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

Long-term results of vaginal repairs with and without xenograft reinforcement

INTRODUCTION AND HYPOTHESIS

The aim of this paper is to study if xenograft reinforcement of vaginal repair reduces recurrence of prolapse.

METHODS

Results 1-5 years after vaginal repair were studied in 41 cases with xenograft and in 82 matched controls without. Symptoms were evaluated by a validated questionnaire and anatomy by pelvic organ prolapse quantification (POPQ).

RESULTS

Significant more cases, 97% versus 81% controls, felt cured or much improved (p = 0.02); 11% of cases and 19% of controls had POP symptoms, POPQ > -1 was found in 31% cases and 24% controls. Defining recurrence as POPQ > -1 plus symptoms revealed recurrence in 3% of cases and 12% controls. None of the recurrence rates was significantly different for cases versus controls. No vaginal erosions were seen. Previous surgery was a significant risk factor with odds ratio 7.3 for another recurrence.

CONCLUSIONS

Recurrence rates defined by POPQ plus symptoms were low compared to literature. Xenograft reinforcement might improve results.

[How to manage multicompartment pelvic organe prolapse?]

Repair of pelvic organ prolapse by vaginal route may use native tissues or meshes, which have been in extensive use over the last decades. Traditional surgery, and particularly sacrospinous fixation, has been proven to be effective with long term follow-up with well-known specific risks that could be avoided by skilled surgeons on condition that he observes basic vaginal surgery rules. This surgery is still recommended as first choice in patients over 70 years old with high-grade prolapse. Nevertheless recurrence rate after high-grade cystocele repair using native tissues as been reported between 30 and 50% depending on the technique used. Mesh repair and particularly the use of mesh kits is a valid option in case of prolapse with cystocele behind the hymen, specifically in case of paravaginal defect. Meshes use is licit in patients with prolapse recurrence as well. In contrast, spread use of transvaginal meshes in young patients with grade 3 or 4 prolapse whom tissues have a poor quality, has to be considered very carefully because of the lack of knowledge about long term results and sexual outcome.

Vaginal surgery for pelvic organ prolapse

The vaginal approach to pelvic organ prolapse repair has been a mainstay of surgical therapy since the beginning of modern gynecologic surgery. In this article, the major vaginal procedures are reviewed with emphasis on techniques of pelvic reconstruction. Vaginal hysterectomy, apical suspension, repair of the anterior and posterior compartments, and perineal repair are covered in detail.

Anatomic outcomes of vaginal mesh procedure (Prolift) compared with uterosacral ligament suspension and abdominal sacrocolpopexy for pelvic organ prolapse: a Fellows' Pelvic Research Network study

OBJECTIVE

The objective of the study was to compare apical support anatomic outcomes following vaginal mesh procedure (VMP) (Prolift) to uterosacral ligament suspension (USLS) and abdominal sacrocolpopexy (ASC).

STUDY DESIGN

This multicenter, retrospective chart review compared apical anatomic success (stage 0 or 1 based on point C or D of the Pelvic Organ Prolapse Quantification), level of vaginal apex (point C or D) 3-6 months after prolapse repair at 10 US centers between 2004 and 2007.

RESULTS

VMP, USLS, and ASC were performed for 206, 231, and 305 subjects respectively. There was no difference in apical success after VMP (98.8%) compared with USLS (99.1%) or ASC (99.3%) (both P = 1.00) 3-6 months after surgery. The average elevation of the vaginal apex was lower after VMP (-6.9 cm) than USLS (-8.05 cm) and ASC (-8.5 cm) (both P < .001)

CONCLUSION

Patients undergoing VMP have similar apical success compared with USLS and ASC despite lower vaginal apex 3-6 month after surgery.

The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication

INTRODUCTION AND HYPOTHESIS

The objective of this study is to evaluate cervical amputation with uterosacral ligament plication (modified Manchester) and compare it to vaginal hysterectomy with high uterosacral ligament plication procedure with special regard to the middle compartment.

METHODS

Consecutive women with pelvic organ prolapse who underwent either vaginal hysterectomy or a modified Manchester procedure were included. Assessments were made preoperatively and at 1-year follow-up, including physical examination with pelvic organ prolapse quantification standardised questionnaires (incontinence impact questionnaire, urogenital distress inventory, and defaecatory distress inventory).

RESULTS

Between 2002 and 2007, 156 patients were included. Ninety-eight patients returned for a 1-year follow-up. In the modified Manchester group, we found no middle compartment recurrence versus two (4%) in the vaginal hysterectomy group. Anterior and posterior compartment prolapse recurrences (stage >or=2) were similar (approximately 50%). Considering operating time and blood loss, modified Manchester was more favourable. There was no difference in the pre- and postoperative subjective scores. The overall functional outcome was acceptable.

CONCLUSIONS

We found an excellent performance of both procedures regarding middle compartment recurrences.

Long-term quality-of-life outcome after mesh sacrocolpopexy for vaginal vault prolapse

OBJECTIVE

To evaluate the long-term outcome of mesh sacrocolpopexy (MSC, which aims to restore normal pelvic floor anatomy to alleviate prolapse related symptoms) and its effect on patient's quality of life, as women with vaginal vault prolapse commonly have various pelvic floor symptoms that can affect urinary, rectal and sexual function.

PATIENTS AND METHODS

From January 2000 to June 2006, consecutive patients with confirmed stage 2-4 vaginal vault prolapse subsequently had a MSC. Detailed telephone interviews using the Cleveland Clinic Short Form-20 Pelvic Floor Distress Inventory (PFDI) questionnaire, with Urinary Distress Inventory (UDI), Pelvic Organ Prolapse Distress Inventory (POPDI) and Colorectal-Anal Distress Inventory (CRADI) subscales was completed by all patients to assess symptoms before and after MSC, improvement in sexual function and overall satisfaction.

RESULTS

In all, 21 patients had abdominal MSC; the median (range) follow-up was 52.2 (21-99) months. Total PFDI scores were significantly better after MSC (mean 44.0/300) than before (mean 113.9/300; P < 0.001). Analysis of the subscale scores showed that all patients reported a significant improvement of symptoms in the POPDI category (P < 0.001). CRADI subscale scores showed no significant change after MSC (before, mean 7.43/100 vs after 8.47/100; P = 0.542). There was an improvement of urinary symptoms on the UDI subscale after MSC but it was not statistically significant (P = 0.08). Analysis of score differences over time after MSC showed an insignificant decreasing slope (P = 0.227), suggesting long-term stability of symptoms after surgery; 90% of patients reported a significant improvement in sexual function and excellent long-term overall satisfaction with MSC.

