Long-term follow-up of laparoscopic sacrocolpopexy: comparison of two different techniques used in urology and gynecology

Three-Year Outcomes of a Multicenter Study of Japanese-Style Laparoscopic Sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Laparoscopic sacrocolpopexy(LSC) is widely performed and has been reported to safe and effective. However, statistical data on this technique are unavailable. Therefore, we designed the Japanese-style LSC, a further evolution of the French-style LSC, and initiated this multicenter study to prospectively evaluate its efficacy and safety. If the Japanese-style LSC is successful, we may be able to propose a more reliable and standardized procedure.

METHODS

This is a prospective study of Japanese-style LSC. The Japanese-style LSC is characterized by the dissection of the vaginal walls as distally as possible and fixation of the mesh with multiple sutures; fixation of the mesh on the promontory without traction; and closure of the peritoneum with high-level peritoneal sutures. We examined the primary (anatomical recurrence, adverse events, and quality of life) and secondary endpoints (voiding symptoms and sexual function) at 3 years postoperatively.

RESULTS

In anatomical recurrence, 24 patients (9.2%) were ≥ stage2 in the Pelvic Organ Prolapse Quantification system at 3 years postoperatively, of which 4 (1.5%) and 20 (7.7%) were stages III and II respectively. No mesh-related complications were observed, and each questionnaire showed predominant improvement, except for sexual and evacuation functions.

CONCLUSIONS

The Japanese-style LSC demonstrated superior anatomical and functional results and we propose it to be an effective procedure.

Triple-compartment strategy for abdominal sacral colpopexy using PVDF mesh: one-year report of anatomical and subjective outcomes

INTRODUCTION AND HYPOTHESIS

Abdominal Sacral Colpopexy (ASC) is one of the best surgical methods to repair apical or uterine prolapse. We aimed to evaluate the short-term results of a triple-compartment open ASC strategy using polyvinylidene fluoride (PVDF) mesh in the treatment of patients with severe apical or uterine prolapse.

METHODS

Women with high-grade uterine or apical prolapse with or without cysto-rectocele were prospectively enrolled in the study from April 2015 to June 2021. We performed all-compartment repair using a tailored PVDF mesh for ASC. We assessed the severity of pelvic organ prolapse (POP) using the Pelvic Organ Prolapse Quantification (POP-Q) system at baseline and 12 months after the operation. The patients completed the International Continence Society Questionnaire Vaginal Symptom (ICIQ-VS) questionnaire at baseline, 3, 6, and 12 months postoperatively.

RESULTS

Thirty-five women with a mean age of 59.8±10.0 years were included in the final analysis. Stage III and stage IV prolapse was evident in 12 and 25 patients, respectively. After 12 months, the median POP-Q stage was significantly lower compared to the baseline (4 vs 0, p=<0.0001). Vaginal symptoms score was also reduced significantly at 3-month (7.5±3.5), 6-month (7.3±3.6), and 12-month (7.2±3.1) compared to the baseline (39.5±6.7) (p values < 0.0001). We did not observe any mesh extrusion or high-grade complications. Six (16.7%) patients had cystocele recurrence during the 12-month follow-up, and two of them needed reoperation.

CONCLUSIONS

Our short-term follow-up showed that using an open ASC technique with PVDF mesh in treating high-grade apical or uterine prolapse is associated with a high rate of procedural success and low rates of complication.

The Outcome of Sacrocolpopexy/Sacrohysteropexy for Patients with Pelvic Organ Prolapse and Predictors of Anatomical Failure

Background

Pelvic organ prolapse (POP) is a medical condition that profoundly impacts women's quality of life. Unfortunately, the literature lacks long-term predictors and risk factors for its recurrence. This study aims to assess the efficacy and safety of Sacrocolpopexy/Sacrohysteropexy and to identify the predictors of recurrence in a Saudi setting.

Methods

In a retrospective cohort study, all patients who underwent Sacrocolpopexy (n=144) and Sacrohysteropexy (n=56) between 2009-2021 were followed up. Electronic medical records were examined to collect data on the following: Patient characteristics [age, parity, BMI, and past medical and surgical history], prolapse-related characteristics/symptoms, Surgery-related characteristics [type and approach of surgery, mesh type, and concomitant surgery], and Outcome characteristics. Postoperative anatomical success and failure rates were determined according to the Baden-Walker classification. Logistic regression analysis was applied to identify the predictors of overall anatomical failure of Sacrocolpopexy. Significance was considered at p<0.05.

