Sexual function after robot-assisted prolapse surgery: a prospective study

Prophylactic mastectomy and bilateral salpingo-oophorectomy in patients with breast cancer: a systematic review of postsurgical sexual function and menopausal hormone therapy symptom mitigation

INTRODUCTION

Preventative surgical procedures for patients who are breast cancer (BRCA) positive-namely, bilateral salpingo-oophorectomy and mastectomy-have been linked to changes in sexual function, including surgically induced menopause. A patient's decision to undergo preventive surgery as opposed to high-risk screening is heavily reliant on advice received from one's health care provider. Quality of life should be considered when shared decision making is conducted with patients.

OBJECTIVES

To assemble and analyze findings related to patient-reported sexual function after these surgical procedures, to see if and how either procedure affects sexual function from patient baseline, and to determine whether the effects can be mitigated with menopausal hormone therapy.

METHODS

A literature review based on the PubMed, Embase, and MEDLINE databases was conducted from inception through January 25, 2022. To be included, studies had to meet an a priori list of Medical Subject Headings: "BRCA" AND "sexual dysfunction" OR "dyspareunia." GRADE criteria were used to determine the quality of studies relating to menopause hormone therapy.

RESULTS

The search yielded 14 results, and 11 reported sufficient data for systematic review. Sexual function was measured via validated and investigator-generated surveys. All studies, no matter the survey metric, found significant reduction in sexual function with bilateral salpingo-oophorectomy; no studies revealed sexual function changes associated with mastectomy postsurgery. Few studies indicated that menopause hormone therapy resulted in significant improvement in sexual function, and all studies reported that postoperative sexual function could not reach baseline levels with therapy. No studies were high quality by GRADE metrics.

CONCLUSION

Prophylactic mastectomies and bilateral salpingo-oophorectomies among patients who are BRCA positive cause SF changes postprocedure. Menopausal hormone therapy offers little help in mediating symptoms. Significantly more research is needed to explore potential changes in sexual function, as it is an important aspect of quality of life for patients with BRCA positivity.

Surgical correction of the genital hiatus at the time of sacrocolpopexy - a 7-year Markov analysis: a cost-effectiveness analysis

INTRODUCTION AND HYPOTHESIS

To perform a cost-effectiveness analysis of concurrent posterior repair performed at the time of laparoscopic hysterectomy with sacrocolpopexy over a 7-year time period. We hypothesize it is not cost-effective to perform a posterior colporrhaphy.

METHODS

We used TreeAge Pro® to construct a decision model with Markov modeling to compare sacrocolpopexy with and without concurrent posterior repair (SCP and SCP+PR) over a time horizon of 7 years. Outcomes included probability and costs associated with prolapse recurrence, prolapse retreatment, and complications including rectal injury, rectovaginal hematoma requiring reoperation, and postoperative dyspareunia. Cost-effectiveness was defined as an incremental cost-effectiveness ratio (ICER) calculated as ∆ costs /∆ effectiveness and the willingness to pay (WTP) was set at $100,000/QALY.

RESULTS

Our model showed that SCP was the dominant strategy, with lower costs (-$ 2681.06) and higher effectiveness (+0.10) compared to SCP+PR over the 7-year period. In two-way sensitivity analyses, we varied the probability of prolapse recurrence after both strategies. Our conclusions would only change if the probability of recurrence after SCP was at least 29.7% higher than after SCP+PR. When varying the probabilities of dyspareunia for both strategies, SCP+PR only became the dominant strategy if the probability of dyspareunia for SCP+PR was lower than the rate of SCP alone.

CONCLUSIONS

In this 7-year Markov cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy. SCP+PR costs more with lower effectiveness than SCP alone, due to higher surgical cost of SCP+PR and higher probability of dyspareunia after SCP+PR.

Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022)

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m² or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

International Urogynecology Consultation Chapter 1 Committee 5: relationship of pelvic organ prolapse to associated pelvic floor dysfunction symptoms: lower urinary tract, bowel, sexual dysfunction and abdominopelvic pain

INTRODUCTION AND HYPOTHESIS

This article from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) establishes the prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP.