CONCLUSION

Our results suggest that MSC is a safe and effective surgical option for treating vaginal vault prolapse, providing symptom improvement and stability in the long term.

Transabdominal uterosacral suspension: outcomes and complications

OBJECTIVE

The objective of the study was to report outcomes and complications following abdominal uterosacral suspension (AUSS) for treatment of pelvic organ prolapse.

STUDY DESIGN

This was a surgical case series of consecutive women who underwent AUSS between 2002 and 2005.

RESULTS

One hundred seven women underwent AUSS using permanent suture (mean age, 55 years; range, 32-83; and mean follow-up, 21; range, 3-74 months). Concomitant surgery included hysterectomy (99%), continence procedures (14%), and anterior and posterior colporrhaphy (9%). In the 75 patients who completed 1 year of follow-up, 9 patients (12%) reported recurrent or persistent symptoms of prolapse and 5 patients (7%) had objective anatomic failure. Complications were few, with the most common complication being erosion of the apical suspension sutures, which occurred in 9% at an average time of 56 (range, 3-75) months.

CONCLUSION

An AUSS successfully suspends the cuff for treatment of prolapse and may be offered prophylactically to women who are undergoing abdominal hysterectomy for nonprolapse indications. Alternative sutures may reduce the suture erosion rate.

A 3D finite element model of anterior vaginal wall support to evaluate mechanisms underlying cystocele formation

OBJECTIVES

To develop a 3D computer model of the anterior vaginal wall and its supports, validate that model, and then use it to determine the combinations of muscle and connective tissue impairments that result in cystocele formation, as observed on dynamic magnetic resonance imaging (MRI).

METHODS

A subject-specific 3D model of the anterior vaginal wall and its supports were developed based on MRI geometry from a healthy nulliparous woman. It included simplified representations of the anterior vaginal wall, levator muscle, cardinal and uterosacral ligaments, arcus tendineus fascia pelvis and levator ani, paravaginal attachments, and the posterior compartment. This model was then imported into ABAQUS and tissue properties were assigned from the literature. An iterative process was used to refine anatomical assumptions until convergence was obtained between model behavior under increases of abdominal pressure up to 168 cm H(2)O and deformations observed on dynamic MRI.

RESULTS

Cystocele size was sensitive to abdominal pressure and impairment of connective tissue and muscle. Larger cystocele formed in the presence of impairments in muscular and apical connective tissue support compared to either support element alone. Apical impairment resulted in a larger cystocele than paravaginal impairment. Levator ani muscle impairment caused a larger urogenital hiatus size, longer length of the distal vagina exposed to a pressure differential, larger apical descent, and resulted in a larger cystocele size.

CONCLUSIONS

Development of a cystocele requires a levator muscle impairment, an increase in abdominal pressure, and apical and paravaginal support defects.

[Vaginal descensus and prolapse. Which operative technique?]

Despite the high prevalence of genital prolapse, there are only few studies so far fulfilling the strict criteria of evidence-oriented data acquisition. On the one hand, this complicates the definition of reliable therapy recommendations, on the other hand, it sounds a note of caution in the application of therapy approaches which are new and have not yet been evaluated adequately.The systematic assessment of common therapy concepts for female genital prolapse and its accompanying pathologies has led to a better understanding of the functional and anatomical background within the last few years. Thus, any invasive anatomical correction should strictly be used with the aim of functional improvement and with evidence of persisting effectivity. Under this premise, traditional methods of vaginal and abdominal prolapse repair still come into use. The choice of the operative technique arises from carefully differentiated, interdisciplinary diagnostics and surgery should be performed in experienced centers.

Uterosacral ligament vaginal vault suspension: anatomy, outcome and surgical considerations

PURPOSE OF REVIEW

With aging populations, primary pelvic organ and recurrent pelvic organ prolapse have become a large-scale public health concern. Surgical options for patients include both abdominal and vaginal approaches, each with its own safety and efficacy profiles. This review summarizes the most recent anatomic, surgical and outcome data for uterosacral ligament vault suspension. It offers data on methods to avoid complications and difficult surgical scenarios.

RECENT FINDINGS

Uterosacral ligament suspension allows reattachment of the vaginal vault high within the pelvis. New modifications in technique including the extraperitoneal and laparoscopic approaches allow surgeons more freedom when planning surgery. Five-year data on the durability of the procedure make it a viable surgical option.

SUMMARY

As a technique widely used by many pelvic reconstructive surgeons, uterosacral ligament vault suspension provides a safe, anatomically correct and durable approach to uterine and vault prolapse. It requires advanced surgical training and an intimate understanding of pelvic anatomy to avoid and identify ureteral injury.

Nerve injury during uterosacral ligament fixation: a cadaver study

INTRODUCTION AND HYPOTHESIS

The objective of this study was to identify nerve(s) vulnerable to entrapment during uterosacral ligament fixation (USLF), which could cause postoperative lower extremity pain previously described in the literature.

METHODS

Preserved cadavers in a medical anatomy course were used. Before the students' pelvic dissections, a 2-0 prolene suture was placed in the middle third of each left uterosacral ligament visualized. The sutures were re-evaluated at the end of the course.

RESULTS

Nine sutures remained in place after the course, and one entrapped a nerve. It was part of the inferior hypogastric plexus, included fibers from S2 and S3, and radiated to the bladder and rectum. The posterior femoral cutaneous nerve was lateral and posterior to this nerve.

CONCLUSIONS

The inferior hypogastric plexus is vulnerable during USLF. Entrapment of S2 and S3 fibers could cause pain in their respective dermatomes and could be responsible for the postoperative pain previously described.

Safety of Trans Vaginal Mesh procedure: retrospective study of 684 patients

AIM

To study peri-surgical complications after cure of genital prolapse by vaginal route using interposition of synthetic prostheses Gynemesh Prolene Soft (Gynecare) following the Trans Vaginal Mesh (TVM) technique.