Results

Success rates of 96.8%, 99.4%, and 85.2% were detected in the anterior, apical, and posterior vaginal prolapse, respectively, with an overall success rate of 83.1%. The overall failure rate was 15.9%, with an incidence density of 5.98 per 100 women-years. The onset of failure in 27 failure cases ranged from 40 days to 11.5 years postoperative. After adjustment for the possible potential confounders, older age (OR=1.06, 95% CI:1.01‒1.13, p=0.03) and the presence of diabetes (OR=4.93, 95% CI:1.33‒18.33, p=0.02) were the only significant predictors of operation failure. As for complications, six cases (3.6%) required reoperation, two cases (1.2%) had a bowel obstruction two and seven years after surgery, and one patient (0.6%) had vaginal mesh exposure.

Conclusion

The outcomes of Sacrocolpopexy/Sacrohysteropexy in our study are comparable to those in previous studies. Diabetes and elder age at the time of the surgery played a role in predicting recurrence. Sacrocolpopexy has a long-term profile of safety and efficacy. These findings could be key to stratifying surgical plans for pelvic organ prolapse cases.

Differences in Surgical Practice Patterns of Vaginal Native Tissue Repair for Pelvic Organ Prolapse Between Urologists and Gynecologists

IMPORTANCE

Surgeon specialty training may influence the combination of transvaginal procedures for pelvic organ prolapse (POP) repair. Isolated transvaginal anterior compartment repair (AR) without concurrent apical suspension (ApS) is a known risk factor for POP recurrence.

OBJECTIVES

Our primary aim was to compare the prevalence of isolated AR between urologists versus gynecologists. Our secondary aim was to compare associated postoperative complications.

STUDY DESIGN

We queried the American College of Surgeons National Surgical Quality Improvement Program for vaginal POP repair procedures (Current Procedural Terminology codes 57240, 57260, 57265, 57268, 57282, 57283) over a 5-year period by designated surgical specialty. We analyzed the relationships between specialty, vaginal repair type, operative details, and 30-day postoperative complications.

RESULTS

Between January 2015 and December 2019, we included 16,093 women who underwent transvaginal POP repair, 90% performed by gynecologists and 10% by urologists. Urologists were more likely to perform an isolated AR without concurrent ApS (56% vs 47%, P < 0.0001). Gynecologists performed more isolated ApS (11% vs 9%) and combined AR with ApS (43% vs 35%, P < 0.0001). Overall, concurrent urethral sling placement was performed in 27% of cases, regardless of POP repair type, with no difference between specialties (P > 0.05). There were no differences in 30-day reoperations, readmissions, surgical site infections, urinary tract infections, or hospital stay lengths between specialties (P > 0.05).

CONCLUSIONS

Urologists perform a minority of vaginal POP repairs and were more likely to perform isolated AR than gynecologists. The absence of concurrent ApS may increase the likelihood of prolapse recurrence. Immediate complication rates for each procedure did not differ.

Redo laparoscopic sacrocolpopexy for POP recurrence: Is it the right call?

OBJECTIVES

As Laparoscopic Sacrocolpopexy (LSCP) has proven to be the gold-standard for treating Pelvic Organ Prolapse, management of recurrence after its failure is a challenge with upcoming interest. In these patients, repeat LSCP might represent a suitable surgical choice.

STUDY DESIGN

We present a retrospective observational study analysing safety, feasibility and outcomes of Redo LSCP. Data of 20 patients with POP recurrence who underwent previous sacrocolpopexy were recruited, and all successfully underwent a repeat LSCP.

RESULTS

Median 24-months follow-up demonstrated a statistically significant improvement of objective and subjective outcome. No intra and postoperative complications were noted. Anatomical cure rate was 95%. Subjective cure rate was 100%, with a statistically significant POP symptoms resolution and improvement of voiding and storage symptoms. We compared perioperative data and outcome of Redo patients to a population who underwent LSCP for a first-time diagnosed POP. The findings demonstrated that surgery did not differ from standard procedure in terms of intra/postoperative complications, hospital stay, blood loss, except for operative time.

CONCLUSIONS

Minimally invasive Redo LSCP appears to be a safe and effective procedure in treating recurrent and symptomatic Pelvic Organ Prolapse. Our series shows low recurrence rates, comparable to data from patients who underwent their primary surgery for POP.

