1
|
Barba M, Cola A, Costa C, De Vicari D, Amatucci N, Melocchi T, Frigerio M. Outcomes of uterosacral ligaments suspension for uterovaginal prolapse native-tissue repair: Over 1000-patient single-center study. Eur J Obstet Gynecol Reprod Biol 2024; 301:206-209. [PMID: 39154516 DOI: 10.1016/j.ejogrb.2024.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 08/04/2024] [Accepted: 08/12/2024] [Indexed: 08/20/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Surgical repair is the mainstay of genital prolapse management. Among native-tissue apical procedures, high uterosacral ligaments suspension is considered a valid and effective option for central compartment repair. In this study, we aimed to evaluate the effectiveness, complications rate, and functional results of high USL suspension as a primary prolapse repair technique in a large cohort of patients. METHODS Patients who underwent vaginal hysterectomy followed by high uterosacral ligaments suspension for POP between January 2008 and December 2020 were retrospectively analyzed. Questionnaires and clinical interviews were preoperatively performed to assess symptoms and severity of urinary, bowel, and sexual dysfunctions. After surgical procedure, diagnostic cystoscopy was performed to evaluate ureteral patency. Postoperative data, objective, and subjective cure rate were then noted at the follow-up evaluation. RESULTS A total of 1099 patients underwent high uterosacral ligaments suspension. The total complication rate was 3.4 % and recurrence in any of the vaginal compartments was 12.4 %. Reoperation for symptomatic prolapse recurrence or pessary treatment was required in 9 women (0.9 %). In the evaluation of postoperative questionnaires, functional outcomes analysis revealed a significant improvement (p < 0.05) in terms of stress urinary incontinence, urge urinary incontinence, voiding symptoms, constipation, and dyspareunia after prolapse repair. CONCLUSION Uterosacral ligament suspension is a safe and effective procedure for primary surgical treatment of pelvic organ prolapse. Anatomical, functional, and subjective outcomes were very satisfactory, and the reoperation rate for recurrence was below 1%.
Collapse
Affiliation(s)
- Marta Barba
- Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alice Cola
- Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | | | | | | | | |
Collapse
|
2
|
Barba M, Cola A, De Vicari D, Melocchi T, Gili MA, Frigerio M. Enhanced recovery after surgery (ERAS) in prolapse repair: A prospective study on pre-emptive uterosacral/cervical block. Int J Gynaecol Obstet 2024; 166:1240-1246. [PMID: 38516832 DOI: 10.1002/ijgo.15483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) protocols have been introduced in gynecology. Postoperative pain management after vaginal procedures remains a relevant issue. In the present study we aimed to evaluate the effectiveness of pre-emptive uterosacral/cervical block (PUCB) for postoperative pain control in patients with uterovaginal prolapse undergoing vaginal hysterectomy and pelvic floor repair. We also evaluated the impact on the length of recovery. METHODS This was a pilot study analyzing 40 women who underwent pelvic organ prolapse repair through uterosacral ligament suspension. Patients who chose to undergo PUCB were considered as cases, otherwise as controls. After general or spinal anesthesia induction, the treatment group received the PUCB with ropivacaine plus clonidine injections at 2, 4, 8, and 10 o'clock of the cervix. The control group did not receive additional treatment. Pain intensity was measured at rest and after forceful cough at 1, 4, 8, 12, 24, and 48 h postoperatively. RESULTS We found a significant reduction in pain values at 1 h (rest and forceful cough) and 24 h (forceful cough) in the PUCB group. The incidence of moderate/severe pain was inferior in the PUCB group at 1 h (rest) and 24 h (rest and forceful cough). There were no differences in terms of the use of rescue opioids (0% vs. 5%; P = 0.311) and length of hospital stay (2.5 ± 0.6 vs. 2.3 ± 0.6; P = 0.180). CONCLUSIONS For the first time, we demonstrated the impact of pre-emptive uterosacral/cervical block on pain control up to 24 h after surgery. Clonidine as a sensory blockade extender appears promising in enhancing the efficacy of local anesthetics.
Collapse
Affiliation(s)
- Marta Barba
- Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alice Cola
- Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | | | | | | |
Collapse
|
3
|
Barba M, Cola A, Frigerio M. Intraoperative Fluorescent Ureter Visualization for Transvaginal High Uterosacral Ligament Suspension for Severe Pelvic Organ Prolapse. Int Urogynecol J 2024; 35:1549-1551. [PMID: 38780627 DOI: 10.1007/s00192-024-05816-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/18/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION AND HYPOTHESIS We aimed to demonstrate the feasibility of ureteral navigation using intra-ureteric indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during transvaginal high uterosacral ligament suspension for prolapse repair to reduce the risk of iatrogenic ureteral injury. METHODS A cystoscope was inserted into the bladder, the tip of a 6-F open-end ureteral catheter was inserted into the ureteral orifices, and ICG was instilled into the ureters. The ureteral path was then clearly identified using NIRF imaging. Sutures were safely placed in the uterosacral ligaments at the level of the ischial spine, taking advantage of direct ureteral visualization. RESULTS At the end of the procedure, diagnostic cystoscopy was performed to confirm ureteral patency. No intraoperative or postoperative complications were observed. CONCLUSIONS Intra-ureteric ICG-NIRF imaging represents a simple, inexpensive, and reproducible trick for intraoperative ureteral detection, and could reassure surgeons during difficult operations, for instance, in the case of severe prolapse and/or when ureteral course abnormalities are expected.
