A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments

Lowest colpopexy sacral fixation point alters vaginal axis and cul-de-sac depth

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.

A randomized trial of prophylactic uterosacral ligament suspension at the time of hysterectomy for Prevention of Vaginal Vault Prolapse (PULS): design and methods

The primary aim of this randomized trial is to evaluate whether a standardized uterosacral ligament suspension colpopexy (USLSC), added to a planned hysterectomy for an indication other than pelvic organ prolapse (POP), decreases the rate of subsequent vaginal vault prolapse in women without preoperative symptomatic POP. Secondary aims include comparison of perioperative complications, urinary, bowel and sexual functions between subjects with and without concomitant USLSC. If shown to be beneficial, the cost-effectiveness of prophylactic USLSC at the time of hysterectomy will be evaluated. This trial will be performed at 4 centers across the United States. The data will be analyzed by the data-coordinating center of the Southern California Kaiser Permanente. Standardized questionnaires and objective measurements will be obtained. The patients and providers performing assessments are masked to treatment assignment. The primary outcome, defined as absence of POP at/distal to the hymen on Pelvic Organ Prolapse Quantitative examination, will be determined 12 months post-operatively. Secondary outcomes include: no prolapse symptoms by questionnaires, and no treatment for POP besides the prophylactic study intervention. Additional follow-up occurs annually for a total of 5 years. Accrual is projected to take 3 years. Given cost and morbidity of surgical repair of post-hysterectomy prolapse, preventive strategies are of outmost importance. The risks and benefits of prophylactic USLSC have never been studied prospectively. This trial is designed to determine if USLSC is an appropriate clinical adjunct at the time of hysterectomy, with subsequent reduction of symptomatic POP.

Lack of preoperative predictors of the immediate return of postoperative bladder emptying after uterosacral ligament suspension

OBJECTIVES

To determine whether preoperative postvoid residual volume (PVR), pelvic organ prolapse quantification (POPQ) stage, patient characteristics, or concurrent operations are predictors of immediate postoperative bladder emptying after uterosacral ligament suspension (USLS).

METHODS

A review of patients undergoing USLS in 2008 and 2009 was performed. The factors analyzed included patient age, body mass index, parity, preoperative PVR, POPQ stage, concurrent anterior repair, posterior repair, hysterectomy and/or sling procedures, and postoperative voiding trial status.

RESULTS

During the study interval, 151 patients underwent USLS with various combinations of concurrent procedures. The mean preoperative PVR was 90 mL. Seventy-five patients (50%) passed the postoperative voiding trial on postoperative day 1. Patients who passed the postoperative voiding trial and those who failed had similar average preoperative PVR (P = 0.94), similar age (P = 0.14), body mass index (P = 0.45), parity (P = 0.82), and preoperative POPQ stage (P = 0.80). There was no difference (P ≥ 0.14) among concurrent surgical procedures in the proportion of patients who passed the postoperative voiding trial based on univariate analyses.

CONCLUSIONS

In our cohort of patients, preoperative PVR, POPQ stage, and other patient characteristics were not predictors of immediate postoperative bladder emptying after USLS. Postoperative voiding function is one of the most unpredictable aspects of pelvic reconstructive surgery.

Where to for pelvic organ prolapse treatment after the FDA pronouncements? A systematic review of the recent literature

INTRODUCTION

With the publication of the updated US Food and Drug Administration (FDA) communication in 2011 on the use of transvaginal placement of mesh for pelvic organ prolapse (POP) it is appropriate to now review recent studies of good quality on POP to assess the safety and effectiveness of treatment options and determine their place in management.

METHODS

A systematic search for studies on the conservative and surgical management of POP published in the English literature between January 2002 and October 2012 was performed. Studies included were review articles, randomized controlled trials, prospective and relevant retrospective studies as well as conference abstracts. Selected articles were appraised by the authors regarding clinical relevance.

RESULTS

Prospective comparative studies show that vaginal pessaries constitute an effective and safe treatment for POP and should be offered as first treatment of choice in women with symptomatic POP. However, a pessary will have to be used for the patient's lifetime. Abdominal sacral colpopexy is effective in treating apical prolapse with an acceptable benefit-risk ratio. This procedure should be balanced against the low but non-negligible risk of serious complications. The results of native tissue vaginal POP repair are better than previously thought with high patient satisfaction and acceptable reoperation rates. The insertion of mesh at the time of anterior vaginal wall repair reduces the awareness of prolapse as well as the risk of recurrent anterior prolapse. There is no difference in anatomic and subjective outcome when native tissue vaginal repairs are compared with multicompartment vaginal mesh. Mesh exposure is still a significant problem requiring surgical excision in approximately ≥ 10 % of cases. The ideal mesh has not yet been found necessitating more basic research into mesh properties and host response. Several studies indicate that greater surgical experience is correlated with fewer mesh complications. In women with uterovaginal prolapse uterine preservation is a feasible option which women should be offered. Randomized studies with long-term follow-up are advisable to establish the place of uterine preservation in POP surgery.