METHODS

The present retrospective multicentered study comprised 684 patients who underwent surgery at seven French centers between October 2002 and December 2004. All patients had a genital prolapse >or=3 (C3/H3/E3/R3) according to International continence society (ICS) classification. According to each case, prosthetic interposition was total, or anterior only or posterior only. Patients were systematically seen 6 weeks, 3 months and 6 months after surgery. Multivaried statistical analysis followed a model of logistic regression applied to each post-surgical complication.

RESULTS

The mean age of patients was 63.5 years (30-94). The mean follow-up period was 3.6 months. 84.3% of patients were post-menopause, 24.3% had hysterectomy, 16.7% previous cure of prolapse, and 11.1% cure of stress urinary incontinence (SUI). During the procedure, hysterectomy was combined in 50.3% of cases, cervix amputation in 1.5%, and cure of SUI in 40.9%. 15.8% were treated for a cystocele only. 14.8% had only a rectocele +/- elytrocele and 69.4% had a prolapse touching both compartments, anterior and posterior. In peri-surgical complications, (2%) were five bladder wounds (0.7%), one rectal wound (0.15%) and seven hemorrhages greater that 200 mL (1%). Among early post-surgical complications (during the first month after surgery) (2.8%) were two pelvic abscesses (0.29%), 13 pelvic hematomas (1.9%), one pelvic cellulitis (0.15%), two vesicovaginal fistulas and one rectovaginal fistula (0.15%). Among late post-surgical complications (33.6%) there were 77 granulomas or prosthetic expositions (11.3% [6.7% in the vaginal anterior wall, 2.1% in the vaginal posterior wall and 4.8% in the fornix]), 80 prosthetic retractions (11.7%), 36 relapse of prolapse (6.9%) and 37 SUI de novo (5.4%). Multivaried analysis shows that previous history of hysterectomy or placing of an isolated anterior prosthesis increase the risk of peri-surgical complication; preserved uterus and isolated posterior prosthesis lessen the risk of granulomas and prosthetic retractions; and association of a Richter's intervention increases the rate of prosthetic retractions.

CONCLUSION

Cure of genital prolapse with synthetic prostheses interposed by vaginal route is now reliable and can be reproduced with a low rate of peri- and early post-surgical complications. However, our study shows a certain number of late post-surgical complications after insertion of strengthening synthetic vaginal implants (prosthetic expositions and prosthetic retractions). These retrospective results will soon be compared to a prospective study.

Operations and pelvic muscle training in the management of apical support loss (OPTIMAL) trial: design and methods

The primary aims of this trial are: 1) to compare surgical outcomes following sacrospinous ligament fixation to uterosacral vaginal vault suspension in women undergoing vaginal surgery for apical or uterine pelvic organ prolapse and stress urinary incontinence and 2) to examine the effects of a structured perioperative program consisting of behavioral techniques and pelvic floor muscle training compared to usual care. This trial is performed through the Pelvic Floor Disorders Network (PFDN), which is funded by National Institute of Child Health and Human Development. Subjects will be enrolled from hospitals associated with seven PFDN clinical centers across the United States. A centralized biostatistical coordinating center will oversee data collection and analysis. Two approaches will be investigated simultaneously using a 2x2 randomized factorial design: a surgical intervention (sacrospinous ligament fixation versus uterosacral vaginal vault suspension) and a perioperative behavioral intervention (behavioral and pelvic floor muscle training versus usual care). Surgeons have standardized essential components of each surgical procedure and have met specific standards of expertise. Providers of the behavioral intervention have undergone standardized training. Anatomic, functional, and health-related quality of life outcomes will be assessed using validated measures by researchers blinded to all randomization assignments. Cost-effectiveness analysis will be performed using prospectively collected data on health care costs and resource utilization. The primary surgical endpoint is a composite outcome defined by anatomic recurrence, recurrence of bothersome vaginal prolapse symptoms and/or retreatment and will be assessed 2 years after the index surgery. Endpoints for the behavioral intervention include both short-term (6-month) improvement in urinary symptoms and long-term (2-year) improvement in anatomic outcomes and prolapse symptoms. This article describes the rationale and design of this randomized trial, focusing on several key design features of potential interest to researchers in the field of female pelvic floor disorders and others conducting randomized surgical trials.

[Effectiveness evaluation of polypropylene mesh in the repair of urogenital prolapse in 106 patients]

OBJECTIVE

To evaluate the efficacy and security of polypropylene meshes in the repair of urogenital prolapse.

MATERIAL AND METHOD

Retrospective and non-randomized study in 106 patients which had different kinds of urogenital prolapse repaired using polypropylene meshes between April 2005 and January 2007. The follow-up was carried out by two visits to the hospital, 2 and 6 months after surgery. The variables analyzed were age, parity, menopause presence, kind of surgical technique, surgical time, time at hospital and complications. Afterwards, the information was analyzed descriptively.

RESULTS

Average age was 64.4 years. The rate of multiparity and menopause women was 91.51% and 92.45% respectively. The most used surgical technique was the anterior mesh with tension-free band (34.90%), to repair the associated urinary incontinence. The rate of intraoperatory complications was 2.83%, immediate complications was 37.73% and late complications was 21.69%. The success rate after 6 months was 80-100% depending on the technique.

CONCLUSIONS

There is a low rate of intraoperatory and 6 months after the repair in the reconstructive surgery of pelvic floor for the urogenital prolapses using polypropylene meshes, which makes this technique a secure and effective option for the treatment of this problem.

A 5-year prospective follow-up study of vaginal surgery for pelvic organ prolapse

The objective of this study was to evaluate anatomic, functional, short- and long-term outcome of vaginal surgery for pelvic organ prolapse. This was a prospective observational study of 185 consecutive women planned for vaginal prolapse reconstructive surgery. Stage of prolapse, urinary incontinence (UI), bowel and mechanical symptoms were assessed preoperatively and at 1, 3 and 5 years postoperatively. The mean follow-up time was 53 months. The anatomic recurrence rate was 41.1% but less than half of them were symptomatic. Anterior compartment was most prone for recurrence and the majority of the recurrences took place within the first year. UI remained at the same level at 1-year follow-up. De novo urge occurred in 22.6% and de novo stress incontinence in 6.0%. An improvement was seen in difficulty in emptying bowel 1 year after surgery (54%). Patients were primarily cured from mechanical symptoms. Re-operation rate was 9.7%; if additional operation for incontinence was included, it was13.5%.