Collapse
Affiliation(s)
- Marta Barba
- Department of Gynecology, Fondazione IRCCS San Gerardo Dei Tintori-University of Milano-Bicocca, Via Pergolesi 33, Monza, Italy
| | - Alice Cola
- Department of Gynecology, Fondazione IRCCS San Gerardo Dei Tintori-University of Milano-Bicocca, Via Pergolesi 33, Monza, Italy
| | - Matteo Frigerio
- Department of Gynecology, Fondazione IRCCS San Gerardo Dei Tintori-University of Milano-Bicocca, Via Pergolesi 33, Monza, Italy.
| |
Collapse
|
4
|
Barba M, Cola A, Costa C, Frigerio M. Impact of Mannitol Bladder Distension in the Intraoperative Detection of Ureteral Kinking During Pelvic Floor Surgery. Int Urogynecol J 2024; 35:689-694. [PMID: 38393333 PMCID: PMC11024013 DOI: 10.1007/s00192-024-05745-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/16/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Ureteral injuries are the most feared complications of gynecological surgery and therefore intraoperative recognition is of the utmost importance. Intraoperative cystoscopy represents the diagnostics of choice to investigate ureteral patency thanks to the direct visualization of ureteral flows after administration of infusion mediums. In this study, we aimed to compare the diagnostic performance of saline versus mannitol intraoperative cystoscopy in terms of false negatives in a large cohort of patients. METHODS We retrospectively analyzed data of patients who underwent vaginal hysterectomy and high uterosacral ligament suspension for POP. Patients were divided in two groups based on the use of saline or mannitol medium for intraoperative cystoscopy. Postoperative daily control of serum creatinine was performed until discharge, as well as urinary tract imaging, in symptomatic patients. RESULTS A total of 925 patients underwent vaginal hysterectomy followed by high USL suspension for POP. Saline and mannitol medium were used in 545 patients and 380 patients respectively. Postoperative ureteral injuries were identified in 12 patients, specifically in 2% of the saline group and in 0.3% of the mannitol group. CONCLUSIONS The use of mannitol instead of saline as a bladder distension medium was able to significantly reduce the occurrence of postoperative ureteral sequelae.
Collapse
Affiliation(s)
- Marta Barba
- Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Alice Cola
- Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
| | - Clarissa Costa
- Milano-Bicocca University, Via G.B. Pergolesi 33, 20900, Monza, Italy.
| | | |
Collapse
|
5
|
Andebrhan SB, Caron AT, Szlachta-McGinn A, Parameshwar PS, Jackson NJ, Rosenman AE, Anger JT, Ackerman AL. Pelvic organ prolapse recurrence after pregnancy following uterine-sparing prolapse repair: a systematic review and meta-analysis. Int Urogynecol J 2023; 34:345-356. [PMID: 35920935 DOI: 10.1007/s00192-022-05306-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 07/07/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION We sought to determine rates of pelvic organ prolapse (POP) recurrence following pregnancy and delivery in reproductive-age women with prior hysteropexy. METHODS Scopus, MEDLine, EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched from inception to May 2020 for combinations of any of the keywords: "pregnancy", "delivery", "fertility", or "cesarean" with a comprehensive list of uterine-sparing surgical procedures for POP repair. Using approach, 1,817 articles were identified describing surgical, uterine-sparing POP repair techniques and subsequent pregnancy and delivery outcomes in reproductive-age women. RESULTS: Twenty-seven studies describing 218 pregnancies, including 215 deliveries and 3 abortions, were summarized using narrative review and descriptive statistics. Successful pregnancies were reported following a diverse range of uterine-sparing prolapse repairs, both native tissue and mesh-augmented, that utilized vaginal, open abdominal, and laparoscopic approaches. We observed shifts from native tissue repairs to mesh-augmented laparoscopic repairs over time. POP recurrence occurred in 12% of subjects overall, 15% after vaginal and 10% after abdominal prolapse repairs. While meta-analysis identified higher recurrence rates after vaginal delivery (15%) than cesarean section (10%), due to small study numbers, multiple confounders, and heterogeneity between studies, no significant differences in recurrence rates could be identified between vaginal and abdominal surgical approaches, utilization of mesh augmentation, or mode of delivery. CONCLUSION Although literature on pregnancy following uterine-sparing POP repair is limited, available data suggest that prolapse recurrence after pregnancy and delivery remains similar to that after prolapse repair without subsequent pregnancies with few documented perinatal complications. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021247722.
