic recurrence rates between patients having a vaginal colpopexy (uterosacral ligament suspension or sacrospinous ligament suspension) and those having ligament shortening and reattachment. Clinically relevant variables significantly associated with recurrence in a univariate analysis were used to create a multivariable logistic regression model to predict recurrence. RESULTS With a mean follow-up of 20 months, there was no significant difference between symptomatic and/or anatomic recurrence rates: 19.4 % of patients (41 of 211) having colpopexy vs. 11.8 % of patients (14 of 119) having ligament shortening (p = 0.07). Baseline prolapse stage was higher in patients having colpopexy (median 3, IQR 2 - 5) than in those having ligament shortening (median 2, IQR 1 - 3; p ≤ 0.0001). In the multivariable logistic regression analysis, the procedure performed was not associated with recurrence (OR 1.57, 95 % CI 0.79 - 3.12). A baseline prolapse of 4 cm or greater was associated with recurrence (OR 2.63, 95 % CI 1.32 - 5.22), as was the time since hysterectomy (OR 1.02 per month, 95 % CI 1.01 - 1.04). CONCLUSIONS When compared with vaginal colpopexy, selective use of the ligament shortening technique at the time of vaginal hysterectomy was associated with similar rates of prolapse recurrence. Preoperative prolapse size was the factor most strongly associated with recurrence.
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Rappa C, Saccone G. Recurrence of vaginal prolapse after total vaginal hysterectomy with concurrent vaginal uterosacral ligament suspension: comparison between normal-weight and overweight women. Am J Obstet Gynecol 2016; 215:601.e1-601.e4. [PMID: 27342042 DOI: 10.1016/j.ajog.2016.06.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/09/2016] [Accepted: 06/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Obesity is one of the most important risk factors for the development and progression of the pelvic organ prolapse. However, data regarding whether obesity is a risk factor for recurrence after pelvic organ prolapse surgery are controversial. OBJECTIVE The aim of this study was to estimate the risk of recurrent prolapse in any vaginal compartment after total vaginal hysterectomy with concurrent uterosacral ligament vaginal vault suspension among normal-weight women compared with either overweight or obese women. STUDY DESIGN This is a 5-year retrospective cohort study of women who underwent total vaginal hysterectomy with concurrent vaginal uterosacral ligament suspension at one referral center for pelvic organ prolapse in Italy from January 2010 to January 2015. All women who underwent total vaginal hysterectomy with concurrent uterosacral ligament suspension were included in the analysis. Laparoscopic approach was excluded. Women were classified according to the body mass index of 2 groups: (1) normal weight (body mass index, 18.5-24.9 kg/m2) and (2) either overweight (body mass index, 25.0-29.9 kg/m2) or obese (body mass index, ≥30.0 kg/m2). The primary outcome was the incidence of recurrent prolapse in any vaginal compartment (anterior, posterior, or apical). Recurrent prolapse was defined as prolapse extending beyond the hymen with straining (pelvic organ prolapse quantification points Ba, C, Bp ≥0) or repeat treatment for prolapse with either pessary or surgery. Uterosacral ligament suspensions were performed with a vaginal approach with the use of sutures placed in the intermediate uterosacral ligament, at or above the ischial spine, and affixed to the vaginal apex. Delayed absorbable sutures were used, with 2 sutures per side. RESULTS Three hundred sixty women who underwent total vaginal hysterectomy with concurrent uterosacral ligament suspension with at least 6 months of follow up after surgery were included in the study. The overall incidence of recurrent prolapse in any vaginal compartment was 19.7% (71/360 women). The risk of recurrent prolapse in any vaginal compartment (ie, primary outcome) was similar in the normal-weight compared with the overweight or obese group (16.7% vs 21.3%; P=.30). Women in the normal-weight group had a lower risk of recurrent anterior vaginal prolapse (10.8% vs 20.0%; adjusted odds ratio, 0.49; 95% confidence interval, 0.25-0.94) and of multiple compartment prolapse (8.3% vs 14.6%; adjusted odds ratio, 0.53; 95% confidence interval, 0.31-0.83). CONCLUSION After total vaginal hysterectomy with concurrent uterosacral ligament suspension, the risk of recurrent vaginal prolapse was 20% based on a composite outcome definition of any anatomic prolapse beyond the hymen or pessary or repeat surgery. The most common site of recurrence was the anterior compartment. The risk of recurrent surgery was 10%. Our study showed that women with normal-weight had similar risk of recurrent prolapse compared with the overweight or obese group. In subgroup analyses, women with normal-weight had one-half the odds of recurrent anterior vaginal wall prolapse compared with those who were overweight or obese.
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Krlin RM, Soules KA, Winters JC. Surgical repair of pelvic organ prolapse in elderly patients. Curr Opin Urol 2016; 26:193-200. [PMID: 26765047 DOI: 10.1097/mou.0000000000000260] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Epidemiologic data suggests that our population greater than 65 years of age will nearly double. In addition, the incidence of women undergoing surgery for pelvic organ prolapse will rise. Chronologic age does not preclude a woman from undergoing a reconstructive procedure, yet the preoperative assessment should be approached most judiciously with great care to insure patient is maximally medically prepared for surgery. RECENT FINDINGS Surgical procedures in this review include: the abdominal sacral colpopexy, anterior repair, posterior repair, sacrospinous ligament fixation, uterosacral suspension, and iliococcygeus fixation. The advent of robotic surgery has decreased the perioperative morbidity of several of these procedures. However, the risk of more severe complications does appear higher following robotic procedures, when compared with vaginal procedures. SUMMARY Intuitively, one would surmise that there is a point where vaginal surgery should be considered as the primary procedure based on age, risk and durability of the surgery - unfortunately that age is not clear. Thus, the proper selection of prevalence of organ prolapse surgery can only be done after careful discussion with the patient and including the patient in the selection process as much as possible.