CONCLUSION

Over the last decade treatment of POP has been dominated by the use of mesh. Conservative treatment is the first option in women with POP. Surgical repair with or without mesh generally results in good short-term objective and functional outcomes. However, basic research into mesh properties with host response and comparative studies with long-term follow-up are urgently needed.

Vaginal Vault Suspension at Hysterectomy for Prolapse - Myths and Facts, Anatomical Requirements, Fixation Techniques, Documentation and Cost Accounting

Vaginal vault suspension during hysterectomy for prolapse is both a therapy for apical insufficiency and helps prevent recurrence. Numerous techniques exist, with different anatomical results and differing complications. The description of the different approaches together with a description of the vaginal vault suspension technique used at the Department for Urogynaecology at St. Hedwig Hospital could serve as a basis for reassessment and for recommendations by scientific associations regarding general standards.

Surgery for pelvic organ prolapse

OBJECTIVES

: Surgery for pelvic organ prolapse (POP) is common with increasing high-quality evidence to guide surgical practice. Yet many important basic questions remain, including the optimal timing for POP surgery, the optimal preoperative evaluation of urinary tract function, and the postoperative outcome assessment. This manuscript reviews traditional surgical approaches for POP.

METHODS

: Formal and hand-searching of prolapse literature was conducted by the committee on Pelvic Organ Prolapse Surgery for the most recent International Consultation on Incontinence. The committee (authors) was composed of prolapse specialists from around the world. Consensus recommendations were made following literature abstraction.

RESULTS

: Surgical correction of POP can be divided into 2 main categories as follows: reconstructive procedures to correct anterior and posterior wall defects and resuspend the vaginal apex or obliterative procedures to close off the vagina. Reconstructive surgery may use the vaginal route or the abdominal route.

CONCLUSIONS

: In addition to recommendations within the report, the committee reaffirms that in planning surgery, the individual patient's risk for surgery, risk of recurrence, previous treatments, and surgical goals are all considered in deciding on obliterative versus reconstructive procedures, and in deciding whether the vaginal or the abdominal approach will be used for reconstructive repairs.

Surgical options for apical prolapse repair

Pelvic organ prolapse is a common medical condition that affects the quality of life of many women. Approximately 50% of parous women have pelvic organ prolapse and the lifetime risk for surgical intervention is 6.7% at the age of 80 years. In the USA, the number of women at risk for symptomatic prolapse is increasing, which is consistent with the recent increase in the overall number of prolapse and incontinence procedures being performed. Although prolapse is usually multicompartmental and isolated defects are rare, the apical compartment deserves special attention because apical support is integral to a durable prolapse repair. Since many women may initially present to their primary care physicians, all members of the medical community should have a basic understanding of the diagnosis and treatment for apical prolapse.

Uterine preservation in pelvic organ prolapse using robot assisted laparoscopic sacrohysteropexy: quality of life and technique

OBJECTIVE

Measuring quality of life of women with disorders of the pelvic floor is crucial when evaluating a therapy. The aim of this study is to profile health related quality of life of women with pelvic organ prolapse who are treated with robot assisted laparoscopic sacrohysteropexy (RALS). We also compare the operative characteristics and learning curve in this study with the current literature and describe the surgical technique.

STUDY DESIGN

A prospective cohort study in a teaching hospital in The Netherlands. Fifty women with uterovaginal prolapse were treated with RALS. This study presents the largest cohort in Europe treated by RALS to date. Quality of life was assessed pre- and post-operatively using the UDI/IIQ validated self-questionnaire designed for Dutch-speaking patients. Clinical and operative data were prospectively collected up to 29 months. RALS was performed with preservation of the uterus. Statistical analysis of categorical data was performed with the paired T-test. Descriptive statistics were computed with the use of standard methods for means, median and proportions.