Collapse
Affiliation(s)
- Sarah B Andebrhan
- Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, IL, USA
| | - Ashley T Caron
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Alec Szlachta-McGinn
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Nicholas J Jackson
- Department of Internal Medicine and Health Services Research, UCLA, Los Angeles, CA, USA
| | - Amy E Rosenman
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jennifer T Anger
- Department of Urology, University of California, San Diego, CA, USA
| | - A Lenore Ackerman
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA. .,Department of Urology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Box 951738, Los Angeles, CA, 90095-1738, USA.
| |
Collapse
|
6
|
Frigerio M, Barba M, Cola A, Spelzini F, Milani R, Manodoro S. Coexisting overactive-underactive bladder and detrusor overactivity-underactivity in pelvic organ prolapse. Int J Gynaecol Obstet 2023; 160:256-262. [PMID: 35617299 PMCID: PMC10083922 DOI: 10.1002/ijgo.14288] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/19/2022] [Accepted: 05/24/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The coexisting overactive-underactive bladder (COUB) syndrome could be related to the increased urethral resistance caused by severe pelvic organ prolapse (POP). We aimed to evaluate the clinical and urodynamic findings of patients with COUB and/or detrusor overactivity-underactivity (DOU) in a cohort of patients scheduled for POP surgery and the possible risk factors of COUB after surgery. METHODS This retrospective study analyzed all patients who underwent POP repair between 2008 and 2013, excluding women with a history of pelvic floor surgery. Patients were divided into COUB and non-COUB according to baseline symptoms and into DOU and non-DOU based on urodynamic findings. A multivariate model was performed to identify risk factors for COUB symptoms after surgery. RESULTS A total of 533 women underwent POP surgery. Preoperatively, patients with COUB had more severe anterior compartment prolapse (Pelvic Organ Prolapse Quantification staging system Aa point, P = 0.008) and more frequently had overactive bladder compared with controls (P = 0.023). The rate of COUB decreased significantly after surgery. Preoperative opening detrusor pressure resulted as the only independent predictor of postoperative COUB symptoms (P = 0.034). CONCLUSION POP is a valid pathogenetic model for COUB development. POP repair induced a significant decrease in COUB symptoms with low opening detrusor pressure resulting as the only independent predictor of postoperative COUB.
Collapse
Affiliation(s)
- Matteo Frigerio
- Department of Obstetrics and Gynecology, ASST Monza, Ospedale San Gerardo, Monza, Italy.,Department of Obstetrics and Gynecology, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Marta Barba
- Department of Obstetrics and Gynecology, ASST Monza, Ospedale San Gerardo, Monza, Italy.,Department of Obstetrics and Gynecology, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Alice Cola
- Department of Obstetrics and Gynecology, ASST Monza, Ospedale San Gerardo, Monza, Italy.,Department of Obstetrics and Gynecology, Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Federico Spelzini
- Department of Obstetrics and Gynecology, AUSL Romagna, Ospedale Infermi, Rimini, Italy
| | - Rodolfo Milani
- Department of Obstetrics and Gynecology, ASST Monza, Ospedale San Gerardo, Monza, Italy
| | - Stefano Manodoro
- Department of Obstetrics and Gynecology, ASST Santi Paolo e Carlo, Ospedale San Paolo, Milan, Italy
| |
Collapse
|
7
|
Cola A, Marino G, Milani R, Barba M, Volontè S, Spelzini F, Manodoro S, Frigerio M. Native-tissue prolapse repair: efficacy and adverse effects of uterosacral ligaments suspension at 10-year follow up. Int J Gynaecol Obstet 2022; 159:97-102. [PMID: 35044675 PMCID: PMC9544876 DOI: 10.1002/ijgo.14096] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/18/2021] [Accepted: 01/12/2022] [Indexed: 11/24/2022]
Abstract
Objective To evaluate the 10‐year outcomes of high uterosacral ligaments suspension as a primary repair for apical prolapse and to evaluate the long‐term impact of prognostic factors. Methods A retrospective study analyzed 10‐year follow up after repair of primary apical prolapse through high uterosacral ligament suspension. Bulging symptoms and postoperative prolapse stage II or above were considered subjective and objective recurrences, respectively. Patient Global Impression of Improvement score was used to evaluate subjective satisfaction after surgery. Results A total of 287 women were analyzed. Ten‐year recurrence rates were 19.1% for objective recurrence and 6.3% for subjective recurrence; surgical retreatment rate was 2.1%. Premenopausal status was related to 15‐fold increased risk of developing either objective or subjective recurrence. Conversely, anterior and posterior repair were protective factors against reoperation. Conclusion High uterosacral ligaments suspension is a safe and long‐lasting effective procedure for the treatment of uterovaginal prolapse even 10 years after index surgery. Premenopausal status and lack of anterior and posterior repair represented long‐term risk factors for surgical failure.