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Affiliation(s)
- Ryan M Krlin
- aDepartment of Urology, Louisiana State University Health Sciences Center, New Orleans, Louisiana bDepartment of Obstetrics and Gynecology, John A. Burns School of Medicine, Honolulu, Hawaii cDepartment of Urology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
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Laparoscopic fixation of the vaginal cuff to the uterosacral ligaments at the time of hysterectomy. Int Urogynecol J 2016; 28:321-323. [PMID: 27614758 DOI: 10.1007/s00192-016-3137-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/18/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Transvaginal ipsilateral uterosacral ligament colpopexy for pelvic organ prolapse (POP), which was reported by Shull et al. (Shull's colpopexy) in 2000, is one of the most frequently performed non-mesh pelvic floor reconstructive surgical procedures. Despite its excellent anatomical outcomes, ureteral injury and difficulty in uterosacral ligament detection (especially in patients with severe POP) are typical issues with this procedure. METHOD This video demonstrates the procedure in a 58-year-old woman, gravida 2 para 2, with POP-Q stage II uterine prolapse and stage I cystocele. At the beginning of the operation, the bilateral uterosacral ligaments were confirmed and separated from the ureters after entering the retroperitoneal space. The inferior hypogastric nerve and pelvic nerve plexus were also separated from the uterosacral ligament. After total laparoscopic hysterectomy, three ipsilateral delayed absorbable monofilament sutures were placed between the uterosacral ligament and the vaginal cuff. Retroperitonealization was then performed using a continuous suture with closure of the Douglas pouch. CONCLUSION Laparoscopic Shull's colpopexy for POP is a secure procedure with the advantages of laparoscopy (magnification and sharing the operative field). This may become one of the most useful operations for apical support as native tissue repair.
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Vaginal hysterectomy, vaginal salpingoophorectomy and uterosacral ligament colpopexy: a view from above (in English and Spanish). Int Urogynecol J 2016; 28:151-153. [PMID: 27503088 DOI: 10.1007/s00192-016-3102-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
Abstract
AIM OF THE VIDEO The aim of this video is to make vaginal hysterectomy (TVH), vaginal salpingoophorectomy and uterosacral ligament (USL) colpopexy approachable by showing the key procedural steps from both the vaginal and abdominal perspectives. METHODS This production shows TVH with salpingoophorectomy and USL colpopexy that was performed on a cadaver and filmed simultaneously from the vaginal and abdominal views. The video begins with an anatomy overview from the open abdomen and proceeds with the TVH. The anterior and posterior peritoneal entries, a technique to safely and easily access the adnexa, as well as the placement of USL suspension sutures are highlighted. The proximity of the ureter and its distance from the three locations most vulnerable to injury during this procedure (the uterine artery pedicle, the infundibulopelvic ligament and the USL) are illustrated. The location of the USL suspension sutures in relation to the ischial spine, the rectum and the sacrum are demonstrated. For all of these crucial steps, a series of picture-in-picture views simultaneously showing the abdominal and vaginal perspectives are presented so that the viewer may better understand the spatial anatomy. CONCLUSION This video provides the viewer with a unique anatomic perspective and helps more confidently perform TVH, vaginal salpingooophorectomy and USL colpopexy.
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Tolstrup CK, Lose G, Klarskov N. The Manchester procedure versus vaginal hysterectomy in the treatment of uterine prolapse: a review. Int Urogynecol J 2016; 28:33-40. [PMID: 27485234 DOI: 10.1007/s00192-016-3100-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Uterine prolapse is a common health problem and the number of surgical procedures is increasing. No consensus regarding the surgical strategy for repair of uterine prolapse exists. Vaginal hysterectomy (VH) is the preferred surgical procedure worldwide, but uterus-preserving alternatives including the Manchester procedure (MP) are available. The objective was to evaluate if VH and the MP are equally efficient treatments for uterine prolapse with regard to anatomical and symptomatic outcome, quality of life score, functional outcome, re-operation and conservative re-intervention rate, complications and operative outcomes. METHODS We systematically searched Embase, PubMed, the Cochrane databases, Clinicaltrials and Clinical trials register using the MeSh terms "uterine prolapse", "uterus prolapse", "vaginal prolapse" "pelvic organ prolapse", "prolapsed uterus", "Manchester procedure" and "vaginal hysterectomy". No limitations regarding language, study design or methodology were applied. In total, nine studies published from 1966 to 2014 comparing the MP to VH were included. RESULTS The anatomical recurrence rate for the middle compartment was 4-7 % after VH, whereas recurrence was very rare after the MP. The re-operation rate because of symptomatic recurrence was higher after VH (9-13.1 %) compared with MP (3.3-9.5 %) and more patients needed conservative re-intervention (14-15 %) than after MP (10-11 %). After VH, postoperative bleeding and blood loss tended to be greater, bladder lesions and infections more frequent and the operating time longer. CONCLUSIONS This review is in favour of the MP, which seems to be an efficient and safe treatment for uterine prolapse. We suggest that the MP might be considered a durable alternative to VH in uterine prolapse repair.
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Affiliation(s)
- Cæcilie Krogsgaard Tolstrup
- Department of Obstetrics and Gynecology, Herlev & Gentofte University Hospital, Herlev Ringvej 75, 2730, Herlev, Denmark.
| | - Gunnar Lose
- Department of Obstetrics and Gynecology, Herlev & Gentofte University Hospital and Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Niels Klarskov
- Department of Obstetrics and Gynecology, Herlev & Gentofte University Hospital and Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Cour F, Le Normand L, Meurette G. Traitement par voie basse des colpocèles postérieures : recommandations pour la pratique clinique. Prog Urol 2016; 26 Suppl 1:S47-60. [DOI: 10.1016/s1166-7087(16)30428-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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The Design of a Randomized Trial of Vaginal Surgery for Uterovaginal Prolapse: Vaginal Hysterectomy With Native Tissue Vault Suspension Versus Mesh Hysteropexy Suspension (The Study of Uterine Prolapse Procedures Randomized Trial). Female Pelvic Med Reconstr Surg 2016; 22:182-9. [PMID: 27054798 PMCID: PMC4919185 DOI: 10.1097/spv.0000000000000270] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES We present the rationale for and design of a randomized controlled superiority trial comparing 2 vaginal surgical approaches for the treatment of uterovaginal prolapse. The Study of Uterine Prolapse Procedures Randomized Trial (SUPeR) trial compares the efficacy and safety of native tissue repair with vaginal hysterectomy and suture apical suspension versus uterine conservation with mesh hysteropexy through 36 to 60 months postoperatively for primary repair of uterovaginal prolapse. METHODS The selection of the primary outcome measure, timing of randomization, patient and evaluator masking to surgical intervention, collection and adjudication of adverse events, cost effectiveness evaluations, partnering with industry, and surgeon certification of competency to perform the 2 procedures is described. A composite primary outcome of success defined as no prolapse symptoms, no objective prolapse beyond the hymen, and no retreatment of prolapse, with a minimum of 36 months postsurgery follow-up using survival analyses is planned. Secondary outcomes measured at baseline and every 6 months postsurgery include validated condition-specific and general quality of life assessments, global impression of improvement, body image, and sexual function measures. Unique challenges during the trial design include maintenance of patient masking to the intervention with routine gynecologic health maintenance and maintenance of evaluator masking. RESULTS Recruitment and randomization of 180 participants is complete, and participants are currently in the follow-up phase. CONCLUSIONS This trial will provide information to help surgeons counsel patients and contribute evidence-based information regarding risks and benefits of 2 approaches for the treatment of uterovaginal prolapse.