RESULTS

Before operation, overall wellbeing was scored at 67.7% and after surgery this improved to 82.1% (p=0.03). Feelings of nervousness, frustration and embarrassment reduced significantly. Sexual functioning improved, but not significantly. The mean operative time was 223 (103-340) min. Operative time decreased significantly with gained experience and became comparable to the operative time for abdominal sacrocolpopexy and classic laparoscopy. Average blood loss was less than 50 ml and patients had a mean hospital stay of 2 days. Of all women, 95.2% were very satisfied with the result after RALS.

CONCLUSION

Health related quality of life improves significantly after RALS. There are high rates of patient satisfaction. RALS proves to be a safe and effective treatment of pelvic organ prolapse. Operative time is comparable to abdominal sacrocolpopexy and classic laparoscopy in the current literature.

Recognition and management of nerve entrapment pain after uterosacral ligament suspension

OBJECTIVE

To estimate the incidence, risk factors, and characteristics of neuropathic pain related to nerve entrapment after uterosacral ligament suspension.

METHOD

A review of patients who underwent uterosacral ligament suspension from January 2007 to August 2011 was performed. Patients with neuropathic pain attributable to nerve entrapment from uterosacral ligament suspensory suture placement were identified. Factors including surgeon's dominant hand, side of pain, onset of pain, day of suture removal, number of sutures placed and removed, patient age, and body mass index (BMI) were collected. Follow-up of patients with neuropathic pain was performed at postoperative visits and by telephone contact.

RESULT

Eight (1.6%) of 515 patients had neuropathic pain requiring suture removal from the affected side. The postoperative pain was recognized after discontinuation of intravenous narcotics on postoperative day 1. Patients reported their pain improved after removal of all sutures on the affected side. Patients with neuropathic pain did not differ from those without in regard to age, BMI, and preoperative prolapse stage, or in the number of sutures placed. None of the eight had recurrent pelvic organ prolapse (POP), with a median follow-up of 5 months.

CONCLUSION

Eight patients (1.6%) had postoperative neuropathic pain that resolved after all sutures were removed on the affected side. The removal of sutures was not associated with recurrent POP in the short-term.

LEVEL OF EVIDENCE

II.

Comparative analysis of pelvic ligaments: a biomechanics study

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) affects one third of women of all ages and is a major concern for gynecological surgeons. In pelvic reconstructive surgery, native ligaments are widely used as a corrective support, while their biomechanical properties are unknown. We hypothesized differences in the strength of various pelvic ligaments and therefore, aimed to evaluate and compare their biomechanical properties.

MATERIALS AND METHODS

Samples from the left and right broad, round, and uterosacral ligaments from 13 fresh female cadavers without pelvic organ prolapse were collected. Uniaxial tension tests at a constant rate of deformation were performed and stress-strain curves were obtained.

RESULTS

We observed a non-linear stress-strain relationship and a hyperelastic mechanical behavior of the tissues. The uterosacral ligaments were the most rigid whether at low or high deformation, while the round ligament was more rigid than the broad ligament.

CONCLUSION

Pelvic ligaments differ in their biomechanical properties and there is fairly good evidence that the uterosacral ligaments play an important role in the maintenance of pelvic support from a biomechanical point of view.

Sensory neuropathy following suspension of the vaginal apex to the proximal uterosacral ligaments

INTRODUCTION AND HYPOTHESIS

Reports of sensory neuropathy attributed to uterosacral ligament suspension (USLS) have emerged. The objectives of this study were to assess the rate of sensory neuropathy symptoms following transvaginal USLS at a single institution during a 5-year period and to describe the evaluation, management, and outcomes in these patients.

METHODS

A retrospective review of records identified 278 women who underwent transvaginal USLS during the study period. Inpatient and outpatient records within the first 4 weeks postsurgery were reviewed. Women with new-onset buttock and/or lower-extremity pain, numbness, weakness or a combination of these symptoms were identified. Demographic data, intraoperative data, and management modalities and outcomes were collected.

RESULTS

Nineteen (6.8 %) women met criteria for inclusion. The most common symptom was buttock pain (73.7 % of cases). Pain radiation to the ipsilateral posterior thigh was present in 11 cases (57.9 %). The majority of women (73.7 %) reported pain symptoms on the right side. Conservative treatment modalities were initially implemented in all women. Four women (21 %) underwent suture removal a median of 1.75 months after USLS. Full symptom resolution was reported in 13 (68.4 %) women a median of 6 months after USLS. The remaining women experienced partial symptom resolution with ongoing conservative management.