Collapse
|
8
|
Kapurubandara SC, Lowes B, Sansom-Daly UM, Deans R, Abbott JA. A systematic review of diagnostic tests to detect pelvic floor myofascial pain. Int Urogynecol J 2022; 33:2379-2389. [PMID: 35796787 PMCID: PMC9427874 DOI: 10.1007/s00192-022-05258-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/24/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Myofascial pain arising from pelvic floor muscles occurs in women with vaginismus, interstitial cystitis and endometriosis but is often overlooked. The aim is to examine alternative diagnostic tests to detect pelvic floor myofascial pain compared with standardized vaginal palpation of pelvic floor muscles as the reference test. METHODS A systematic review was prospectively conducted (PROSPERO-CRD42020183092) according to PRISMA guidelines. Databases searched included Ovid Medline 1946-, Embase 1957-, Scopus 1960-, Cochrane Combined, Clinical trials, Google Scholar (top 200 articles), Web of Science, TRIP, BIOSIS, DARE, CINHAL, EmCare, PEDro, ProQuest and EBSCOhost up to July 2020. Articles were independently screened by two authors and assessed for bias using QUASDAS-2 tool. RESULTS A total of 26,778 articles were screened and 177 were selected for full text review, of which 5 were selected for final analysis. Five studies included 9694 participants of which 1628 had pelvic floor myofascial pain. Only one study reported data to calculate sensitivities and specificities of the index test, which utilized a score of > 40 on the Central Sensitization Inventory to detect women with pelvic floor myofascial pain and revealed a sensitivity of 34.8% and a specificity of 84.9% compared to the reference test. CONCLUSIONS This systematic review did not reveal any diagnostic test superior to the pre-defined reference test. There is a lack of consensus on the definition of pelvic floor myofascial pain and a lack of a validated diagnostic criteria which must be addressed to progress with meaningful research in this field.
Collapse
Affiliation(s)
- Supuni C. Kapurubandara
- School of Clinical Medicine, UNSW Medicine & Health, Discipline of Obstetrics and Gynaecology, Level 1, Royal Hospital for Women, Barker Street, Randwick, Sydney, NSW 2031 Australia ,Department of O&G, Westmead Hospital, Sydney, Australia ,Sydney West Advanced Pelvic Surgical Unit, SWAPS, Sydney, Australia
| | - Basia Lowes
- Sydney West Advanced Pelvic Surgical Unit, SWAPS, Sydney, Australia ,Western Sydney University, Sydney, Australia ,Department of O&G, Blacktown Hospital, Sydney, Australia
| | - Ursula M. Sansom-Daly
- School of Clinical Medicine, UNSW Medicine & Health, Discipline of Obstetrics and Gynaecology, Level 1, Royal Hospital for Women, Barker Street, Randwick, Sydney, NSW 2031 Australia ,Behavioural Sciences Unit, Kids Cancer Centre, Sydney Children’s Hospital, Sydney, Australia ,Sydney Youth Cancer Service, Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Sydney, Australia
| | - Rebecca Deans
- School of Clinical Medicine, UNSW Medicine & Health, Discipline of Obstetrics and Gynaecology, Level 1, Royal Hospital for Women, Barker Street, Randwick, Sydney, NSW 2031 Australia ,GRACE Unit, Royal Hospital for Women, Sydney, Australia
| | - Jason A. Abbott
- School of Clinical Medicine, UNSW Medicine & Health, Discipline of Obstetrics and Gynaecology, Level 1, Royal Hospital for Women, Barker Street, Randwick, Sydney, NSW 2031 Australia ,GRACE Unit, Royal Hospital for Women, Sydney, Australia
| |
Collapse
|
9
|
Hickman LC, Tran MC, Paraiso MFR, Walters MD, Ferrando CA. Intermediate term outcomes after transvaginal uterine-preserving surgery in women with uterovaginal prolapse. Int Urogynecol J 2021; 33:2005-2012. [PMID: 34586437 PMCID: PMC8479721 DOI: 10.1007/s00192-021-04987-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/24/2021] [Indexed: 12/02/2022]
Abstract
Introduction and hypothesis There is growing interest in and performance of uterine-preserving prolapse repairs. We hypothesized that there would be no difference in pelvic organ prolapse (POP) recurrence 2 years following transvaginal uterosacral ligament hysteropexy (USLH) and sacrospinous ligament hysteropexy (SSLH). Methods This is a retrospective cohort study with a cross-sectional survey of women who underwent transvaginal uterine-preserving POP surgery from May 2016 to December 2017. Patients were included if they underwent either USLH or SSLH. POP recurrence was defined as a composite of subjective symptoms and/or retreatment. A cross-sectional survey was used to assess pelvic floor symptoms and patient satisfaction. Results A total of 47 women met the criteria. Mean age was 52.8 ± 12.5 years, and all had a preoperative POP-Q stage of 2 (55.3%) or 3 (44.7%). Thirty (63.8%) underwent SSLH and 17 (36.2%) underwent USLH. There were no differences in patient characteristics or perioperative data. There was no difference in composite recurrence (26.7% [8] vs 23.5% [4]) and retreatment (6.7% [2] vs 0%) retrospectively between SSLH and USLH groups at 22.6 months. Survey response rate was 80.9% (38) with a response time of 30.7 (28.0–36.6) months. The majority of patients (84.2%) reported POP symptom improvement, and both groups reported great satisfaction (89.5%). In respondents, 13.2% (5) reported subjective recurrence and 5.3% (2) underwent retreatment, with no differences between hysteropexy types. There were no differences in other pelvic floor symptoms. Conclusions Although 1 in 4 women experienced subjective POP recurrence after transvaginal uterine-preserving prolapse repair and <5% underwent retreatment at 2 years, our results must be interpreted with caution given our small sample size. No differences in outcomes were identified between hysteropexy types; however, additional studies should be performed to confirm these findings. Both hysteropexy approaches were associated with great patient satisfaction. Supplementary Information The online version contains supplementary material available at 10.1007/s00192-021-04987-5
Collapse
Affiliation(s)
- Lisa C Hickman
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA. .,Division of Female Pelvic Medicine and Reconstructive Surgery, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, Room 504, OH, 43210, Columbus, USA.