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Abstract
Surgical intervention for female voiding dysfunction is common, involving a single or multifaceted approach affecting multiple organ systems in the pelvis. Surgical success relies on knowledge of surgical history, anatomic approaches, and judicious use of supports or materials. Owing to the varied repairs used over the last few decades, it is important for the general surgeon to understand both current and historic approaches. This understanding will help in planning future pelvic surgery as well as in evaluating current ramifications of prior surgery.
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Affiliation(s)
- Ilija Aleksic
- Division of Urology, Albany Medical College, 23 Hackett Boulevard MC 208, Albany, NY 12208, USA
| | - Elise J B De
- Division of Urology, Albany Medical College, 23 Hackett Boulevard MC 208, Albany, NY 12208, USA.
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Lukacz ES, Warren LK, Richter HE, Brubaker L, Barber MD, Norton P, Weidner AC, Nguyen JN, Gantz MG. Quality of Life and Sexual Function 2 Years After Vaginal Surgery for Prolapse. Obstet Gynecol 2016; 127:1071-1079. [PMID: 27159758 PMCID: PMC4879084 DOI: 10.1097/aog.0000000000001442] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To longitudinally assess the effect of native tissue vaginal apical prolapse repair with anti-incontinence surgery on quality of life, sexual function, and body image between uterosacral and sacrospinous suspensions. METHODS A planned secondary analysis was performed on 374 women enrolled in a randomized trial of the two types of native tissue repair for apical prolapse. Condition-specific and generic quality of life, sexual function, overall and de novo dyspareunia, and body image were assessed using validated instruments at baseline; 6, 12, and 24 months postoperatively; and changes from baseline were assessed and compared between surgical groups. General linear mixed models were used for comparisons and clinically significant differences were assessed using minimum important differences. RESULTS Of the women randomized, 82% had outcomes available at 2 years. Overall, clinically and statistically significant improvements in generic and condition-specific quality of life and sexual function were observed after surgery. Dyspareunia rates decreased from 25% to 16% by 24 months with only 3% of all women undergoing treatment. De novo dyspareunia occurred in 5% and 10% by 12 and 24 months, respectively. Body image scores also significantly improved from baseline. There were no clinically meaningful or statistically significant differences between groups for any of these outcomes (all P>.05). CONCLUSION Native tissue vaginal prolapse surgery results in statistically and clinically significant improvements in quality of life, sexual function, and body image at 24 months with no significant differences between uterosacral and sacrospinous suspensions. One in 10 women experience de novo dyspareunia but few requested treatment. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00597935.
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Affiliation(s)
- Emily S Lukacz
- Department of Reproductive Medicine, University of California San Diego Health Systems, San Diego, California; Social, Statistical & Environmental Sciences, RTI International, Research Triangle Park, North Carolina; the Departments of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, University of Utah Medical Center, Salt Lake City, Utah, Duke Medical Center, Durham, North Carolina, and Southern California Kaiser Permanente, Downey, California; the Department of Obstetrics and Gynecology and Urology, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois; and Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
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Paz-Levy D, Yohay D, Neymeyer J, Hizkiyahu R, Weintraub AY. Native tissue repair for central compartment prolapse: a narrative review. Int Urogynecol J 2016; 28:181-189. [PMID: 27209309 DOI: 10.1007/s00192-016-3032-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 04/19/2016] [Indexed: 11/28/2022]
Abstract
Central descent due to a level 1 defect is a main component in pelvic organ prolapse (POP) reconstructive surgery, whether for symptomatic apical prolapse or for the prolapse repair of other compartments. A recent growth in the rate of native tissue repair procedures for POP, following the US Food and Drug Administration (FDA) warnings regarding the safety and efficacy of synthetic meshes, requires a re-evaluation of these procedures. The safety, efficacy, and determination of the optimal surgical approach should be the center of attention. Functional outcome measures and patient-centered results have lately gained importance and received focus. A comprehensive literature review was performed to evaluate objective and subjective outcomes of apical prolapse native tissue repair, with a special focus on studies reporting impact on patients' functional outcomes, quality of life, and satisfaction. We performed a MEDLINE search for articles in the English language by using the following key words: apical prolapse, sacrospinous ligament fixation, uterosacral ligament suspension, sacral colpopexy, McCall culdoplasty, iliococcygeus vaginal fixation, and functional outcomes. We reviewed references as well. Despite a prominent shortage of studies reporting standardized prospective outcomes for native tissue repair interventions, we noted a high rate of safety and efficacy, with a low complication rate for most procedures and low recurrence or re-treatment rates. The objective and subjective results of different procedures are reviewed. Functional outcomes of native tissue repair procedures have not been studied sufficiently, though existing data present those procedures as favorable and not categorically inferior to sacrocolpopexy. Apical compartment prolapse repair using native tissue is not a compromise. Functional outcomes of native tissue repair procedures are favorable, have a high rate of success, improve women's quality of life (QoL), and result in high rates of patient satisfaction. This subject requires further long-term, standardized prospective studies following the International Continence Society/International Urogynecologists Association guidelines for surgical outcomes report, with the focus on patient-centered functional outcomes.