CONCLUSIONS

Sensory neuropathy is common in women who undergo transvaginal USLS. As quality of life may be significantly affected, any symptoms of buttock or lower-extremity pain in the immediate postoperative period warrant a thorough evaluation and close follow-up, with early suture removal consideration.

A novel transvaginal approach to correct recurrent apical prolapse after failed sacral colpopexy: case series

INTRODUCTION AND HYPOTHESIS

The objective of the study was to describe the transvaginal approach utilizing the existing sacral colpopexy (SC) graft for recurrent apical prolapse following failed SC.

METHODS

Twenty-two patients with recurrent vaginal vault prolapse following a prior SC were treated between January 2000 and December 2009. Twelve patients had a standard uterosacral ligament cuff suspension (USLS) performed. In ten patients, the vaginal cuff was suspended to the left uterosacral ligament and reattached to the graft material from the prior SC. One of these ten subsequently failed and a standard USLS was performed. Patient characteristics, preoperative pelvic floor assessment, operative information, and postoperative follow-up were collected. Cases in which the graft material was used were compared with those undergoing standard USLS.

RESULTS

Demographic characteristics and preoperative Baden-Walker scores were similar. Of 23 cases, 21 (91 %) were a consequence of graft separation from the vagina and not the sacrum. Two of nine patients with follow-up where the SC graft was utilized transvaginally had recurrent prolapse. One required reoperation. Of 13 patients in the group that underwent traditional USLS, 2 had asymptomatic recurrent anterior prolapse; neither required additional surgery.

CONCLUSIONS

A transvaginal surgical approach for recurrent vaginal prolapse after a history of failed abdominal SC should be considered. If feasible, the SC graft material can be used when performing USLS instead of the right uterosacral ligament for these patients with a prior history of abdominal SC.

Hysteropexy compared to hysterectomy for uterine prolapse surgery: does durability differ?

INTRODUCTION AND HYPOTHESIS

The aim of this study is to assess the impact of hysterectomy on durability of uterine prolapse repair by comparing hysterectomy/uterosacral cuff suspension (VH) to a new vaginal uterosacral hysteropexy (USH).

METHODS

A retrospective chart review of uterine prolapse patients after USH or VH with concomitant procedures as indicated was conducted, analyzing Baden-Walker grading of apex, anterior, and posterior compartments (Kaplan-Meier analysis) Baden et al. (Tex Med 64(5):56-58, 1968).

RESULTS

A total of 200 charts met criteria. USH women weighed less, were younger, and more constipated with larger rectoceles. Levator parameters did not differ Romanzi et al. (Neurourol Urodyn 18(6):603-612, 1999). Baden-Walker data were entered at recurrence or minimum of 6 months (2.4 months-10 years; median, 1.5 years). All-apex durability was 96.4%, with no difference between hysteropexy and cuff suspension (96.0% vs. 96.8%, p = 0.90), cystocele (86.8% vs. 93.8%, p = 0.31), or rectocele (97.8% vs. 100%, p = 0.16) at 2 years.

CONCLUSION

In uterine prolapse patients, technically similar uterosacral hysteropexy durability did not differ from hysterectomy-based cuff suspension nor between cohorts for cystocele or rectocele.

Use of surgisis for treatment of anterior and posterior vaginal prolapse

Aim. To evaluate the anatomical success and complication rate of Surgisis in the repair of anterior and posterior vaginal wall prolapse. Methods. A retrospective review of 65 consecutive Surgisis prolapse repairs, involving the anterior and/or posterior compartment, performed between 2003 and 2009, including their objective and subjective success rates using the pelvic organ prolapse quantification (POPQ) system. Results. The subjective success rate (no symptoms and no bulge beyond the hymen) was 92%, and the overall objective success rate (no subsequent prolapse in any compartment) was 66% (43 of 65). The overall reoperation rate for de novo and recurrent prolapse was 7.7% with 3 women undergoing repeat surgery at the same site (anterior compartment). No long-term complications occurred. Conclusions. Surgisis has a definite role in the surgical treatment of prolapse. It may decrease recurrences seen with native tissue repair and long-term complications of synthetic mesh. Its use in posterior compartment repair in particular is promising.

One-year objective and functional outcomes of a randomized clinical trial of vaginal mesh for prolapse

OBJECTIVE

The purpose of this study was to show 12-month outcomes of a randomized trial that compared vaginal prolapse repair with and without mesh.

STUDY DESIGN

Women with stage ≥2 prolapse were assigned randomly to vaginal repair with or without mesh. The primary outcome was prolapse stage ≤1 at 12 months. Secondary outcomes included quality of life and complications.