| | - Misha C Tran
- University of Chicago School of Medicine, Chicago, IL, USA
| | - Marie Fidela R Paraiso
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mark D Walters
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cecile A Ferrando
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
10
|
Kachroo N, Raffee S, Elshatanoufy S, Atiemo H. High uterosacral ligament hysteropexy for the management of pelvic organ prolapse. Int Braz J Urol 2021; 47:902-904. [PMID: 33848087 PMCID: PMC8321477 DOI: 10.1590/s1677-5538.ibju.2020.0384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/25/2020] [Indexed: 11/22/2022] Open
Abstract
Objective: To demonstrate our transvaginal high uterosacral ligament (HUL) hysteropexy technique as an alternative mesh-free uterine-preserving pelvic organ prolapse (POP) repair approach and present our institutional outcomes. Concurrent hysterectomy with POP repair is controversial as uterine-preserving techniques may beneficially allow fertility, body image and sexual function preservation (1, 2). Materials and Methods: This video illustrates a step-by-step sequence of our HUL hysteropexy technique in a symptomatic Stage III POP patient. Retrospective single-institution, single-surgeon analysis of patients treated by either HUL hysteropexy or hysterectomy with HUL suspension for symptomatic prolapse was performed with minimum 2 years of follow-up. Patient demographics, operative characteristics, pre and post-operative POP-Q evaluation, American Urological Association Symptom scores (AUASS) and post-operative Pelvic Floor Distress Inventory (PFDI-20) were compared. Results: Surgery time was 3 hours 24 minutes. No immediate/early complications were noted, with successful repair on follow-up. Outcomes of 18 patients (10 HUL hysteropexy, 8 hysterectomy and HUL suspension) were assessed (Supplemental Table). The only baseline difference was a lower body mass index in the HUL hysteropexy cohort (25.8 vs. 35.8kg/m2, p=0.008). In the HUL hysteropexy cohort, blood loss (mean: 58 vs. 205ml, p=0.00086) and operative time (190.4 vs. 279.1minutes, p=0.0021) were significantly reduced. There was no difference in post-operative AUASS, POP-Q or PFDI-20 at 2 years. Conclusion: We present our HUL hysteropexy technique. Although limited by sample size and retrospective design, resulted in significantly reduced blood loss and operative time with comparable post-operative 2 year outcomes to non-uterine-preserving techniques. In our opinion, HUL hysteropexy is a safe, durable POP management option for women without significant endometrial pathology risk factors.
Collapse
Affiliation(s)
- Naveen Kachroo
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA.,Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Samantha Raffee
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| | | | - Humphrey Atiemo
- Vattikuti Urology Institute, Henry Ford Hospital, Detroit, MI, USA
| |
Collapse
|
11
|
Barba M, Schivardi G, Manodoro S, Frigerio M. Obstetric outcomes after uterus-sparing surgery for uterine prolapse: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 256:333-338. [PMID: 33271407 DOI: 10.1016/j.ejogrb.2020.11.054] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/18/2020] [Indexed: 11/18/2022]
Abstract
Up-to-date there are no guidelines about uterus-sparing prolapse repair procedures for women desiring childbearing. This systematic review and meta-analysis aims to evaluate obstetrical outcomes after uterus-sparing apical prolapse repair in terms of pregnancy rate, obstetrical adverse outcomes and delivery mode according to the type of procedure. To identify potentially eligible studies, we searched PubMed, Scopus, Cochrane Library and ISI Web of Science (up to April 15, 2020). Case reports, reviews, letters to Editor, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded. Twenty-four studies met inclusion criteria and were incorporated into the final assessment, which included 1518 surgical procedures. In total 151 patients got pregnant after prolapse surgical repair, for a resulting pregnancy raw rate of 9.9 %. Overall, adverse obstetric outcomes resulted low, rating 4.6 %. Manchester procedure resulted associated with the highest risk of adverse obstetrical outcomes and preterm premature rupture of membranes (p < 0.0001). After exclusion of Manchester procedure, sacrohysteropexy was found to be associated with higher risk of obstetrical adverse outcomes compared to native-tissue procedures (p = 0.04). Native-tissue surgery might represent the most cautious option for women wishing for pregnancy.