METHODS

An international group of nine urogynecologists/urologists and one medical student performed a search of the literature using pre-specified search terms in Ovid, MEDLINE, Embase and CINAHL from January 2000 to March 2019. Publications were eliminated if not relevant or they did not include clear definitions of POP or the symptoms associated with POP. Definitions of POP needed to include both a physical examination finding using a validated examination technique and the complaint of a bothersome vaginal bulge. Symptoms were categorized into symptom groups for ease of evaluation. The Specialist Unit for Review Evidence (SURE) was used to evaluate for quality of the included articles. The resulting list of articles was used to determine the prevalence of various symptoms in women with POP. Cohort studies were used to evaluate for possible causation of POP as either causing or worsening the symptom category.

RESULTS

The original search yielded over 12,000 references, of which 50 were used. More than 50% of women with POP report lower urinary tract symptoms. Cohort studies suggest that women with POP have more obstructive lower urinary tract symptoms than women without POP. Pain described in various ways is frequently reported in women with POP, with low back pain being the most common pain symptom reported in 45% of women with POP. In cohort studies those with POP had more pain complaints than those without POP. Sexual dysfunction is reported by over half of women with POP and obstructed intercourse in 37-100% of women with POP. Approximately 40% of women have complaints of bowel symptoms. There was no difference in the median prevalence of bowel symptoms in those with and without POP in cohort studies.

CONCLUSIONS

The prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP are common but inconsistently reported. There are few data on incidence of associated symptoms with POP, and cohort studies evaluating causality are rare or inconsistent. Obstructive voiding, lower abdominal and pelvic pain, and sexual dysfunction are most frequently associated with POP.

Sexual activity and function in women with advanced stages of pelvic organ prolapse, before and after laparoscopic or vaginal mesh surgery

INTRODUCTION AND HYPOTHESIS

The differential impact of specific pelvic organ prolapse (POP) surgery on sexual activity and function is unknown. Our primary aim was to analyse sexual inactivity and function in women with symptomatic advanced stages of POP and the changes incurred after laparoscopic or vaginal mesh surgery.

METHODS

We performed a secondary analysis of sexual outcomes of a previously published randomised controlled trial comparing laparoscopic sacrocolpopexy/cervicopexy (LSC-Cx) and anterior vaginal mesh (AVM) in 120 women (60/group) with symptomatic anterior POP stage ≥ 3 and apical ≥ 2. Sexual activity and function were assessed preoperatively and 1 and 2 years postoperatively using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire-IUGA-Revised (PISQ-IR).

RESULTS

Sexual activity was recovered in 42.9% of non-sexually active (NSA) women 1 year postoperatively, mainly in women with higher preoperative POP-related subscale scores of the PISQ-IR, which indicated a negative preoperative sexuality by POP. Recovery of sexual activity was greater after LSC-Cx, albeit not significantly (2 years: 35.5% AVM vs. 45% LSC-Cx). Among sexually active (SA) women preoperatively remaining SA postoperatively, the difference in the mean PISQ-IR summary score significantly improved [mean baseline difference - 2 years; all: 0.3 (95% CI 0.1 to 0.5) p = 0.001; AVM 0.19 (95% CI -0.1 to -0.5) p > 0.05; LSC-Cx 0.37 (95% CI 0.1 to 0.7) p = 0.003]. Preoperative dyspareunia was significantly reduced after LSC-Cx (baseline: 24.6%, 2 years: 9.8%, p = 0.0448), but not after AVM (baseline: 20.7%, 2 years: 18.2%, p = 0.7385).

CONCLUSIONS

Most women reported improved sexual activity and function 2 years after LSC-Cx or AVM, mainly because of enhanced POP-related subscales in both NSA and SA women. Recovery of sexual activity and improved sexual function were greater after LSC-Cx compared to AVM, likely related to less postoperative dyspareunia.