RESULTS

All 65 evaluable participants were followed for 12 months after trial stoppage for mesh exposures. Thirty-two women had mesh repair; 33 women had traditional repair. At 12 months, both groups had improvement of pelvic organ prolapse-quantification test points to similar recurrence rates. The quality of life improved and did not differ between groups: 96.2% mesh vs 90.9% no-mesh subjects reported a cure of bulge symptoms; 15.6% had mesh exposures, and reoperation rates were higher with mesh.

CONCLUSION

Objective and subjective improvement is seen after vaginal prolapse repair with or without mesh. However, mesh resulted in a higher reoperation rate and did not improve 1-year cure.

Minimally invasive urogynecology

Laparoscopic and other forms of minimally invasive pelvic floor defect repair represent alternative approaches to performing established procedures; laparoscopy can offer benefits to the surgeon (improved visualization, access for multiple procedures) and patient (decreased pain, scar formation, recuperation, and improved cosmesis). Many practitioners prefer the term “minimal access surgery” to the more prevalent “minimally invasive surgery,” as, ideally, only the route of access, not the procedure itself, is changed. Similarly, dialogue and debate about the merits and concerns of trocar-based mesh prolapse repair kits continue. While gynecology will benefit from further investigations of outcomes of minimally invasive pelvic reconstruction,there is evidence already that these techniques are feasible and offer options and advantages in the treatment of patients with pelvic floor disorders.

Uterine prolapse: from antiquity to today

Uterine prolapse is a condition that has likely affected women for all of time as it is documented in the oldest medical literature. By looking at the watershed moments in its recorded history we are able to appreciate the evolution of urogynecology and to gain perspective on the challenges faced by today's female pelvic medicine and reconstructive surgeons in their attempts to treat uterine and vaginal vault prolapse."He who cannot render an account to himself of at least three thousand years of time, will always grope in the darkness of inexperience"-Goethe, Translation of Panebaker.

3D analysis of cystoceles using magnetic resonance imaging assessing midline, paravaginal, and apical defects

INTRODUCTION AND HYPOTHESIS

This study assesses relative contributions of "midline defects" (widening of the vagina) and "paravaginal defects" (separation of the lateral vagina from the pelvic sidewall).

METHODS

Ten women with anterior predominant prolapse and ten with normal support underwent pelvic MR imaging. 3-D models of the anterior vaginal wall (AVW) were generated to determine locations of the lateral AVW margin, vaginal width, and apical position.

RESULTS

The lateral AVW margin was farther from its normal position in cases than controls throughout most of the vaginal length, most pronounced midvagina (effect sizes, 2.2-2.8). Vaginal widths differed in the midvagina with an effect size of 1.0. Strong correlations between apical and paravaginal support were evident in mid- and upper vagina (r = 0.77-0.93).

CONCLUSIONS

Changes in lateral AVW location were considerably greater than changes in vaginal width in cases vs controls, both in number of sites affected and effect sizes. These "paravaginal defects" are highly correlated with apical descent.

Measurement of the 3D geometry of the fascial arches in women with a unilateral levator defect and "architectural distortion"

INTRODUCTION AND HYPOTHESIS

The arcus tendineus fascia pelvis (ATFP) and arcus tendineus levator ani (ATLA) are elements of anterior vaginal support. This study describes their geometry in women with unilateral levator ani muscle defects and associated "architectural distortion."

METHODS

Fourteen subjects with unilateral defects underwent MRI. 3D models of the arcus were generated. The locations of these relative to an ilial reference line were compared between the unaffected and affected sides.

RESULTS

Pronounced changes occurred on the defect sides' ventral region. The furthest point of the ATLA lays up to a mean of 10 mm (p = 0.01) more inferior and 6.5 mm (p = 0.02) more medial than that on the intact side. Similarly, the ATFP lays 6 mm (p = 0.01) more inferior than on the unaffected side.

CONCLUSIONS

The ventral arcus anatomy is significantly altered in the presence of levator defects and architectural distortion. Alterations of these key fixation points will change the supportive force direction along the lateral anterior vaginal wall, increasing the risk for anterior vaginal wall prolapse.

Vaginal support as determined by levator ani defect status 6 weeks after primary surgery for pelvic organ prolapse

OBJECTIVE

To evaluate whether major levator ani muscle defects were associated with differences in postoperative vaginal support after primary surgery for pelvic organ prolapse (POP).