Collapse
|
12
|
Manodoro S, Braga A, Barba M, Caccia G, Serati M, Frigerio M. Update in fertility-sparing native-tissue procedures for pelvic organ prolapse. Int Urogynecol J 2020; 31:2225-2231. [PMID: 32809111 DOI: 10.1007/s00192-020-04474-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
Uterine-sparing prolapse surgery has been gaining back popularity with clinicians and patients. Although both prosthetic and native-tissue surgery procedures are described, the latter is progressively regaining a central role in pelvic reconstructive surgery, owing to a lack of mesh-related complications. Available native-tissue procedures have different advantages and pitfalls, as well as different evidence profiles. Most of them offer anatomical and subjective outcomes comparable with those of hysterectomy-based procedures. Moreover, native-tissue procedures in young women desiring childbearing allow to avoid synthetic material implantation, which may lead to potentially serious complications during pregnancy. As a consequence, we do think that offering a reconstructive native-tissue procedure for uterine preservation (with the exception of the Manchester procedure) is the safest option in women wishing for pregnancy. Sacrospinous ligament hysteropexy and high uterosacral ligament hysteropexy may be considered first-line options in consideration of the higher level of evidence and lack of adverse obstetrical outcomes.
Collapse
Affiliation(s)
| | - Andrea Braga
- EOC-Beata Vergine Hospital, Mendrisio, Switzerland
| | | | | | | | - Matteo Frigerio
- San Gerardo University Hospital, Via Pergolesi 33, 20900, Monza, Italy.
| |
Collapse
|
13
|
Uterus-Sparing Surgery: Outcomes of Transvaginal Uterosacral Ligament Hysteropexy. J Minim Invasive Gynecol 2020; 28:100-106. [PMID: 32387566 DOI: 10.1016/j.jmig.2020.04.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/21/2020] [Accepted: 04/26/2020] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Recently, there has been a paradigm shift toward uterine conservation during the surgical management of pelvic organ prolapse (POP), specifically uterine prolapse. There are few reports on transvaginal uterosacral ligament hysteropexy (TULH). This study aimed to describe our surgical technique and outcomes. DESIGN Retrospective review and description of surgical technique. Anatomic outcome has been reported using the POP quantification system. Complications were segregated. A comparison of parametric continuous variables was performed using paired t test. Categoric variables were evaluated using the Pearson χ2 test and the Fisher exact test. A p-value <.05 was considered significant. SETTING Teaching hospital. PATIENTS Forty patients who underwent TULH from 2009 to 2017. INTERVENTIONS TULH. MEASUREMENTS AND MAIN RESULTS A total of 40 patients met the inclusion criteria. Of these, 56.1% had preoperative stage 3 prolapse. The median operative time was 116 minutes. The mean estimated blood loss was 158.5 mL. Transient ureteral obstruction occurred in 2 patients. The mean follow-up time was 17.2 months, and all patients had significant improvement of prolapse (p <.001). There was also an improvement in urinary incontinence and bladder storage symptoms (p <.001). None of the patients were reoperated on for recurrent POP. CONCLUSION TULH is an effective uterus-preserving surgical alternative for the treatment of uterovaginal prolapse and provides good apical support. It is also associated with a low short-term recurrence and incidence of reoperation. TULH is a viable option for suitable patients with uterovaginal prolapse who desire uterine conservation.
Collapse
|
14
|
Milani R, Manodoro S, Cola A, Bellante N, Palmieri S, Frigerio M. Transvaginal uterosacral ligament hysteropexy versus hysterectomy plus uterosacral ligament suspension: a matched cohort study. Int Urogynecol J 2019; 31:1867-1872. [DOI: 10.1007/s00192-019-04206-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/03/2019] [Indexed: 11/25/2022]
|
15
|
Deo G, Bernasconi DP, Cola A, Palmieri S, Spelzini F, Milani R, Manodoro S, Frigerio M. Long-term outcomes and five-year recurrence-free survival curves after native-tissue prolapse repair. Int J Gynaecol Obstet 2019; 147:238-245. [PMID: 31400224 DOI: 10.1002/ijgo.12938] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/03/2019] [Accepted: 08/08/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the long-term objective and subjective outcomes to build recurrence-free survival curves after mesh-free uterosacral ligament suspension and to evaluate the long-term impact of prognostic factors on outcome measures. METHODS A retrospective study analyzed 5-year follow-up after repair of primary prolapse through high uterosacral ligament suspension. Bulging symptoms and post-operative prolapse stage II or above were considered subjective and objective recurrences, respectively. The cumulative proportion of relapse-free patients in time was analyzed by Kaplan-Meier curves. RESULTS A total of 353 women were analyzed. Five-year recurrence rates were 15.0% for objective recurrence, 13.0% for subjective recurrence, and 4.0% for the combined objective and subjective recurrences. Premenopausal status was shown to be a risk factor for anatomic (P=0.022), symptomatic (P=0.001), and combined (P=0.047) recurrence. Conversely, anterior repair was shown to be a protective factor for symptomatic (P=0.012) and combined (P=0.002) recurrence. Most of the recurrences occurred within 2 years after surgery. CONCLUSION Long-term outcomes after high uterosacral ligament suspension were satisfactory. Premenopausal status and lack of anterior repair represented risk factors for recurrence in the long term.