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Affiliation(s)
- Dorit Paz-Levy
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - David Yohay
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Joerg Neymeyer
- Department of Urology, Charitè University, Berlin, Germany
| | - Ranit Hizkiyahu
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
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Maldonado PA, Stuparich MA, McIntire DD, Wai CY. Proximity of uterosacral ligament suspension sutures and S3 sacral nerve to pelvic landmarks. Int Urogynecol J 2016; 28:77-84. [DOI: 10.1007/s00192-016-3039-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/02/2016] [Indexed: 11/24/2022]
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125
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Milani R, Frigerio M, Manodoro S, Cola A, Spelzini F. Transvaginal uterosacral ligament hysteropexy: a retrospective feasibility study. Int Urogynecol J 2016; 28:73-76. [DOI: 10.1007/s00192-016-3036-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
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126
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Modified McCall culdoplasty versus Shull suspension in pelvic prolapse primary repair: a retrospective study. Int Urogynecol J 2016; 28:65-71. [DOI: 10.1007/s00192-016-3016-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 03/21/2016] [Indexed: 02/03/2023]
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Does Pelvic Organ Prolapse Quantification Examination D Point Predict Uterosacral Ligament Suspension Outcomes? Female Pelvic Med Reconstr Surg 2016; 22:146-50. [PMID: 26829342 DOI: 10.1097/spv.0000000000000245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The best predictors for postoperative anatomic apical success after transvaginal uterosacral ligament suspension remain unknown. The aim of this study was to determine if there is a correlation between the preoperative D point and anatomic outcomes for apical prolapse after 1 year. METHODS This retrospective cohort study included subjects undergoing transvaginal uterosacral ligament suspension from 2008 through 2013 who had at least 1 year follow-up. Demographic information, preoperative and postoperative Pelvic Organ Prolapse Quantification (POPQ) examination measurements, need for retreatment or repeat surgery, and assessment of pelvic floor symptoms were reviewed. Postoperative apical success was defined as C point descent no more than one third into the vaginal canal. RESULTS One hundred twenty-five women met inclusion criteria and had follow-up at 1 year or more. Concomitant procedures included anterior/posterior repair and midurethral sling. Mean follow-up time was 22.8 months (range, 12-63 months). At last follow-up, 96% met criteria for apical success. A more negative preoperative D point was significantly related to improved postoperative apical support, with each 1-cm descent in preoperative D point resulting in a postoperative C point that was 0.21 cm lower (P = 0.0005). Based on the receiver operating characteristic curve, a "cutoff" D point value of -4.25 (sensitivity, 0.8; specificity, 0.65) was determined to be a predictor of postoperative apical success at 1 year or more. CONCLUSIONS The preoperative D point correlates with postoperative apical support, and a clinically meaningful relationship exists between the preoperative D point and anatomic apical success.
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Comparison of complications and prolapse recurrence between laparoscopic and vaginal uterosacral ligament suspension for the treatment of vaginal prolapse. Int Urogynecol J 2015; 27:797-803. [PMID: 26658893 DOI: 10.1007/s00192-015-2897-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/15/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Our objective was to compare complications and prolapse recurrence between laparoscopic (L-USLS) and vaginal (V-USLS) uterosacral ligament suspensions. METHODS This is a retrospective study of USLS procedures performed at a large academic center from 2011 to 2014. Patient demographics, surgical data, complications, and prolapse recurrence of L-USLS and V-USLS were compared. Logistic regression identified predictors of operative time, complications, and prolapse recurrence. RESULTS There were 54 L-USLS and 119 V-USLS procedures with median follow-up of 21.5 weeks (IQR 9.3-50.8). Women undergoing L-USLS were less likely to have medical comorbidities and had less severe prolapse, but were more likely to report prior hysterectomy. L-USLS had longer operative times (190.1 ± 46.8 vs 172.7 ± 47.3 min, p = 0.03), but after correcting for concomitant procedures, the operative times of the two approaches were not significantly different (adjusted OR 1.00, 95%CI 0.99-1.00). There was no significant difference in complications between groups (24.1 % vs 21.8 %, p = 0.75). However, there were nonsignificant trends toward more ureteral injuries and suture removals following V-USLS. Postoperative POP-Q points of the groups did not differ, except for total vaginal length (TVL), which was longer after L-USLS (8.3 ± 1.1 cm vs 7.4 ± 1.2 cm, p < 0.001). 19 patients met the composite definition of prolapse recurrence, with no significant difference between groups (16.2 % vs 16 %, p = 0.98). After adjusting for preoperative prolapse stage, route was not a significant predictor of prolapse recurrence (adjusted OR 0.39, 95 % CI 0.12-1.30). CONCLUSIONS L-USLS has comparable clinical outcomes, with similar rates of complications and prolapse recurrence to the traditional vaginal approach.
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Ow LL, Walsh CE, Rajamaheswari N, Dwyer PL. Technique of extraperitoneal uterosacral ligament suspension for apical suspension. Int Urogynecol J 2015; 27:637-9. [PMID: 26612207 DOI: 10.1007/s00192-015-2873-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/16/2015] [Indexed: 11/28/2022]
Abstract
AIM OF THE VIDEO/INTRODUCTION Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky-Navratil retractor. METHODS This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension. CONCLUSIONS This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.
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Affiliation(s)
- Lin L Ow
- Department of Urogynaecology, Mercy Hospital for Women, 155 Studley Road, Heidelberg, Victoria, 3084, Australia.
| | - Caroline E Walsh
- Department of Urogynaecology, Mercy Hospital for Women, 155 Studley Road, Heidelberg, Victoria, 3084, Australia
| | | | - Peter L Dwyer
- Department of Urogynaecology, Mercy Hospital for Women, 155 Studley Road, Heidelberg, Victoria, 3084, Australia
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Risk factors for ureteral occlusion during transvaginal uterosacral ligament suspension. Int Urogynecol J 2015; 26:1809-14. [PMID: 26174656 DOI: 10.1007/s00192-015-2770-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/18/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To determine any risk factors associated with ureteral occlusion during transvaginal uterosacral ligament suspension (USLS). METHODS A retrospective query to identify patients that underwent transvaginal USLS at a teaching hospital from 2008 to 2013 was performed. Patients in which ureteral occlusion was identified by cystoscopy were identified (cases), and compared with those without occlusion (controls). Medical records were reviewed for data abstraction. Variables compared between cases and controls included demographics, medical history/examination, concomitant procedures, number of suspension sutures placed, estimated blood loss and length of hospital stay. Univariate analyses were performed to identify potential risk factors for ureteral occlusion, followed by multivariate regression analysis to estimate odds ratios for identified predictors. RESULTS A total of 144 USLS procedures were performed. Thirteen cases of ureteral occlusion were identified (9%). Baseline prolapse stage, body mass index, parity, previous hysterectomy or pelvic surgery of the groups were similar (all P > 0.05). Univariate analysis identified age (P = 0.04), concomitant anterior colporrhaphy (P = 0.01), and use of a suture-capturing device for suture placement (P = 0.04) as significant factors. On multivariate logistic regression analysis, concomitant anterior colporrhaphy increased ureteral occlusion risk (OR 10.5, 95%CI 2.37-74.99, P = 0.001), while use of a suture-capturing device decreased it (OR 0.1, 95%CI 0-0.41, P = 0.01). The mean number of suspension sutures placed per side was similar in the two groups (2.6 [range 2-4] for cases and 2.4 [range 1-4] for controls, P = 0.15). CONCLUSIONS During transvaginal USLS, performance of a concomitant anterior colporrhaphy increased the risk of ureteral occlusion, while the use of a suture-capturing device for suspension suture placement was associated with decreased risk.