METHODS

A retrospective chart review of a subgroup of patients in the Organ Prolapse and Levator (OPAL) study. Of the 247 women recruited into OPAL, 107 underwent surgery for prolapse and were the cohort for the present analysis. Major levator ani defects were diagnosed when more than 50% of the pubovisceral muscle was missing on MRI. Postoperative vaginal support was assessed via POP-quantification system. Postoperative anatomic outcome was analyzed according to levator ani defect status, as determined by MRI.

RESULTS

Support of the anterior vaginal wall 2 cm above the hymen occurred among 62% of women with normal levator ani muscles/minor defects and 35% of those with major defects. Support of the anterior wall 1cm above the hymen occurred among 32% women with normal muscles /minor defects and 59% of those with major defects. Levator ani defects were not associated with differences in postoperative apical/posterior vaginal support.

CONCLUSION

Six weeks after primary surgery for prolapse, women with normal levator ani muscles/minor defects had better anterior vaginal support than those with major levator defects.

Long-term outcomes of modified high uterosacral ligament vault suspension (HUSLS) at vaginal hysterectomy

INTRODUCTION AND HYPOTHESIS

The aim of this study was to prospectively evaluate long-term outcomes of a modified high uterosacral ligament suspension (HUSLS) at vaginal hysterectomy for pelvic organ prolapse (POP).

METHODS

POP was assessed 5 years postoperatively in 42 women who underwent vaginal hysterectomy and HUSLS for POP. Bladder, bowel, sexual function and quality of life (QoL) were evaluated.

RESULTS

Preoperatively, 27/42 women had at least BW grade 2 uterine prolapse. At a mean follow-up period of 59.4 months (range: 40-79 months), two women had undergone surgical intervention for vault prolapse, 33 had no vault prolapse and six grade 1 vault prolapse. One woman declined vaginal examination. Twenty women were sexually active and 18 completed the PISQ-31. The mean total score for all domains was 91/125. On QoL assessments high scores were noted in all domains.

CONCLUSIONS

Modified HUSLS at vaginal hysterectomy is associated with satisfactory long-term objective and subjective outcomes, sexual function and quality of life scores.

One-year clinical outcomes after prolapse surgery with nonanchored mesh and vaginal support device

OBJECTIVE

The purpose of this study was to evaluate outcomes after standardized transvaginal prolapse repair with nonanchored mesh and a vaginal support device.

STUDY DESIGN

Postoperative vaginal support was assessed by pelvic organ prolapse quantitative examination after repair of symptomatic stage II/III prolapse. Validated questionnaires assessed pelvic symptoms and sexual function. Visual analog scales quantified experience with the vaginal support device.

RESULTS

One hundred thirty-six women received the planned surgery; 95.6% of the women returned for the 1-year assessment: 76.9% of the cases were stage 0/I; however, in 86.9% of the cases, the leading vaginal edge was above the hymen. Pelvic symptoms, quality of life, and sexual function improved significantly from baseline (P < .05). Median visual analog scale scores for vaginal support device awareness and discomfort were 2.6 and 1.2, respectively (0 = none; 10 = worst possible).

CONCLUSION

Vaginal support, pelvic symptoms, and sexual function improved at 1 year, compared with baseline, after trocar-free prolapse repair with nonanchored mesh and a vaginal support device.

Evaluation of a transvaginal mesh delivery system for the correction of pelvic organ prolapse: subjective and objective findings at least 1 year after surgery

OBJECTIVE

We sought to track objective and subjective outcomes ≥1 year after transvaginal mesh system to correct prolapse.

STUDY DESIGN

This was a retrospective cohort study of 120 women who received a transvaginal mesh procedure (Avaulta Solo, CR Bard Inc, Covington, GA). Outcomes were pelvic organ prolapse quantification values; Pelvic Floor Distress Inventory, Short Form 20/Pelvic Floor Impact Questionnaire, Short Form 7 scores; and a surgical satisfaction survey. "Surgical failure" was defined as pelvic organ prolapse quantification point >0, and/or any reports of vaginal bulge.

RESULTS

Of 120 patients, 116 (97%) were followed up for a mean of 14.4 months (range, 12-30). In all, 74 patients had only anterior mesh, 21 only posterior mesh, and 21 both meshes. Surgical cure rate was 81%. Surgical failure was more common if preoperative point C ≥+2 (35% vs 16%; P = .04). Mesh erosion and de novo pain occurred in 11.7% and 3.3%, respectively. Pelvic Floor Distress Inventory, Short Form 20/Pelvic Floor Impact Questionnaire, Short Form 7 scores improved (P < .01).