Long-term safety and efficacy of laparoscopically placed mesh for apical prolapse

INTRODUCTION AND HYPOTHESIS

Concerns regarding the use of vaginal mesh for prolapse have led to questions about the safety and efficacy of abdominally placed mesh. Mesh procedures for treating apical prolapse have become popular, either a laparoscopic hysteropexy (LSH) for uterine prolapse or a sacrocolpopexy (LSC) for vaginal vault prolapse. Robust long-term safety and efficacy data for these procedures are essential.

METHODS

All patients who had LSH or LSC since 2010 were invited back for face-to-face review and examination. Case notes were reviewed for surgical morbidities and patients were questioned about short- and long-term complications. The Patient Global Impression of Improvement (PGI-I) scale was used to assess prolapse, bladder and bowel symptoms postoperatively.

RESULTS

One hundred twelve patients were included in the review, 93 of whom were examined. The median time since surgery was 6 years (range 1-9 years); 2.7% cases had an intraoperative complication, two conversions to laparotomy and one bladder injury. Overall, 17.3% patients sought medical review postoperatively, with 10.7% having problems with their skin incisions. With regard to mesh safety, there was one case of bowel obstruction requiring resection following LSH and two vaginal mesh exposures following LSC; 97% had stage 1 or less apical prolapse at long-term follow-up and 79.6% reported symptoms of prolapse to be 'much better' or 'very much better' on the PGI-I scale.

CONCLUSIONS

This study shows excellent long-term results from LSC and LSH with comprehensive follow-up, demonstrating a very low and acceptable level of intraoperative, short- and long-term complications.

Long-term pelvic organ prolapse recurrence and mesh exposure following sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Large, long-term studies are needed to compare pelvic organ prolapse (POP) recurrence and mesh exposure following all modes of sacrocolpopexy (open, robotic, and laparoscopic). We hypothesized that the prevalence of recurrent POP and mesh exposure does not differ between modes of sacrocolpopexy.

METHODS

This is a retrospective cohort study with a cross-sectional, prospective survey. Participants were surveyed regarding complications, retreatments, and symptoms following sacrocolpopexy. Baseline characteristics, POP recurrence, mesh exposure, and survey responses were compared.

RESULTS

A total of 709 participants met the criteria. Median time from sacrocolpopexy to last follow-up for all participants was 0.5 years (2 days to 13.4 years). 15.0% experienced recurrent stage 2 or greater POP or underwent retreatment (open 11.7% [95% CI 7.8-17.2%]; robotic 21.1% [95% CI 15.6-27.9%]; laparoscopic 13.8% [95% CI 10.6-17.9%]; p = 0.03). After adjusting for baseline differences there was no significant difference among groups (p = 0.30). 5.3% experienced mesh and/or suture exposure (mesh n = 19, suture n = 10, mesh and suture n = 8) with no significant difference among groups (open 7.7% [95% CI 4.6-12.5%]; robotic 3.6% [95% CI 1.7-7.6%]; laparoscopic 4.9% [95% CI 3.1-7.7%]; p = 0.20). Median time from sacrocolpopexy to survey completion was 6.5 (1.6-13.4) years. 9.2% reported evaluation or treatment for recurrent POP (open 6.3% [95% CI 2.1-16.8%]; robotic 12.5% [95% CI 6.9-21.5%]; laparoscopic 8.5% [5.1-13.8%]; p = 0.44). 6.9% reported evaluation or treatment for mesh exposure (open 6.0% [95% CI 2.1-16.2%]; robotic 3.9% [95% CI 1.3-10.7%]; laparoscopic 8.6% [5.2-13.9%]; p = 0.38).

CONCLUSIONS

Objective and patient-reported long-term prevalence of POP recurrence and mesh exposure are low following all modes of sacrocolpopexy.

Sacrocolpopexy: Patient Outcomes Support the Use of Non-Crosslinked Acellular Dermal Matrix as an Alternative to the Synthetic Polypropylene Mesh

Objective: This study was conducted to evaluate the use of non-crosslinked acellular dermal matrix (ADM) in laparoscopic sacrocolpopexy by analyzing clinical outcomes and patient-satisfaction surveys.

Materials and Methods: Two hundred and eleven patients underwent laparoscopic sacrocolpopexy for pelvic organ prolapse (POP) between January 6, 2012, and December 31, 2017. Each patient had her pelvic-floor measurements diagrammed with the POP-Q [Quantification] system using the interactive tool provided by the American Urogynecologic Society. The Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7), used to make comprehensive assessments of women with urogynecologic problems, were mailed to all patients. If responses were not received, the patients were contacted by telephone. Patients who were not reached by either mail or telephone had their charts individually reviewed to extract the information. Trained surveyors scored the PFDI-20 and the PFIQ-7 questionnaires. The de-identified data were analyzed for patient satisfaction and outcomes. This information was obtained by a review of patient charts at 4-week postoperative and annual examinations; any phone calls with complaints and/or problem office visits were noted. Biopsies from the sacrocolpopexy area were taken if a patient had another incidental gynecologic procedure unrelated to the prolapse or at the time of repeat sacrocolpopexy for POP and the paraffin cell block was sent to McGowan Institute for Tissue Regeneration.