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Tsai CP, Hung MJ, Shen PS, Chen GD, Su TH, Chou MM. Factors that affect early recurrence after prolapse repair by a nonanchored vaginal mesh procedure. Taiwan J Obstet Gynecol 2015; 53:337-42. [PMID: 25286787 DOI: 10.1016/j.tjog.2014.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2012] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE Prosima (Ethicon, Somerville, NJ, USA) is a novel procedure for treating pelvic organ prolapse (POP) that uses nonanchored vaginal mesh. However, nonfixation of the mesh may limit effectiveness. The aim of this study was to evaluate the safety, efficacy, and limitations of this procedure. MATERIALS AND METHODS From January 2011 through to December 2011, 52 patients with symptomatic POP ≥ Stage 2 undergoing the Prosima procedure at a tertiary hospital were enrolled consecutively in this prospective study. A Data and Safety Monitoring Plan (DSMP) was developed to assess the results. RESULTS Fifty of the 52 patients (96%) attended the 3-6-month postoperative assessment. Symptom and quality-of-life scores were found to have improved significantly after surgery (p < 0.05). Forty-two patients (84%) underwent successful treatment for POP (Stage 0-1). The other eight patients (16%) were found to have recurrent Stage 2 anterior vaginal wall prolapse, although most of them (5/8) were asymptomatic. The highest morbidity, namely vaginal mesh exposure, occurred in four patients (8%) and was managed as a minor issue. Statistical analysis showed that anatomic recurrence was significantly (p < 0.05) associated with a "preoperative Ba ≥ +4 cm" (odds ratio = 20.57), "conservation of the prolapsed uterus" (odds ratio = 10.56) and "use of a concomitant midurethral sling" (odds ratio = 0.076). CONCLUSION Prosima seems to have limitations when used to manage severe anterior vaginal wall prolapse and concomitant surgery may further affect its effectiveness. The information obtained from this study's DSMP will contribute to developing a strategy to improve the use of nonanchored vaginal mesh for POP repair.
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Affiliation(s)
- Ching-Pei Tsai
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Man-Jung Hung
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Obstetrics and Gynecology, Chung Shan Medical University School of Medicine, Taichung, Taiwan.
| | - Pao-Sheng Shen
- Department of Statistics, Tunghai University, Taichung, Taiwan
| | - Gin-Den Chen
- Department of Obstetrics and Gynecology, Chung Shan Medical University School of Medicine, Taichung, Taiwan
| | - Tsung-Hsien Su
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Min-Min Chou
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Obstetrics and Gynecology, Chung Shan Medical University School of Medicine, Taichung, Taiwan
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Pong J, Bohlin KS, Pedroletti C, Strandell A. Does anesthetic method influence vaginal bulge symptoms and patient satisfaction after vaginal wall repair surgery? Int Urogynecol J 2015; 26:1361-7. [PMID: 25941125 DOI: 10.1007/s00192-015-2715-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 04/02/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Surgery for pelvic organ prolapse (POP) under local anesthesia has been advocated for several reasons such as lower costs and application in multimorbid patients. The aim of this study was to investigate how the anesthetic method influences the rate of recurrent prolapse and patient satisfaction with POP surgery. METHODS In this retrospective study 4,936 women operated for single-compartment prolapse between 2006 and 2011 were included from the Swedish National Register for Gynecological Surgery. The feeling of vaginal bulge 1 year after surgery indicated presence of recurrent prolapse. Multivariate logistic regression analyses were used to identify independent factors affecting the outcomes, presented as adjusted odds ratios (aOR) with 95 % confidence interval (CI). RESULTS After surgery for single-compartment prolapse patients with cystocele were at a higher risk of feeling a vaginal bulge than patients with rectocele (1.62, CI 1.28-2.06). Applied anesthesia was no independent predictor of bulge symptoms in the cystocele/rectocele population. In the cystocele group local anesthesia compared with general or regional anesthesia implied an increased risk of vaginal bulge symptoms (1.32, CI 1.03-1.68) as well as POP-Q-stage III-IV (1.30, CI 1.09-1.55), and a higher BMI class (1.22, CI 1.03-1.46), while a higher age class decreased the risk (0.79, CI 0.70-0.89). Choice of anesthesia had no impact on bulge symptoms in the rectocele group and no influence on patient satisfaction in any of the groups. CONCLUSION Patients operated for cystocele under local anesthesia were at a higher risk of experiencing vaginal bulge symptoms 1 year after surgery compared with general or regional anesthesia.
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Affiliation(s)
- Joanna Pong
- The Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden,
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Unger CA, Walters MD, Ridgeway B, Jelovsek JE, Barber MD, Paraiso MFR. Incidence of adverse events after uterosacral colpopexy for uterovaginal and posthysterectomy vault prolapse. Am J Obstet Gynecol 2015; 212:603.e1-7. [PMID: 25434838 DOI: 10.1016/j.ajog.2014.11.034] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 11/01/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Abstract
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.