CONCLUSION

Objective and subjective improvements occurred at ≥1 year, yet failure rates were high when preoperative point C was ≥+2.

Delayed presentation of complete ureteral obstruction deligated transvaginally

Complete ureteral obstruction with delayed presentation is managed first by percutaneous nephrostomy and later with ureteral deligation, reimplantation, and stenting. Transvaginal deligation of complete obstruction after delayed presentation has not been described. We present two cases of ureteral ligation after pelvic reconstructive surgery. The first patient underwent high uterosacral ligament vaginal vault suspension then presented on postoperative day 22. The second patient underwent anterior colporrhaphy and presented on postoperative day 6. Both patients had flank pain, elevated creatinine, and signs of complete obstruction on CT scan. They both underwent transvaginal ureterolysis, retrograde stent placement, and later removal without any sequelae. Transvaginal ureterolysis of complete obstruction after delayed presentation is better tolerated and less morbid than traditional management.

Midline uterosacral plication anterior colporrhaphy combo (MUSPACC): preliminary surgical report

INTRODUCTION AND HYPOTHESIS

the objective of this study is to examine the surgical safety and early efficacy of the midline uterosacral (ligament) plication anterior colporrhaphy (MUSPACC) procedure.

METHODS

a retrospective review of the perioperative data of 41 women who had undergone an MUSPACC procedure without any other vaginal vault supportive procedure was performed.

RESULTS

the MUSPACC procedure can be performed comfortably through a single midline anterior vaginal wall incision, providing concomitant levels 1 and 2 support at anterior colporrhaphy. The procedure is safe and relatively quick (median 23 min) with consistent access to the intermediate section of the uterosacral ligament. Blood loss is generally minimal to small. Dissection is relatively limited. The ureters (2 cm or more lateral) are not deemed to be at risk. Short-term anatomical results are promising. There was no significant change in vaginal length.

CONCLUSIONS

the MUSPACC procedure is safe, relatively quick, and free of significant bleeding. It provides concomitant levels 1 and 2 vaginal support.

Laparoscopic extraperitoneal uterine suspension to anterior abdominal wall bilaterally using synthetic mesh to treat uterovaginal prolapse

Between August 2007 and May 2009, 28 patients with uterovaginal prolapse, stage 2 or greater, and who desired uterine preservation, underwent laparoscopic extraperitoneal uterine suspension to the anterior abdominal wall bilaterally using mesh. The primary outcome was recurrence, which was evaluated using point C. Secondary outcomes were effects on quality of life (Pelvic Floor Distress Inventory [PFDI-20] and Pelvic Floor Impact Questionnaire [PFIQ-7]) and sexual symptom (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire [PISQ-12]) scores, operative time, blood loss, duration of hospitalization, and adverse events. After surgery, there was significant improvement in all pelvic organ prolapse quantification (POP-Q) measurements. The POP-Q score for point C was significantly farther from the hymen at 6-months and 1-year follow-up compared with the preoperative value (-7.8 and -8.0 vs 2.6, respectively; p < .001). The objective cure rates at 6 months and 1 year were 96.4% and 94.1%, respectively. There were no major intraoperative or postoperative complications. However, all patients reported postoperative dragging pain at the points of puncture ports where the mesh was fixed to the abdominal wall. The mean visual analog scale decreased from a mean (SD) 3-day score of 2.61 (1.26) to 0 at 1 month follow-up. Baseline PISQ-12 score changed significantly compared with the value at 6 months after operation (28.4 [2.7] vs 29.3 [2.9]; p < .001). The PFDI-20 and PFIQ-7 scores at 6 and 12 months after surgery improved significantly compared with the baseline scores (p < .001). The subjective success rates at 6 months and 1 year were 96.4% and 94.1%. respectively. Laparoscopic extraperitoneal uterine suspension to the anterior abdominal wall using mesh is a simple, safe, and effective procedure for treating uterovaginal prolapse. However, further studies of the long-term efficiency and reliability of this technique are needed to evaluate its value.

Levator avulsion is a risk factor for cystocele recurrence

OBJECTIVES

To determine whether levator avulsion is a risk factor for recurrence after cystocele repair.

METHODS

This was an audit of women who underwent anterior colporrhaphy at a tertiary hospital between 2002 and 2005, who were followed up by interview, clinical examination and four-dimensional translabial ultrasound examination 3-6 years later.