Laparoscopic management of uterine prolapse with cystocele and rectocele using "Gynemesh PS"

OBJECTIVE

Our department performed laparoscopic correction of uterine or vault prolapse with cystocele and rectocele using the "Gynemesh PS." The aim of this study was to evaluate the surgical outcomes and perioperative morbidity after a laparoscopic operation.

MATERIALS AND METHODS

From August 2004 to September 2005, we performed laparoscopic pelvic floor repairs in 6 cases of vault prolapse and 15 cases of uterine prolapse at the Department of Obstetrics and Gynecology at the Kyungpook National University Hospital (Daegu, Korea). Uterine and vault prolapse were repaired by laparoscopic rectocele and cystocele repair using the Gynemesh PS, uterosacral ligament suspension, paravaginal repair, and Burch colposuspension. In uterine prolapse, we also carried out a subtotal hysterectomy. The stage of prolapse was classified by means of the pelvic organ prolapse quantification (POPQ) system.

RESULTS

The mean age, Q-index, and parity were 64 years (range, 47-79), 24.6 (range, 18.7 approximately 27.8), and 5 (range, 3 approximately 10), respectively. Mean operation time was 141 minutes (range, 90 approximately 211). Mean estimated blood loss was 53 mL (range, 20 approximately 80). Mean hospital stay was 5 days (range, 3 approximately 9 days). There were no major complications, but postoperative voiding difficulty developed in 1 case. Mean preoperative POPQ stage was 3 and immediate, 6-week, 3-month, 6-month, and 1-year postoperative POPQ score was 0. Mean follow-up period was 7.5 months (range, 3 approximately 13). The objective success rate was 100%.

CONCLUSIONS

Laparoscopic pelvic floor repair is an effective procedure and enables us to combine the advantages of laparotomy with the low morbidity of the vaginal route. In Europe, the sacrocolpopexy was more popular, but uterosacral ligament suspension is the most natural anatomic repair of defects and, hence, the least likely to be predisposed to future defects in the anterior or posterior vaginal wall or to compromise vaginal function. However, further studies are required on the long-term efficiency and reliability in order to evaluate the value of this technique.

Abdominal sacral colpopexy: surgical pearls and outcomes

Vaginal vault prolapse is a challenging form of pelvic organ prolapse that occurs in combination with cystocele, rectocele, or enterocele in nearly 75% of affected patients. Clinical presentation will vary depending on the associated defects. Any successful therapy for vaginal vault prolapse will depend on a thorough evaluation of the vaginal compartments and concomitant lower urinary tract function. Surgical correction of vaginal vault prolapse can be achieved through a variety of vaginal or abdominal approaches. This review focuses on the abdominal approach for vaginal vault prolapse surgery. We review outcomes of abdominal sacral colpopexy (ASC) and available comparisons to vaginal vault suspension. We address the role of laparoscopy and robotics in ASC and examine the outcomes of such procedures. We also discuss available literature on the management of the lower urinary tract in combination with ASC.

Uterosacral ligament suspension sutures: Anatomic relationships in unembalmed female cadavers

OBJECTIVE

The objective of the study was to characterize anatomic relationships of uterosacral ligament suspension (USLS) sutures.

STUDY DESIGN

The relationship of USLS sutures to the ureters, rectal lumen, and sidewall neurovascular structures was examined in 15 unembalmed female cadavers.

RESULTS

The mean distance of the proximal sutures to the ureters and rectal lumen was 14 mm (range, 0-33) and 10 mm (range, 0-33), respectively. The mean distance of the distal sutures to the ureters was 14 mm (range, 4-33) and to the rectal lumen 13 mm (range, 3-23). Right sutures were noted at the level of S1 in 37.5%, S2 in 37.5%, and S3 in 25% of specimens. Left sutures were noted at the level of S1 in 50%, S2 in 29.2%, and S3 in 20.8% of cadavers. Of 48 sutures passed, 1 entrapped the S3 nerve. Sutures perforated the pelvic sidewall vessels in 4.1% of specimens.

CONCLUSION

USLS sutures can directly injure the ureters, rectum, and neurovascular structures in the pelvic walls.

A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery

OBJECTIVE

The purpose of this pilot study was to compare the efficacy of 2 techniques for evaluating bladder function after transvaginal surgery.

STUDY DESIGN

Subjects scheduled for transvaginal, outpatient surgery were consecutively enrolled and randomized to backfill-assisted voiding trial or a trial of spontaneous voiding after surgery.

RESULTS

Sixty subjects were enrolled. The mean time in the perioperative anesthesia care unit for the backfill group was 199.5 minutes vs 226.6 minutes in the spontaneous voiding group (P = .08). Subjects randomized to backfill were more likely to adequately empty their bladders and be discharged home without catheter drainage than subjects in the spontaneous voiding group (61.5% vs 32.1%, respectively, P = .02). Multiple logistic regression further demonstrated that the backfill-assisted technique predicted successful bladder emptying after vaginal surgery (P = .02).

CONCLUSION

Women undergoing transvaginal outpatient surgery are more likely to empty their bladder effectively before discharge if they are evaluated with a backfill-assisted voiding trial.

Vaginal paravaginal repair with an AlloDerm graft: Long-term outcomes

OBJECTIVE

The aim of this study was to describe the long-term objective and subjective outcomes after vaginal paravaginal repair with AlloDerm graft (LifeCell, Branchburg, NJ).

STUDY DESIGN

Thirty-three women with either recurrent stage II or primary or recurrent stage III-IV anterior vaginal wall prolapse underwent a vaginal paravaginal repair with AlloDerm graft between November 1998 and April 2002. Postoperative follow-up was obtained on an annual basis. Objective failure was defined as a stage II or greater anterior wall defect. Descriptive statistics were performed.

RESULTS

Long-term follow-up was obtained on 24/33 subjects (72.7%). The mean length of follow-up for the 24 women was 52.0 months (range, 18-86 months). Fourteen of the 24 subjects (58.3%) had recurrent stage II prolapse in the anterior compartment, of which only 4 of 14 (28.6%) were symptomatic.