Collapse
Affiliation(s)
- Giuseppe Deo
- School of Medicine, University Milano-Bicocca, Milan, Italy
| | | | - Alice Cola
- School of Medicine, University Milano-Bicocca, Milan, Italy.,Department of Gynecology, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Stefania Palmieri
- School of Medicine, University Milano-Bicocca, Milan, Italy.,Department of Gynecology, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Federico Spelzini
- Department of Gynecology, AUSL Romagna, Infermi Hospital, Rimini, Italy
| | - Rodolfo Milani
- Department of Gynecology, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Stefano Manodoro
- Department of Gynecology, AUSL Romagna, Infermi Hospital, Rimini, Italy
| | - Matteo Frigerio
- School of Medicine, University Milano-Bicocca, Milan, Italy.,Department of Gynecology, ASST Monza, San Gerardo Hospital, Monza, Italy
| |
Collapse
|
16
|
Outcomes of Transvaginal High Uterosacral Ligaments Suspension: Over 500-Patient Single-Center Study. Female Pelvic Med Reconstr Surg 2019; 24:203-206. [PMID: 29697546 DOI: 10.1097/01.spv.0000533751.41539.5b] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Uterosacral ligament (USL) suspension is a safe and effective procedure in terms of anatomical, functional, and subjective outcomes for primary surgical treatment of prolapse. OBJECTIVES There has been a renewed interest toward native tissue prolapse repair by vaginal route because of low cost and lack of mesh-related complications. Uterosacral ligaments are considered safe, effective, and durable as suspending structures for primary surgical repair of the apical compartment. Our aim was to evaluate complications, anatomical, functional and subjective outcomes of high USL suspension for primary prolapse repair. METHODS Data of patients who underwent vaginal hysterectomy followed by high USL suspension for pelvic organ prolapse were retrospectively analyzed. Operative data, as well as complications, were recorded. Anatomical recurrence was defined as descent of any compartment stage II or greater according to the Pelvic Organ Prolapse Quantification system. Functional outcomes focused on urinary, bowel, and sexual dysfunctions. International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, Wexner, and Patient Global Impression of Improvement questionnaires were collected. RESULTS Data of 533 women were analyzed. Mean follow-up was 32 (SD, 19) months (dropout rate, 2.6%). Most frequent complication was ureteral kinking (2.6%). Total recurrence rate was 13.7%, with anterior compartment being the most frequent (9.4%), whereas reoperation for symptomatic prolapse recurrence was required in only 1% of patients. Improvement of urinary incontinence, voiding dysfunction, constipation, and dyspareunia was observed. Overall subjective satisfaction was high (Patient Global Impression of Improvement score, 1.3), ranging from "much improved" to "very much improved." CONCLUSIONS Uterosacral ligament suspension is a safe and effective procedure in primary surgical treatment of pelvic organ prolapse. Anatomical, functional, and subjective outcomes were very satisfactory, and reoperation rate for recurrence was only 1%.
Collapse
|
17
|
Risk factors for persistent, de novo and overall overactive bladder syndrome after surgical prolapse repair. Eur J Obstet Gynecol Reprod Biol 2018; 233:141-145. [PMID: 30597338 DOI: 10.1016/j.ejogrb.2018.12.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 11/02/2018] [Accepted: 12/21/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Overactive bladder (OAB) symptoms are frequently associated with pelvic organ prolapse (POP) and both postoperative improvement and de novo onset of OAB symptoms have been described. The aim of the study is to identify risk factors for persistent, de novo and overall postoperative OAB after POP repair. STUDY DESIGN This was a retrospective study including patients who underwent primary POP surgery. Medical interview, urogenital examination and urodynamics were performed preoperatively; patients were examined one and six months after surgery and then yearly. RESULTS 518 patients were included. 36.1% of women preoperatively complained of OAB symptoms while detrusor overactivity was found in 20.5%. The rate of persistent and de novo OAB after surgery were respectively 14.1% and 13.5%. Multivariate analysis found age, BMI, preoperative OAB, sling placement and postoperative SUI as independent risk factors for overall OAB after surgery. Moreover, preoperative OAB and postoperative constipations were associated with OAB persistence after surgery. Finally, age, sling placement, postoperative SUI and voiding symptoms were independently associated with de novo OAB. CONCLUSION Preoperative OAB symptoms are associated with OAB persistence after POP surgery, while age and sling placement correlate with de novo OAB. Finally, increased BMI is related to postoperative OAB.