RESULTS

Of 242 patients identified through theater records we were able to contact 171 (71%). Of 83 who agreed to attend, 24 (29%) reported symptoms of recurrent prolapse. There were 33 (40%) recurrent cystoceles (ICS POP-Q ≥ 0), [corrected] and 34 (41%) had a significant cystocele on ultrasound examination. On pelvic floor tomographic ultrasound examination, a levator avulsion was detected in 29 (35%) patients. The relative risk of recurrence in women with avulsion was 3.9 (95% CI, 2.4-5.8) when ultrasound criteria of recurrent cystocele were used, and 2.9 (95% CI, 1.7-4.5) when using clinical staging.

CONCLUSION

Levator avulsion is associated with a relative risk of 3-4 for cystocele recurrence after anterior colporrhaphy.

Surgical anatomy of the uterosacral ligament

INTRODUCTION AND HYPOTHESIS

This study aims to elucidate and expand current knowledge of the uterosacral ligament (USL) from a surgical viewpoint.

METHODS

Studies were performed on 12 unembalmed cadaveric pelves and five formalin-fixed pelves.

RESULTS

The USL, 12-14-cm long, can be subdivided into three sections: (1) distal (2-3 cm), intermediate (5 cm), and proximal (5-6 cm). The thick (5-20 mm) distal section, attached to cervix and upper vagina, is confluent laterally with the cardinal ligament. The proximal section is diffuse in attachment and generally thinner. The relatively unattached intermediate section is wide, and thick, well defined when placed under tension, more than 2 cm from the ureter and suitable for surgical use. The strength of the USL is perhaps derived not only from the ligament itself, but also from the addition of extraperitoneal connective tissue.

CONCLUSIONS

The USL can be subdivided into three sections according to thickness and attachments with the intermediate section suitable for surgical use, particularly for vaginal vault support.

Magnetic resonance imaging-based three-dimensional model of anterior vaginal wall position at rest and maximal strain in women with and without prolapse

INTRODUCTION AND HYPOTHESIS

Two-dimensional magnetic resonance imaging (MRI) demonstrates apical support and vaginal length contribute to anterior wall prolapse (AWP). This paper describes a novel three-dimensional technique to examine the vagina and its relationship to pelvic sidewalls at rest and Valsalva.

METHODS

Twenty women (10 with AWP and 10 with normal support) underwent pelvic magnetic resonance imaging at rest and Valsalva. Three-dimensional reconstructions of the pelvic bones and anterior vaginal wall were created to assess morphologic changes occurring in prolapse.

RESULTS

In women with AWP, Valsalva caused downward translation of the vagina along its length. A transition point separated a proximal region supported by levator muscles and a distal, unsupported region no longer in contact with the perineal body. In this latter region, sagittal and frontal plane "cupping" occurs. The distal vagina rotated inferiorly along an arc centered on the inferior pubis.

CONCLUSION

Downward translation, cupping, and distal rotation are three novel characteristics of AWP demonstrated by this three-dimensional technique.

Abdominal, laparoscopic, and robotic surgery for pelvic organ prolapse

Abdominal correction of pelvic organ prolapse remains a viable option for patients and surgeons. The transition from open procedures to less invasive laparoscopic and robotic-assisted surgeries is evident in the literature. This article reviews the surgical options available for pelvic organ prolapse repair and their reported outcomes. Procedures reviewed include apical support (sacral, uterosacral, and others), and abdominal anterior and posterior vaginal wall support. Long-term follow-up and appropriately designed studies will further help direct surgeons in deciding which approach to incorporate into their practice.

Suture complications in a teaching institution among patients undergoing uterosacral ligament suspension with permanent braided suture

Introduction and hypothesis

Our study aimed to identify the rate of suture complications over a 5-year period using braided permanent suture for uterosacral ligament suspension (USLS) surgery.

Methods

We reviewed the medical records of patients who underwent vaginal uterosacral ligament suspensions using braided polyester suture. Outcome measures included rate and timing of suture complications, patient symptoms post-operatively, efficacy of treatment modalities and surgical success.

Results

Eighty-three patients had undergone USLS with braided, polyester suture over the study period that met inclusion criteria. Thirty-seven patients (44.6%) had suture-related complications post-operatively with a mean follow-up of 10.4 months. When only silver nitrate was applied, 16.7% improved, and when the suture was cut in clinic, 77.8% resolved.

Conclusions

Permanent polyester braided suture for suspension of vaginal vault may lead to an unacceptably high suture erosion rate, cutting the suture in clinic results in the highest resolution.