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High uterosacral vault suspension vs Sacrocolpopexy for treating apical defects: a randomized controlled trial with twelve months follow-up. Int Urogynecol J 2015; 26:1131-8. [DOI: 10.1007/s00192-015-2666-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 12/22/2014] [Indexed: 10/23/2022]
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Iliococcygeus fixation for the treatment of apical vaginal prolapse: efficacy and safety at 5 years of follow-up. Int Urogynecol J 2015; 26:1007-12. [PMID: 25653034 DOI: 10.1007/s00192-015-2629-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/07/2015] [Indexed: 11/26/2022]
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Coskun B, Lavelle RS, Alhalabi F, Christie AL, Zimmern PE. Anterior Vaginal Wall Suspension Procedure for Moderate Bladder and Uterine Prolapse as a Method of Uterine Preservation. J Urol 2014; 192:1461-7. [DOI: 10.1016/j.juro.2014.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Burhan Coskun
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas
| | | | - Feras Alhalabi
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas
| | - Alana L. Christie
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas
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Abstract
Quality of life is adversely affected by pelvic organ prolapse, the prevalence of which is increasing because of the persistently growing older population. Today, the tension-free vaginal mesh kit has grown in popularity owing to its comparable cure rate to traditional reconstructive surgery and the feasibility of an early return to normal life. However, significant debate remains over the long-term cure rate and the safety of tension-free vaginal mesh in the United States. The U.S. Food and Drug Administration recommends obtaining informed consent about the safety and cure rate when the patient chooses surgery using the tension-free vaginal mesh kit or meshes before surgery. The goal of surgery for pelvic organ prolapse is the restoration of anatomic defects. This review article provides an overview of basic surgical techniques and the results, advantages, and disadvantages of surgery for pelvic organ prolapse.
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Affiliation(s)
- Kyung Hwa Choi
- Department of Urology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jae Yup Hong
- Department of Urology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Effects of Horizontal vs Vertical Vaginal Cuff Closure Techniques on Vagina Length After Vaginal Hysterectomy: A Prospective Randomized Study. J Minim Invasive Gynecol 2014; 21:884-7. [DOI: 10.1016/j.jmig.2014.03.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 03/21/2014] [Accepted: 03/30/2014] [Indexed: 11/18/2022]
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Abstract
INTRODUCTION AND HYPOTHESIS The aim was to review the safety and efficacy of pelvic organ prolapse surgery for vaginal apical prolapse. METHODS Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials (RCT) or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. RESULTS Abdominal sacral colpopexy (ASC) has a higher success rate than sacrospinous colpopexy with less SUI and postoperative dyspareunia for vault prolapse. ASC had greater morbidity including operating time, inpatient stay, slower return to activities of daily living and higher cost (grade A). ASC has the lowest inpatient costs compared with laparoscopic sacral colpopexy (LSC) and robotic sacral colpopexy (RSC). LSC has lower inpatient costs than RSC (grade B).In single RCTs the RSC had longer operating time than both ASC and LSC (grade B). In small trials objective outcomes appear similar although postoperative pain was greater in RSC. LSC is as effective as ASC with reduced blood loss and admission time (grade C). The data relating to operating time are conflicting. ASC performed with polypropylene mesh has superior outcomes to fascia lata (level I), porcine dermis and small intestine submucosa (level 3; grade B). In a single RCT, LSC had a superior objective and subjective success rate and lower reoperation rate compared with polypropylene transvaginal mesh for vault prolapse (grade B).Level 3 evidence suggests that vaginal uterosacral ligament suspension, McCall culdoplasty, iliococcygeus fixation and colpocleisis are relatively safe and effective interventions (grade C). CONCLUSION Sacral colpopexy is an effective procedure for vault prolapse and further data are required on the route of performance and efficacy of this surgery for uterine prolapse. Polypropylene mesh is the preferred graft at ASC. Vaginal procedures for vault prolapse are well described and are suitable alternatives for those not suitable for sacral colpopexy.
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Laparoscopic uterosacral ligament suspension and sacral colpopexy: results and complications. Int Urogynecol J 2014; 25:1645-53. [DOI: 10.1007/s00192-014-2407-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/13/2014] [Indexed: 11/26/2022]
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Yousuf A, Chen L, Larson K, Ashton-Miller JA, DeLancey JOL. The length of anterior vaginal wall exposed to external pressure on maximal straining MRI: relationship to urogenital hiatus diameter, and apical and bladder location. Int Urogynecol J 2014; 25:1349-56. [PMID: 24737299 DOI: 10.1007/s00192-014-2372-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/07/2014] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS In cystoceles, the distal anterior vaginal wall (AVW) bulges out through the introitus and is no longer in contact with the posterior vaginal wall or perineal body, exposing the pressure differential between intra-abdominal pressure and atmospheric pressure. The goal of this study is to quantify the length of the exposed vaginal wall length and to investigate its relationship with other factors associated with the AVW support, such as most dependent bladder location, apical location, and hiatus diameter, demonstrating its key role in cystocele formation. METHODS Fifty women were selected to represent a full spectrum of AVW support. Each underwent supine, dynamic MR imaging. Most dependent bladder location and apical location were measured relative to the average normal position on the mid-sagittal plane using the Pelvic Inclination Correction System . The length of the exposed AVW and the hiatus diameter were measured as well. The relationship between exposed AVW and most dependent bladder location, apical location, and hiatus diameter were examined. RESULTS A bilinear relationship has been observed between exposed vaginal wall length and most dependent bladder location (R(2) = 0.91, P < 0.001). When the bladder descents up to the inflection point (about 4.4 cm away from its normal position), there is little change in the exposed AVW length. With further descent, the exposed vaginal wall length increases significantly, with a 2 cm increase in exposed AVW length for every additional 1 cm of drop bladder location. A similar but weaker bilinear relationship exists between exposed AVW and apical location. Exposed vaginal wall length is also highly correlated with hiatus diameter (R(2) = 0.85, P < 0.001). CONCLUSION A bilinear relationship exists between exposed vaginal wall length and most dependent bladder location and apical location. It is when the bladder descent is beyond the inflection point that exposed vaginal wall length increases significantly.