Collapse
|
18
|
Milani R, Manodoro S, Cola A, Palmieri S, Reato C, Frigerio M. Transvaginal native-tissue repair of enterocele. Int Urogynecol J 2018; 29:1705-1707. [PMID: 29934767 DOI: 10.1007/s00192-018-3686-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/04/2018] [Indexed: 02/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS). METHODS A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique. RESULTS Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how. CONCLUSIONS Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.
Collapse
Affiliation(s)
| | - Stefano Manodoro
- AUSL Romagna, Infermi Hospital, Rimini, Italy. .,AUSL della Romagna - Ospedale Infermi, U.O. Ostetricia e Ginecologia, Viale Luigi Settembrini 2, 47923, Rimini, RN, Italy.
| | - Alice Cola
- ASST Monza, San Gerardo Hospital, Monza, Italy
| | | | | | | |
Collapse
|
19
|
Frigerio M, Manodoro S, Palmieri S, Spelzini F, Milani R. Risk factors for stress urinary incontinence after native-tissue vaginal repair of pelvic organ prolapse. Int J Gynaecol Obstet 2018; 141:349-353. [PMID: 29333601 DOI: 10.1002/ijgo.12443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/13/2017] [Accepted: 01/12/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To identify risk factors for postoperative stress urinary incontinence (POSUI) after native-tissue prolapse repair without a concomitant anti-incontinence procedure. METHODS The present single-center retrospective study included women with genital prolapse who underwent high uterosacral ligament suspension without a concomitant anti-incontinence procedure during 2008-2013. Univariate and multivariate analyses were performed to identify risk factors for POSUI (identified through clinical interview and International Consultation on Incontinence Modular Questionnaire-Short Form [ICIQ-SF] self-administration) at 6 months. RESULTS In total, 87 (20.9%) of 417 women developed POSUI. Preoperative stress urinary incontinence (SUI) and urodynamically diagnosed SUI were significantly associated with POSUI; moreover, women with POSUI had a higher preoperative ICIQ-SF score, a lower opening detrusor pressure, and a lower detrusor pressure at maximum flow than did women without POSUI (P<0.05 for all comparisons). In the multivariate analysis, preoperative SUI (odds ratio 3.11), a detrusor pressure at maximum flow of less than 30 cm H2 O (odds ratio 2.93), and urodynamically diagnosed SUI (odds ratio 2.26) were independent risk factors for POSUI. CONCLUSION Preoperative urodynamic parameters, obtained before prolapse repair surgery, were associated with POSUI and could be useful in providing adequate counseling to facilitate decision making on whether to add a concomitant anti-incontinence procedure.
Collapse
Affiliation(s)
- Matteo Frigerio
- ASST Monza, Ospedale San Gerardo, Monza, Italy.,Università degli Studi di Milano-Bicocca, Milan, Italy
| | | | - Stefania Palmieri
- ASST Monza, Ospedale San Gerardo, Monza, Italy.,Università degli Studi di Milano-Bicocca, Milan, Italy
| | - Federico Spelzini
- Università degli Studi di Milano-Bicocca, Milan, Italy.,AUSL Romagna, Ospedale Infermi, Rimini, Italy
| | - Rodolfo Milani
- ASST Monza, Ospedale San Gerardo, Monza, Italy.,Università degli Studi di Milano-Bicocca, Milan, Italy
| |
Collapse
|
20
|
Outcomes of Transvaginal High Uterosacral Ligaments Suspension: Over 500-Patient Single-Center Study. Female Pelvic Med Reconstr Surg 2018; 24:39-42. [DOI: 10.1097/spv.0000000000000403] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
21
|
Detrusor underactivity in pelvic organ prolapse. Int Urogynecol J 2017; 29:1111-1116. [DOI: 10.1007/s00192-017-3532-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/28/2017] [Indexed: 10/18/2022]
|
22
|
Manodoro S, Frigerio M, Milani R, Spelzini F. Tips and tricks for uterosacral ligament suspension: how to avoid ureteral injury. Int Urogynecol J 2017; 29:161-163. [DOI: 10.1007/s00192-017-3497-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/25/2017] [Indexed: 11/29/2022]
|
23
|
Transvaginal uterosacral ligament suspension for posthysterectomy vaginal vault prolapse repair. Int Urogynecol J 2017; 28:1421-1423. [DOI: 10.1007/s00192-017-3277-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/16/2017] [Indexed: 02/03/2023]
|
24
|
Milani R, Frigerio M, Spelzini F, Manodoro S. Transvaginal uterosacral ligament hysteropexy: a video tutorial. Int Urogynecol J 2016; 28:789-791. [DOI: 10.1007/s00192-016-3222-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/21/2016] [Indexed: 02/04/2023]
|