The current status of sacrocolpopexy in the management of apical prolapse

Pelvic organ prolapse (POP) is a prevalent condition that negatively affects women' s quality of life. There is growing recognition that adequate support for the vaginal apex is an important component of a durable surgical repair for women with advanced prolapse, including the anterior and posterior wall prolapse. Surgical treatment options include abdominal and vaginal approaches, the former of which can be performed open, laparoscopically, and robotically. Sacrocolpopexy is a common procedure designed for the treatment of prolapse including uterine or vaginal vault prolapse and multiple-compartment prolapse. Although traditionally performed as an open abdominal procedure, minimally invasive sacrocolpopexy, whether laparoscopic or robotic, has been successfully performed in the clinical practice by many pelvic reconstructive surgeons. In order to require an outstanding cosmetic result, transumbilical/transvaginal single-port sacrocolpopexy has been developed to achieve the goal and initial outcomes have demonstrated their efficacy, safety and feasibility. However, up to date, there are many variations to these procedures, with different levels of evidence to support each of them. Herein we reviewed the current literatures on current surgical choices for women with apical prolapse.

Sexual function after total laparoscopic hysterectomy or transabdominal hysterectomy for benign uterine disorders: a retrospective cohort

The objective of this study was to evaluate changes in sexual function after total laparoscopic hysterectomy (TLH) or transabdominal hysterectomy (TAH). This retrospective cohort study included patients with benign uterine tumors that were divided into TLH group and TAH group based on the hysterectomy technique used. Baseline, intraoperative, and postoperative characteristics were compared between groups. Postoperative sexual function was assessed using the Brief Index of Sexual Functioning for Women. The TLH and TAH groups contained 119 patients (age, 51.5±6.1 years) and 126 patients (age, 50.0±4.7 years), respectively. Baseline characteristics were comparable between groups, although uterine size was larger in the TAH group (P<0.001). Compared with the TAH group, the TLH group had a longer operative time (130.0±36.2 vs 107.3±28.5 min, P<0.001), lower pain index at 24 h (2.0±1.6 vs 4.0±2.6, P<0.001), and shorter hospitalization time (5.7±1.1 vs 8.1±1.2 days, P<0.001). Many patients in the TLH and TAH groups reported decreased satisfaction with their sexual life (67.5 and 56.0%, respectively), reduced frequency of sexual activity (70.1 and 56.0%, respectively), decreased libido (67.5 and 56.0%, respectively), orgasm dysfunction (42.9 and 42.9%, respectively), and increased dyspareunia (77.9 and 85.7%, respectively). However, there was no significant difference between groups in any of the indexes of postoperative sexual function (P>0.05). Both TLH and TAH had comparable negative effects on sexual function in women treated for benign uterine tumors in China, with a decreased frequency of sexual activity, reduced libido, orgasm dysfunction, and increased dyspareunia.

Robot-Assisted Laparoscopic Surgery for Pelvic Organ Prolapse among Peri- and Post-Menopausal Women

For patients with apical compartment pelvic organ prolapse (POP), abdominal sacrocolpopexy has been considered superior to the vaginal approach in terms of less dyspareunia and decreased risk of recurrence. Robot-assisted sacrocolpopexy (RSC) can help overcome difficulties in laparoscopic sacrocolpopexy (LSC) by facilitating deep dissection and suturing. Moreover, RSC is a safe and efficacious option for patients with POP. It has several benefits, such as its high anatomical cure rate, improvement of sexual function, reduction of perioperative complications, and low recurrence rate. In addition, it can be a safe option for elderly patients. RSC has a steep learning curve and numerous other reported advantages compared with LSC; however, insufficient data conclude that the former is universally superior, especially in cost effectiveness. Thus, further studies are needed to support the widespread adoption of robot-assisted surgery for pelvic floor reconstruction.

Learning curve of robot-assisted laparoscopic sacrocolpo(recto)pexy: a cumulative sum analysis

BACKGROUND

Determination of the learning curve of new techniques is essential to improve safety and efficiency. Limited information is available regarding learning curves in robot-assisted laparoscopic pelvic floor surgery.

OBJECTIVE

The purpose of this study was to assess the learning curve in robot-assisted laparoscopic pelvic floor surgery.

STUDY DESIGN

We conducted a prospective cohort study. Consecutive patients who underwent robot-assisted laparoscopic sacrocolpopexy or sacrocolporectopexy were included (n=372). Patients were treated in a teaching hospital with a tertiary referral function for gynecologic/multicompartment prolapse. Procedures were performed by 2 experienced conventional laparoscopic surgeons (surgeons A and B). Baseline demographics were scored per groups of 25 consecutive patients. The primary outcome was the determination of proficiency, which was based on intraoperative complications. Cumulative sum control chart analysis allowed us to detect small shifts in a surgeon's performance. Proficiency was obtained when the first acceptable boundary line of cumulative sum control chart analysis was crossed. Secondary outcomes that were examined were shortening and/or stabilization of surgery time (measured with the use of cumulative sum control chart analysis and the moving average method).