CONCLUSIONS

Long-term evaluation of vaginal paravaginal repairs with AlloDerm graft reveals good subjective success, despite a moderate rate of objective failure within the first 24 months.

Positive symptom improvement with laparoscopic uterosacral ligament repair for uterine or vaginal vault prolapse: Interim results from an active multicenter trial

STUDY OBJECTIVE

To evaluate the use of laparoscopic uterosacral ligament repair for long-term patient symptom improvement in patients with uterine prolapse or posthysterectomy vaginal vault prolapse and to evaluate how laparoscopic instrumentation kits facilitate procedure performance for the surgeon.

DESIGN

Nonrandomized, prospective, multicenter case series (Canadian Task Force classification II-2).

SETTING

Five clinical sites consisting of 4 community hospitals and 1 university medical center.

PATIENTS

Seventy-two patients with stage II or worse uterine prolapse (58%, n = 42) or posthysterectomy vaginal vault prolapse (42%, n = 30). One patient with stage I vaginal vault prolapse was included in the group due to her significant symptoms.

INTERVENTIONS

Laparoscopic uterosacral ligament repair was performed on all patients; round ligament truncation was also performed selectively on patients with uterine prolapse. Fifty-seven percent (41 patients) had concomitant pelvic procedures.

MEASUREMENTS AND MAIN RESULTS

At 12-month follow-up, Pelvic Organ Prolapse Quantification (POP-Q) scores and patient self-reported symptom scores were significantly improved over baseline after laparoscopic repair of pelvic organ prolapse. Positive mean change in POP-Q score was 14.4 (p = .0003) for uterine prolapse repair and 9.28 (p = .017) for vaginal vault prolapse repair. Positive mean change in total symptom score was 20.36 (p <.0001) for uterine prolapse repair and 11.43 (p = .005) for vaginal vault prolapse repair. Surgeons reported a mean procedure time of 31.6 minutes for uterine prolapse repair and 21.7 minutes for vaginal vault prolapse repair. A mean rating of 7.5 was documented for ease of use for the uterine prolapse kit and 4.1 for the vaginal vault prolapse kit on a scale of 1 to 10.

CONCLUSION

Laparoscopic uterosacral ligament repair improves symptoms and POP-Q scores over the long term in patients with uterine or vaginal vault prolapse. Laparoscopic instrumentation kits facilitate procedure performance for the surgeon with expedited surgery times.

Bilateral extraperitoneal uterosacral suspension: a new approach to correct posthysterectomy vaginal vault prolapse

Restoration of apical vaginal support remains a challenging problem for the pelvic reconstructive surgeon. The transvaginal use of the uterosacral-cardinal ligament complex is gaining increasing popularity in the surgical treatment of uterovaginal and posthysterectomy vault prolapse. We describe an extraperitoneal surgical approach using this ligamentous complex to reattach the vaginal apex in women with posthysterectomy vault prolapse and report our surgical experience with this procedure in 123 women over 5 years. The relevant anatomy related to the procedure and risk of ureteric injury with uterosacral suspension is also reviewed. Extraperitoneal vault suspension can be combined with the use of polypropylene mesh if required. The extraperitoneal approach is an alternative procedure in women with vault prolapse with or without concomitant enterocele or where access to the Pouch of Douglas is difficult particularly after previous pelvic surgery. We believe this procedure to have less risk of ureteral injury than the intraperitoneal approach.

Anterior vaginal wall length and degree of anterior compartment prolapse seen on dynamic MRI

The objective of the study was to determine the relationship between midsagittal vaginal wall geometric parameters and the degree of anterior vaginal prolapse. We have previously presented data indicating that about half of anterior wall descent can be explained by the degree of apical descent present (Summers et al., Am J Obstet Gynecol, 194:1438-1443, 2006). This led us to examine whether other midsagittal vaginal geometric parameters are associated with anterior wall descent. Magnetic resonance (MR) scans of 145 women from the prior study were suitable for analysis after eight were excluded because of inadequate visibility of the anterior vaginal wall. Subjects had been selected from a study of pelvic organ prolapse that included women with and without prolapse. All patients underwent supine dynamic MR scans in the midsagittal plane. Anterior vaginal wall length, location of distal vaginal wall point, and the area under the midsagittal profile of the anterior vaginal wall were measured during maximal Valsalva. A linear regression model was used to examine how much of the variance in cystocele size could be explained by these vaginal parameters. When both apical descent and vaginal length were considered in the linear regression model, 77% (R (2) = 0.77, p < 0.001) of the variation in anterior wall descent was explained. Distal vaginal point and a measure anterior wall shape, the area under the profile of the anterior vaginal wall, added little to the model. Increasing vaginal length was positively correlated with greater degrees of anterior vaginal prolapse during maximal Valsalva (R (2) = 0.30, p < 0.01) determining 30% of the variation in anterior wall decent. Greater degrees of anterior vaginal prolapse are associated with a longer vaginal wall. Linear regression modeling suggests that 77% of anterior wall descent can be explained by apical descent and midsagittal anterior vaginal wall length.

Chapitre H - Les conséquences neuro-urologiques de la chirurgie de l’incontinence urinaire d’effort et de la statique pelvienne

It is difficult to prove the neurourological origin of a voiding disorder, pain or postoperative functional disorders after stress urinary incontinence and pelvic repair surgery and their incidence is difficult to evaluate. The purpose of this chapter is to review the data of the literature concerning complications of this type of surgery, possibly related to a neurological injury, regardless of the site. The most frequently encountered postoperative problem is acute urinary retention. Prevention of acute urinary retention must be based on preoperative assessment looking for risk factors and the quality of postoperative resumption of voiding after removal of the bladder catheter Medium-term and long-term de novo dysuria and/or urgency must be analysed according to a neurourological approach, looking for obstruction (that must be removed) and complications related to the implanted prosthetic material or to the operative technique. The most difficult symptom to assess is postoperative pelvic pain "induced" by surgery. It can be accentuated by a previously undiagnosed concomitant spinal or regional lesion (hip) and the diagnostic assessment must be based on a multidisciplinary approach. This review emphasizes the low level of proof of data of the literature in this field and supports the impression that prospective data from homogeneous cohorts must be recorded in registries, for example, despite the difficulty of long-term evaluation (> 5 years). In the future, patients in whom prosthetic material is implanted should probably be encouraged to more readily cooperate in this field to ensure continuing improvement of the quality of surgical care.