Results: One hundred and five patients responded to the survey. Charts were completed for 106. The majority of interviewed patients stated that they were doing a “little better” or “much better” (77/88; 87.5%). The third-quartile PFDI-20 score was 93 with a median of 60 and the PFIQ-7 score was 43 with a median of 29. Five patients underwent reoperations (4.76%). The most-common postoperative complaint was overactive bladder symptoms, followed by vaginal discharge. Histology showed either a lack of regenerative healing tissue at the failure site or good results showing neovascularization and a presence of connective and ligamentous tissue around the matrix. No intense fibrosis or neoplastic formation was reported.

Conclusions: A non-crosslinked ADM patch can be a good alternative to synthetic polypropylene mesh in patients undergoing sacrocolpopexy for POP.

Laparoscopic sacral colpopexy with polyester fiber suture: Ozerkan modification

INTRODUCTION AND HYPOTHESIS

Mesh-related problems are significant complications of laparoscopic sacral colpopexy. The conventional technique precludes performing laparoscopic sacral colpopexy without using a mesh. We describe the Ozerkan modification for laparoscopic sacral colpopexy using a polyester fiber suture instead of a standard mesh and report 1-year objective and subjective outcomes.

METHODS

Women diagnosed with stage ≥ 2 vaginal vault prolapse were prospectively recruited for the Ozerkan modification between 2015 and 2017. The primary outcome was the anatomic success of the repair, defined by objective parameters using the pelvic organ prolapse quantification system (stage 0 or 1). Secondary outcomes were subjective outcomes assessed with the quality of life scores.

RESULTS

Twenty-two women underwent the Ozerkan modified laparoscopic sacrocolpopexy. Mean operation time was 85.6 min. Mean estimated blood loss was 71 ml. One patient was lost during the clinical follow-up in the outpatient clinic up to 1 year. Nineteen of 21 patients had stage 0 or 1 prolapse at the end of 1 year. Two patients were not satisfied with their pelvic floor after 1 year. Both the objective and subjective cure rates were 90.4%. There were no bladder or bowel complications during the peri- or postoperative period.

CONCLUSIONS

The new modification of laparoscopic sacral colpopexy seems a feasible and safe option to avoid mesh complications in the treatment of vaginal vault prolapse.

Mesh-related complications of laparoscopic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Apical vaginal support for post-hysterectomy vault prolapse can be provided by vaginal, abdominal, or laparoscopic routes. Sacrocolpopexy is associated with higher satisfaction rates and a lower re-operation rate than vaginal sacrospinous fixation. The laparoscopic approach can reduce hospital stay and blood loss. There are concerns about the use of mesh in urogynaecological procedures, but limited data indicate a low mesh complication rate with sacrocolpopexy (0-5%). This study was aimed at establishing the incidence of complications following laparoscopic sacrocolpopexy.

METHODS

We carried out a retrospective cohort study of patients who underwent laparoscopic sacrocolpopexy at a large tertiary hospital. Cases were identified from coding data, theatre logs and the national urogynaecology procedure database. Data were gathered from theatre records, patient notes and the national database. Demographic data, concomitant procedures performed, duration of surgery, intra-operative complications, change in pelvic organ prolapse quantification point C, duration of stay, late complications and further urogynaecological surgery were assessed.

RESULTS

A total of 660 patients underwent laparoscopic sacrocolpopexy between 2005 and 2017 (median time from surgery 4 years 3 months). Five cases (0.7%) developed vaginal mesh exposure. Two were successfully managed conservatively with topical oestrogen. Three required surgical excision of the mesh. Four patients (0.6%) presented with erosion of non-absorbable vaginal sutures. Two were successfully managed conservatively with topical oestrogen and oral antibiotics. Two were managed with vaginal suture excision.

CONCLUSIONS

This large series suggests that laparoscopic sacrocolpopexy might confer a low risk of mesh exposure. Together with good anatomical and patient-reported outcomes, laparoscopic sacrocolpopexy is a safe option for patients presenting with post-hysterectomy vault prolapse.