RESULTS

Surgeon A performed 242 surgeries; surgeon B performed 137 surgeries (n=7 surgeries were performed by both surgeons). Intraoperative complications occurred in 1.9% of the procedures. The learning curve never fell below the unacceptable failure limits and stabilized after 23 of 41 cases. Proficiency was obtained after 78 cases for both surgeons. Surgery time decreased after 24-29 cases in robot-assisted sacrocolpopexy (no distinct pattern for robot-assisted sacrocolporectopexy). Limitations were the inclusion of 2 interventions and concomitant procedures, which limited homogeneity. Furthermore, analyses treated all complications in cumulative sum as equal weight, although there are differences in the clinical relevance of complications.

CONCLUSION

After 78 cases, proficiency was obtained. After 24-29 cases, surgery time stabilized for robot-assisted sacrocolpopexy. In this age of rapidly changing surgical techniques, it can be difficult to determine the learning curve of each procedure. Cumulative sum control chart analysis can assist with this determination and prove to be a valuable tool. Training programs could be individualized to improve both surgical performance and patient benefits.

Impact of vertical versus horizontal vaginal cuff closure on vaginal length following hysterectomy: a meta-analysis of randomized trials

INTRODUCTION AND HYPOTHESIS

Posthysterectomy vaginal length has been previously associated with postoperative sexual dysfunction, but evidence for this in the literature is controversial. The purpose of this meta-analysis was to investigate whether vertical or horizontal closure of the vaginal cuff has a direct effect on posthysterectomy vaginal length and on postoperative sexual dysfunction.

METHODS

The study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched Medline, Scopus, Clinicaltrials.gov , EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar databases.

RESULTS

Overall, five randomized trials were included in this meta-analysis with 223 patients. The results suggest that horizontal closure of the vaginal cuff results in a shorter vaginal length compared with vertical closure [mean difference (MD) -0.77 cm, 95% confidence interval (CI) -1.12 to -0.43]. Mean vaginal length significantly decreased when the horizontal method was used (MD -0.61 cm, 95% CI -0.97 to -0.24). The subgroup analysis revealed that vertical closure was associated with longer vaginal length only in cases treated with vaginal hysterectomy. Trial sequential analysis revealed that our meta-analysis had adequate power to support these results. Postoperative sexual function was evaluated in only one study; no differences were observed.

CONCLUSIONS

Findings of our meta-analysis suggest that horizontal closure of the vaginal vault results in shorter vaginal length in vaginal hysterectomies; thus, we suggest that this technique be avoided. Data concerning quality of life of patients and specifically sexual dysfunction remain extremely limited and should be studied in future trials.

Questions surrounding the optimal time for surgical treatment of pelvic organ prolapse

OBJECTIVE

The purpose of study is to evaluate the recurrence rate of pelvic organ prolapse after surgical treatment and pre- to postoperative changes in sexual function of patients with different stages of pelvic organ prolapse.

METHODS

The presented study was a single-centre observational nonrandomized analysis of an ongoing prospective cohort study evaluating anatomical and clinical outcomes in reproductive aged women scheduled for nature tissue repair of POP staged I-III. Two hundred and ten women were recruited, of whom 120 (57.1%) had the advanced prolapse form (POP-Q III). Women at preoperative POP stage I-II were compared with women at stage III without apical prolapse.

RESULTS

The best effectively rate with low recurrence depends on preoperative prolapse stage. The overall objective success rate was about 80% in five years in patients with preoperative stage I-II. Study shows a significant improvement in sexual function in all patients with pelvic organ prolapse in five years after surgery.

CONCLUSION

This study showed that women with advanced POP have a higher risk of recurrence after POP native tissue repair compared with early stages and proved the improvement of sexual function especially in women with advanced prolapse forms. Women with early stage of POP should be advised to postpone surgery until progression of complaints because of the high recurrence risk.