Small bowel obstruction after vaginal vault suspension: a series of three cases

Surgical correction of pelvic organ prolapse is increasingly common. The vaginal approach is often favored secondary to its limited peritoneal cavity access and low complication rates. A thorough review of the literature revealed no previous reports of primary vaginal reconstructive surgery leading to small bowel obstruction (SBO). Three patients who underwent transvaginal hysterectomy, uterosacral ligament vaginal vault suspension, and other reconstructive procedures subsequently suffered from SBO. All patients failed conservative management and required surgery. All were treated with laparoscopy initially, but two patients required laparotomy to correct iatrogenic enterotomies. The complication of SBO should be considered in the post vaginal surgery patient with abdominal pain. Though laparoscopic surgery can be considered, our experience has been discouraging. Candidate selection is critical and care should be taken to avoid enterotomy.

Sedation and local anaesthesia for vaginal pelvic floor repair of genital prolapse using mesh

In this study of the surgical repair of pelvic organ prolapse (POP), the vaginal pelvic floor repair with mesh (PFR-Mesh) procedure was used. The procedure is originally named TVM. All 55 patients in the series were operated upon under sedation and local anaesthesia as pain relief. The objectives were twofold. Firstly, the objective was to evaluate peri-operative and immediate post-operative complications. Secondly, the objective was to evaluate the feasibility of performing these relatively complex procedures under sedation and local anaesthesia. The visual analogue scale (VAS) was used to record pain during and after the operations. At a follow-up visit 8-12 weeks post-operatively, a self-instructed questionnaire evaluating subjective opinions of the operation itself and the post-operative period was handed in. Of the 55 patients, anterior, posterior and total PFR-Mesh procedures were performed in 39 (71%), 12 (22%) and 4 (7%) patients, respectively. Mean age was 68 years (52-93). All patients could be operated as scheduled under sedation and local anaesthesia. Mean operative time was 38 min (26-70). Peri-operative complications consisted of two cases of bladder perforation with the superior needle in an anterior repair and vaginal perforation with the inferior needle also in an anterior repair. At the conclusion of the operation VAS was recorded to be 0-3 in 65% of the patients. There were no immediate post-operative complications. Out of 55 patients, 35 (64%) left the ward on the day of operation whilst the remaining 20 (36%) patients stayed for only one night. The safety of the PFR-Mesh procedure and the feasibility of performing these procedures under sedation and local anaesthesia were demonstrated. However, expertise in vaginal surgery is required.

Histological features of the rectovaginal septum in elderly women and a proposal for posterior vaginal defect repair

To get support from morphological findings to develop a novel surgical procedure for posterior vaginal defect repair, we histologically examined the rectum-vagina interface tissues obtained from 20 elderly female cadavers. The rectovaginal septum (RVS) was defined here as an elastic fiber-rich plate (EFRP) along the posterior vaginal wall. It lined the posterior surface of the vein-rich zone of the vaginal wall and extended between the bilateral paracolpiums. The septum was more evident in the lower half of the interface than in the upper half. The RVS was often thin and interrupted. Since the RVS was not so clearly demonstrated in the upper vagina histologically, augmentation using some implant is considered to be necessary for the enterocele and high rectocele. Since the thickness and tightness of the RVS vary with the case in the lower vagina, surgical procedures for low rectocele repair should be individualized, including implant-augmentation.

Risk factors for the recurrence of pelvic organ prolapse after vaginal surgery: a review at 5 years after surgery

The objective of this study was to determine the factors associated with the anatomic and functional recurrence of prolapse. An examination was performed in 134 of the 228 patients who underwent primary vaginal surgery for prolapse of the pelvic organs (POP) between 2000 and 2001. Anatomical recurrence of the prolapse was established by pelvic examination using the pelvic organ prolapse quantification (POPQ) staging system. Functional results were obtained by interview with the patients. Descriptive statistical analyses and multivariate logistic regression were performed to determine the factors associated with recurrence. Five years after surgery, 42 women (31.3%) presented anatomical recurrence of the prolapse (grade > or = II), and only 10 of the 134 (7.4%) had prolapse-related symptoms. Those with high body weight (>65 kg) and younger women (<60 years) were associated with an increase in the risk for both anatomical and functional recurrence. Advanced preoperative prolapse (grade III-IV) of any compartment was associated with anatomical failure but not with symptomatic recurrence. There was a poor correlation between anatomical and symptomatic recurrence. Younger women and those with a higher body weight are more likely to experience recurrent prolapse after vaginal repair.

Outcomes of vaginal vault prolapse repair with a high uterosacral suspension procedure utilizing bilateral single sutures

The aim of this study was to describe an approach for performing a high uterosacral vaginal vault suspension and to report anatomical and subjective results. Anatomic measures and validated symptom-specific questionnaires were performed pre- and postoperatively. Patient satisfaction was also ascertained. Thirty-five women, who underwent a two-suture high uterosacral suspension, participated. Mean follow-up interval was 23.1+/-10.1 months. Postoperative point C was -7.8+/-1.60 (median, -8.0, range, -4.0 to -10.0), and the mean preoperative to postoperative change in point C was 5.9+/-5.56 cm (median 4.75, range -3.0 to 20.0, p-value<0.0001). Patient satisfaction was high with 88.9% indicating that they would have the surgery again. There were no ureteral injuries or kinks noted on intraoperative cystoscopy. No patient required reoperation for recurrent prolapse or urinary incontinence. Overall, the two-suture high uterosacral vaginal vault suspension is an acceptable technique for repairing apical prolapse.

Anterior compartment prolapse repair with a hybrid biosynthetic mesh implant technique

The aim of the present study is to assess the safety and feasibility of a new technique for cystocele repair using a hybrid biosynthetic graft fixed by the transobturator approach. This is a retrospective study of 13 women diagnosed with symptomatic anterior compartment prolapse that were in stages II and IV, using Pelvic Organ Prolapse Quantification score and treated between 2003 and 2006. The surgical procedure was carried out through a vaginal approach, exposing the arcus tendineus and the posterior surface of the obturator foramen from the ischial spine to the inferior pubic ramus bone. The patients were followed-up after 3, 6 and 12 months. The anatomical cure rate was 85% (stage 0), although two patients had a recurrence 8 months after surgery. All patients would repeat the procedure, if necessary. No de novo dyspareunia was observed in these small series. The results suggest that this technique is safe and feasible and is a comprehensive surgical approach for anterior compartment prolapse, without postoperative morbidity.