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Affiliation(s)
- Aisha Yousuf
- Department of Obstetrics and Gynecology (Pelvic Floor Research Group), University of Michigan Hospital, Ann Arbor, MI, 48109, USA
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Barber MD, Brubaker L, Burgio KL, Richter HE, Nygaard I, Weidner AC, Menefee SA, Lukacz ES, Norton P, Schaffer J, Nguyen JN, Borello-France D, Goode PS, Jakus-Waldman S, Spino C, Warren LK, Gantz MG, Meikle SF. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA 2014; 311:1023-34. [PMID: 24618964 PMCID: PMC4083455 DOI: 10.1001/jama.2014.1719] [Citation(s) in RCA: 283] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE More than 300,000 surgeries are performed annually in the United States for pelvic organ prolapse. Sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) are commonly performed transvaginal surgeries to correct apical prolapse. Little is known about their comparative efficacy and safety, and it is unknown whether perioperative behavioral therapy with pelvic floor muscle training (BPMT) improves outcomes of prolapse surgery. OBJECTIVE To compare outcomes between (1) SSLF and ULS and (2) perioperative BPMT and usual care in women undergoing surgery for vaginal prolapse and stress urinary incontinence. DESIGN, SETTING, AND PARTICIPANTS Multicenter, 2 × 2 factorial, randomized trial of 374 women undergoing surgery to treat both apical vaginal prolapse and stress urinary incontinence was conducted between 2008 and 2013 at 9 US medical centers. Two-year follow-up rate was 84.5%. INTERVENTIONS The surgical intervention was transvaginal surgery including midurethral sling with randomization to SSLF (n = 186) or ULS (n = 188); the behavioral intervention was randomization to receive perioperative BPMT (n = 186) or usual care (n = 188). MAIN OUTCOMES AND MEASURES The primary outcome for the surgical intervention (surgical success) was defined as (1) no apical descent greater than one-third into vaginal canal or anterior or posterior vaginal wall beyond the hymen (anatomic success), (2) no bothersome vaginal bulge symptoms, and (3) no re-treatment for prolapse at 2 years. For the behavioral intervention, primary outcome at 6 months was urinary symptom scores (Urinary Distress Inventory; range 0-300, higher scores worse), and primary outcomes at 2 years were prolapse symptom scores (Pelvic Organ Prolapse Distress Inventory; range 0-300, higher scores worse) and anatomic success. RESULTS At 2 years, surgical group was not significantly associated with surgical success rates (ULS, 59.2% [93/157] vs SSLF, 60.5% [92/152]; unadjusted difference, -1.3%; 95% CI, -12.2% to 9.6%; adjusted odds ratio [OR], 0.9; 95% CI, 0.6 to 1.5) or serious adverse event rates (ULS, 16.5% [31/188] vs SSLF, 16.7% [31/186]; unadjusted difference, -0.2%; 95% CI, -7.7% to 7.4%; adjusted OR, 0.9; 95% CI, 0.5 to 1.6). Perioperative BPMT was not associated with greater improvements in urinary scores at 6 months (adjusted treatment difference, -6.7; 95% CI, -19.7 to 6.2), prolapse scores at 24 months (adjusted treatment difference, -8.0; 95% CI, -22.1 to 6.1), or anatomic success at 24 months. CONCLUSIONS AND RELEVANCE Two years after vaginal surgery for prolapse and stress urinary incontinence, neither ULS nor SSLF was significantly superior to the other for anatomic, functional, or adverse event outcomes. Perioperative BPMT did not improve urinary symptoms at 6 months or prolapse outcomes at 2 years. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00597935.
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Affiliation(s)
- Matthew D Barber
- Obstetrics/Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Linda Brubaker
- Departments of Obstetrics and Gynecology and Urology, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Kathryn L Burgio
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham4Department of Veterans Affairs, Birmingham, Alabama
| | - Holly E Richter
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham
| | - Ingrid Nygaard
- Department of Obstetrics and Gynecology, University of Utah, Medical Center, Salt Lake City
| | - Alison C Weidner
- Department of Obstetrics and Gynecology, Duke University, Medical Center, Durham, North Carolina
| | - Shawn A Menefee
- Department of Obstetrics and Gynecology, Southern California Kaiser Permanente, San Diego
| | - Emily S Lukacz
- Department of Reproductive Medicine, University of California San Diego Health Systems
| | - Peggy Norton
- Department of Obstetrics and Gynecology, University of Utah, Medical Center, Salt Lake City
| | - Joseph Schaffer
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - John N Nguyen
- Department of Obstetrics and Gynecology, Southern California Kaiser Permanente, Downey
| | | | - Patricia S Goode
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham4Department of Veterans Affairs, Birmingham, Alabama
| | - Sharon Jakus-Waldman
- Department of Obstetrics and Gynecology, Southern California Kaiser Permanente, Downey
| | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor
| | - Lauren Klein Warren
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, North Carolina
| | - Marie G Gantz
- Social, Statistical, and Environmental Sciences, RTI International, Research Triangle Park, North Carolina
| | - Susan F Meikle
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Cosma S, Menato G, Preti M, Petruzzelli P, Chiadò Fiorio Tin M, Riboni F, Benedetto C. Advanced utero-vaginal prolapse and vaginal vault suspension: synthetic mesh vs native tissue repair. Arch Gynecol Obstet 2013; 289:1053-60. [DOI: 10.1007/s00404-013-3104-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 11/18/2013] [Indexed: 11/28/2022]
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Functional and anatomic comparison of 2 versus 3 suture placement for uterosacral ligament suspension: a cadaver study. Am J Obstet Gynecol 2013; 209:486.e1-5. [PMID: 23770468 DOI: 10.1016/j.ajog.2013.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 05/17/2013] [Accepted: 06/07/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of the study was to compare the vaginal apex pullout distance using 2 vs 3 suspension sutures during transvaginal uterosacral ligament suspension (USLS) and to describe relationships to ipsilateral ureter and nerve structures. STUDY DESIGN Eight fresh-frozen female cadavers were studied. After hysterectomy, a transvaginal USLS was performed with placement of 3 suspension sutures per side. The 2 most distal sutures on each ligament were tied. A screw-and-washer attachment was secured in the middle of the vaginal cuff and tied to a pulley system with surgical filament. Distal traction was applied with sequentially increasing weight loads. Distal migration of the vaginal apex from baseline with each weight load was recorded. The most proximal suspension suture was tied and the procedure repeated. Horizontal distances between each USLS suture to the ipsilateral ureter were measured. Three discrete points were marked on sacral nerves S1-S3, and the shortest distance between each point and each ipsilateral USLS suture was measured. Descriptive statistics and repeated-measures analysis of variance were performed. RESULTS Application of each load resulted in greater migration distances for the 2 suture configuration when compared with 3 sutures (P < .05). Differences were greatest for the 3 kg load (mean ± SEM, 2.0 ± 0.2 vs 1.5 ± 0.1 cm, respectively). Distances to ipsilateral ureter between the 2 most cranial sutures were comparable (P > .05). The most cranial USLS suture was closest to sacral nerves S1-S3. CONCLUSION In this cadaveric study, 3 USLS sutures provided more support to the vaginal apex than 2 sutures, although the absolute difference may not be clinically significant. The most cranial suture had the smallest distances to sacral nerves S1-S3.