Sensory nerve injury after uterosacral ligament suspension

OBJECTIVE

Uterosacral ligament suspension is a technique that is performed commonly to suspend the prolapsed vaginal apex. This case series describes our experience with the clinical evaluation and management of lower extremity sensory nerve symptoms after uterosacral ligament suspension.

STUDY DESIGN

Hospital and office medical records from our 2 institutions were reviewed from January 2002 to August 2005, and all women who underwent uterosacral ligament suspension through a vaginal approach were identified. Women with symptoms of buttock and posterior thigh pain during the 6-week postoperative period were identified, and detailed clinical information was abstracted from the charts.

RESULTS

From 182 uterosacral ligament suspension procedures, 7 women were identified. The age range was 42 to 70 years. Concurrent procedures included 6 vaginal hysterectomies, 5 anterior repairs, 4 posterior repairs, 2 slings, and 1 bilateral salpingo-oophorectomy. Within 24 hours of the surgical procedure, all the women experienced similar, substantial sharp buttock pain and numbness that radiated down the center of the posterior thigh to the popliteal fossa in 1 or both lower extremities. The ipsilateral uterosacral ligament suture was removed within 2 days of the procedure in 3 women who had immediate subjective reduction in their pain and complete resolution of pain by 6 weeks. The remaining 4 women were treated with gabapentin and narcotics. Three women had resolution of the pain by 12 to 14 weeks after the operation, and the last woman's pain resolved gradually by 6 months.

CONCLUSION

Women who undergo uterosacral ligament suspension are at risk of postoperative pain and numbness in a S2-4 distribution. These symptoms appear to be related to the placement of uterosacral ligament sutures and may be relieved either by prompt removal of the ipsilateral uterosacral ligament suture or with prolonged medical therapy.

Uterosacral ligament vault suspension: five-year outcomes

OBJECTIVE

To evaluate the five-year anatomic and functional outcomes of the high uterosacral vaginal vault suspension.

METHODS

One hundred ten patients with advanced symptomatic uterovaginal or posthysterectomy prolapse treated between January 1997 and January 2000 were identified and 72 (65%) consented to participate in this study. Anatomic outcomes were obtained by Pelvic Organ Prolapse Quantification. Functional results were obtained subjectively and with quality-of-life questionnaires, including the short-form Incontinence Impact Questionnaire (IIQ) and Urogenital Distress Inventory (UDI), and Female Sexual Function Index.

RESULTS

The mean follow-up period was 5.1 years (range 3.5-7.5 years). Vaginal hysterectomy (37.5%), anterior colporrhaphy (58.3%), posterior colporrhaphy (87.5%), and suburethral slings (31.9%) were performed as indicated. Surgical failure (symptomatic recurrent prolapse of stage 2 or greater in one or more segments) was 11 of 72 (15.3%). Two patients (2.8%) had recurrence of apical prolapse of stage 2 or greater. For those sexually active preoperatively and postoperatively (n=34), mean postoperative Female Sexual Function Index scores for arousal, lubrication, orgasm, satisfaction, and pain were normal, whereas the desire score was abnormal (mean= 3.2). However, 94% (n=29) were currently satisfied with their sexual activity. Postoperative IIQ/UDI scores were significantly improved in all three domains (irritative, P= .01; obstructive, P<.001; stress, P=.03) and overall (IIQ-7, P<.001; UDI, P<.001) compared with preoperatively. Bowel dysfunction occurred 33.3% preoperatively compared with 27.8% postoperatively (P=.24).

CONCLUSION

Uterosacral ligament vaginal vault fixation seems to be a durable procedure for vaginal repair of enterocele and vaginal vault prolapse. Lower urinary tract, bowel, and sexual function may be maintained or improved.

Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and quality of life outcomes

Our aim was to study the anatomic recurrence rates and quality of life outcomes of patients who had undergone either anterior colporrhaphy (AC) or anterior colporrhaphy and vaginal paravaginal repair (AC + VPVR) as part of surgery for pelvic organ prolapse. Chart reviews were used to identify anatomic prolapse recurrence. Phone interviews assessed quality of life outcomes [Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ)] outcomes. There was a trend towards longer time to anatomic recurrence (any compartment > or =grade 2) in the AC group compared with the AC + VPVR group (median 24 vs 13 months, p=0.069). If only patients who had undergone previous surgery were compared, time to anatomic recurrence appeared significantly longer in the AC group (median 41 vs 12 months, p=0.022). There were 55% of women in the AC group and 46% of women in the AC + VPVR group who reported significant bladder or bulge symptoms based on responses to the phone-administered UDI and IIQ (p=0.89). Our retrospective study did not suggest that adding VPVR was superior in terms of anatomic or quality of life outcomes. Prospective assessment of the role of VPVR in the treatment of pelvic organ prolapse is needed.

Relationship of the uterosacral ligament to the sacral plexus and to the pudendal nerve

We describe the anatomy of the uterosacral ligament with respect to the sacral plexus. In six adult female embalmed cadavers, we identified the uterosacral ligament and its lateral nerve relations. Using the ischial spine as the starting point and measuring along the axis of the uterosacral ligament, we noted that the S1 trunk of the sacral plexus passes under the ligament 3.9 cm [95% confidence interval (CI), 2.1-5.8 cm] superior to the ischial spine. The S2 trunk passes under the ligament at 2.6 cm (95% CI; 1.5, 3.6 cm), the S3 trunk passes under the ligament at 1.5 cm (95% CI; 0.7, 2.4 cm), and the S4 trunk passes under the ligament at 0.9 cm (95% CI; 0.3, 1.5 cm) superior to the ischial spine. The pudendal nerve forms lateral to the uterosacral ligament. Our data demonstrate that the S1-S4 trunks of the sacral plexus, not the pudendal nerve, are vulnerable to injury during uterosacral ligament suspension.

Functional results and quality-of-life after bilateral sacrospinous ligament fixation for genital prolapse

OBJECTIVES

To evaluate intra- and post-operative complications, anatomical results, quality-of-life and sexuality after bilateral sacrospinous ligament fixation (SSLF).