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Luo J, Betschart C, Chen L, Ashton-Miller JA, DeLancey JOL. Using stress MRI to analyze the 3D changes in apical ligament geometry from rest to maximal Valsalva: a pilot study. Int Urogynecol J 2013; 25:197-203. [PMID: 24008367 DOI: 10.1007/s00192-013-2211-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 08/10/2013] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS A method was developed using 3D stress magnetic resonance imaging (MRI) and was piloted to test hypotheses concerning changes in apical ligament lengths and lines of action from rest to maximal Valsalva. METHODS Ten women with (cases) and ten without (controls) pelvic organ prolapse (POP) were selected from an ongoing case-control study. Supine, multiplanar stress MRI was performed at rest and at maximal Valsalva and was imported into 3D Slicer v. 3.4.1 and aligned. The 3D reconstructions of the uterus and vagina, cardinal ligament (CL), deep uterosacral ligament (USL(d)), and pelvic bones were created. Ligament length and orientation were then measured. RESULTS Adequate ligament representations were possible in all 20 study participants. When cases were compared with controls, the curve length of the CL at rest was 71 ±16 mm vs. 59 ± 9 mm (p = 0.051), and the USL(d)was 38 ± 16 mm vs. 36 ± 11 mm (p = 0.797). Similarly, the increase in CL length from rest to strain was 30 ± 16 mm vs. 15 ± 9 mm (p = 0.033), and USL(d) was 15 ± 12 mm vs. 7 ± 4 mm (p = 0.094). Likewise, the change in USL(d) angle was significantly different from CL (p < 0.001). CONCLUSIONS This technique allows quantification of 3D geometry at rest and at strain. In our pilot sample, at maximal Valsalva, CL elongation was greater in cases than controls, whereas USL(d) was not; CL also exhibited greater changes in ligament length, and USL(d) exhibited greater changes in ligament inclination angle.
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Affiliation(s)
- Jiajia Luo
- Pelvic Floor Research Group, University of Michigan, Ann Arbor, MI, USA,
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Takase-Sanchez MM, Hale DS. Minimally Invasive Pelvic Reconstructive Surgery: A Literature Review of Laparoscopic Surgery for Pelvic Organ Prolapse. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2013. [DOI: 10.1007/s13669-013-0050-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Osborn DJ, Reynolds WS, Dmochowski R. Vaginal approaches to pelvic organ prolapse repair. Curr Opin Urol 2013; 23:299-305. [DOI: 10.1097/mou.0b013e3283619e1a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Vaginal prolapse recurrence after uterosacral ligament suspension in normal-weight compared with overweight and obese women. Obstet Gynecol 2013; 121:554-559. [PMID: 23635618 DOI: 10.1097/aog.0b013e3182839eeb] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare recurrent prolapse after vaginal uterosacral ligament suspension in normal-weight compared with overweight or obese women. METHODS We performed a retrospective cohort study of the risk of recurrent prolapse after uterosacral ligament suspension in normal-weight compared with overweight or obese women at our institution from December 1, 1996, through June 30, 2011. Women with fewer than 6 months of follow-up and those with a prior vault suspension were excluded. Our primary outcome was a composite measure defined as anterior, posterior, or apical prolapse recurrence extending beyond the hymen or repeat treatment for prolapse with surgery or a pessary in women undergoing uterosacral ligament suspension and other vaginal repairs. RESULTS We included 219 participants (81 [37%] normal-weight and 138 [63%] overweight or obese women). There was no difference in median follow-up (14 months; interquartile range 8.5-26.5 months] in the normal-weight compared with 13 months [interquartile range 9.0-29.0 months] in the overweight or obese women, P=.98). Prolapse recurred in 22.2% (n=18) of the normal-weight group and 26.1% (n=36) of the overweight or obese group (P=.52). Surgery for recurrent prolapse was performed in 16.0% (n=13) of the normal-weight women and in 14.5% (n=20) of the overweight or obese women (P=.76). The most common site of recurrence was the anterior compartment (17.4% [n=38]) compared with the apical compartment (8.7% [n=19]) or posterior compartment (6.8% [n=15]) with no significant difference between cohorts. CONCLUSIONS After uterosacral ligament suspension, overweight or obese women have similar prolapse recurrence compared with normal-weight women. Anterior prolapse is the most common site of recurrence after uterosacral ligament suspension.
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Balgobin S, Good MM, Dillon SJ, Corton MM. Lowest colpopexy sacral fixation point alters vaginal axis and cul-de-sac depth. Am J Obstet Gynecol 2013; 208:488.e1-6. [PMID: 23500452 DOI: 10.1016/j.ajog.2013.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Revised: 02/04/2013] [Accepted: 03/07/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine the variation in vaginal axis and posterior cul-de-sac depth when the lowest suture used to attach the sacrocolpopexy mesh to the anterior longitudinal ligament is anchored at different levels. STUDY DESIGN At five lumbosacral mesh attachment sites, the anterior vaginal wall axis angle was measured relative to a line between the lowest border of the pubic symphysis and fourth sacral (S4) foramen in 9 unembalmed cadavers. The vertical distance from S4 to the posterior mesh was measured as a surrogate of cul-de-sac depth. RESULTS From a mesh fixation point at the lower border of S2 to a point at the lower border of L5, there was a 3-fold increase in both vaginal axis angle (13.04 ± 3.19 vs 42.88 ± 4.16 cm) and distance from S4 to the posterior mesh (2.50 ± 0.61 vs 7.38 ± 1.30 cm) between these points. CONCLUSION During sacrocolpopexy, progressively cephalad sacral attachment increases vaginal axis angle and cul-de-sac depth.
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