STUDY DESIGN

Retrospective longitudinal study. Between March 2001 and September 2003, 51 women with stage III or IV genital prolapse underwent bilateral SSLF at the gynecology and obstetrics university department of Tenon Hospital, Paris, France. The population characteristics were as follows: mean age (+/-S.D.) was 64+/-10 years. Mean+/-SD BMI was 25+/-4 and median (range) parity was (0-12). Forty-eight (94%) women were post-menopausal, and one-third had previously undergone hysterectomy. Intra- and post-operative complications and anatomical results were recorded. Quality-of-life questionnaires (IIQ-7 and PISQ-12) and numerical analog scales were administered as well as nine questions on digestive symptoms.

RESULTS

The overall complication rate was 17.3%, with rectal injury in one (1.9%) women. One pararectal hematoma necessitated repeat surgery. Anterior vaginal wall prolapse (Ba=-1) occurred in three women, at 10, 16 and 19 months, but did not necessitate further surgery. The global patient satisfaction rate after bilateral SSLF was 93% (47 women). Digestive symptoms were improved after bilateral SSLF. The mean pre- and post-operative scores on the IIQ-7 and PISQ-12 questionnaires were 41+/-27 and 10+/-18 (p<0.0001), and 62+/-14 and 72+/-11 (p<0.0001), respectively. Posterior perineorrhaphy was associated with significantly altered sexuality.

CONCLUSION

These results support the feasibility of bilateral SSLF: intra- and post-operative complication rates are acceptable, quality-of-life and sexuality are improved, and bowel function is unaffected.

The incidence of ureteral obstruction and the value of intraoperative cystoscopy during vaginal surgery for pelvic organ prolapse

OBJECTIVE

The objective of the study was to determine the incidence of ureteral obstruction during vaginal surgery for pelvic organ prolapse and the accuracy and efficacy of intraoperative cystoscopy.

STUDY DESIGN

The study was a retrospective review of 700 consecutive patients who underwent vaginal surgery for anterior and/or apical pelvic organ prolapse with universal intraoperative cystoscopy.

RESULTS

Thirty-seven patients (5.3%) had no spillage of dye from 1 or both ureters intraoperatively. The false-positive and negative cystoscopy rates were 0.4% and 0.3%, respectively. Thus, the true incidence of intraoperative ureteral obstruction was 5.1%. Intraoperative cystoscopy was accurate in 99.3% of cases, with a sensitivity and specificity of 94.4% and 99.5%, respectively. Suture removal relieved ureteral obstruction in 88% of cases. Six subjects (0.9%) had true ureteral injuries.

CONCLUSION

Vaginal surgery for anterior and/or apical pelvic organ prolapse is associated with an intraoperative ureteral obstruction rate of 5.1%. Intraoperative cystoscopy accurately detects ureteral obstruction and allows for relief of obstruction in the majority of cases.

Outcomes with porcine graft placement in the anterior vaginal compartment in patients who undergo high vaginal uterosacral suspension and cystocele repair

OBJECTIVE

The purpose of this study was to prospectively assess the cases of patients who had undergone a high uterosacral suspension and anterior repair with anterior compartment placement of porcine dermis graft.

STUDY DESIGN

Thirty-six patients who underwent transvaginal high uterosacral suspension and cystocele repair with graft augmentation from June 2001 to July 2004 were identified from the University of Alabama at Birmingham Genitourinary Disorders database. Analysis included the pre- and postoperative Pelvic Organ Prolapse Quantification examinations and incontinence impact questionnaire-7/urogenital distress inventory-6.

RESULTS

Mean Pelvic Organ Prolapse Quantification Ba improved from +3.3 +/- 2.2 cm to -0.6 +/- 1.7 cm (P < .01). Postoperative Ba was prolapse stage II or greater in 50% of subjects. Mean incontinence impact questionnaire-7 scores improved from 36.2 +/- 31.9 to 15.6 +/- 26.2 (P < .01), as did mean urogenital distress inventory-6 scores from 58.2 +/- 26.8 to 23.8 +/- 22.6 (P < .01).

CONCLUSION

Significant improvements in Pelvic Organ Prolapse Quantification measures, urinary symptoms, and the impact of incontinence were seen after the operation. However, a significant proportion of patients had Pelvic Organ Prolapse Quantification stage II prolapse or greater, which made it unclear whether graft use confers a significant advantage.

Neural pain after uterosacral ligament vaginal suspension

Neural compromise has been reported after a wide variety of reconstructive pelvic procedures. We report on two women who had undergone a seemingly uncomplicated transvaginal uterosacral suspension for the treatment of pelvic organ prolapse. Both women presented shortly after surgery with a unilateral, shooting groin pain with radiation along the ipsilateral lumbosacral nerve distribution. Surgical removal of the permanent stitch and physical therapy provided prompt and near-complete relief. This case report describes the possibility of neural compromise after uterosacral ligament suspension.

Histopathological evaluation of the uterosacral ligament: is this a dependable structure for pelvic reconstruction?

OBJECTIVE

To explore, by histological examination, whether the uterosacral ligament complex is an adequate support structure for vaginal vault suspension and other reconstructive procedures of the female pelvis.

MATERIALS AND METHODS

We dissected 14 fresh hemipelves from seven adult female cadavers. The uterosacral complexes were excised from the pelvic sidewall immediately beneath the uterosacral pedicle. The specimens were stained with connective tissue-specific Movat stain and evaluated microscopically for the presence of collagen and/or elastin.

RESULTS

Uterosacral tissue similar to that identified during pelvic reconstructive surgery was obtained in all cases. Six of the women had had a hysterectomy. A ligamentous structure with clearly aligned collagen and interspersed elastin was identified in only three specimens, two from one cadaver of a young woman who had not had a hysterectomy. The other specimens had an attenuated, poorly organized layer of collagen immediately beneath the peritoneum.

CONCLUSION

We could not consistently identify normal ligamentous tissue in the uterosacral complexes. The overwhelming majority of specimens from women who had had a hysterectomy showed disorganized tissue with reduced cellularity. This reinforces doubts about the integrity of these tissues as structural supports in pelvic reconstructive surgery, particularly in elderly women who have had a hysterectomy.