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El Haraki AS, Shepherd JP, Matthews CA, Cadish LA. Long-Term Costs of Minimally Invasive Sacral Colpopexy Compared to Native Tissue Vaginal Repair With Concomitant Hysterectomy. J Minim Invasive Gynecol 2024; 31:674-679. [PMID: 38705377 DOI: 10.1016/j.jmig.2024.04.025] [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: 01/22/2024] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 05/07/2024]
Abstract
STUDY OBJECTIVE To determine the long-term costs of hysterectomy with minimally invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair. DESIGN A hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with USLS or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome. SETTING Tertiary center for urogynecology. PATIENTS Female patients undergoing surgical repair by the same team for primary uterovaginal prolapse. INTERVENTIONS Comparison analysis of estimated long-term costs was performed. MEASUREMENTS AND MAIN RESULTS Our primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19 935 and that undergoing USLS as the primary index procedure cost $15 457, a difference of $4478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30 054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse. CONCLUSION The higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.
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Affiliation(s)
- Amr S El Haraki
- Departments of Urology and Obstetrics and Gynecology, Atrium Wake Forest Baptist Medical Center (Drs. El Haraki and Matthews) Winston-Salem, NC.
| | - Jonathan P Shepherd
- Department of Obstetrics and Gynecology, University of Connecticut Health Center (Dr. Shepherd), Farmington, CT
| | - Catherine A Matthews
- Departments of Urology and Obstetrics and Gynecology, Atrium Wake Forest Baptist Medical Center (Drs. El Haraki and Matthews) Winston-Salem, NC
| | - Lauren A Cadish
- Department of Obstetrics and Gynecology, Providence Saint John's Health Center (Dr. Cadish), Santa Monica, CA
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Ekin M, Dura MC, Yildiz S, Gürsoy B, Yildiz YY, Dogan K, Kaya C. Comparison of transvaginal natural orifice transluminal endoscopic surgery versus conventional surgery for uterosacral ligament suspension in patients who had concomitant vaginal hysterectomy for subtotal uterine prolapse. Asian J Endosc Surg 2024; 17:e13333. [PMID: 38839273 DOI: 10.1111/ases.13333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/28/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION The study aimed to compare the short-term outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for uterosacral ligament suspension (USLS) versus nonendoscopic USLS in patients with subtotal uterine prolapse who had a concomitant vaginal hysterectomy. METHODS There were 51 patients who underwent vNOTES USLS, whereas the nonendoscopic conventional USLS group had 49 patients. The information about patient demographics, and perioperative data including the operative duration, blood loss, intraoperative and postoperative complications, and length of postoperative hospital stay were determined from the patients' files. Postoperative follow-up visits were scheduled at the first week and 1 month after surgery. RESULTS The demographic variables including age, body mass index, menopausal status, and parity were comparable, and no significant differences were found. A total of 90.2% of the patients in the vNOTES group and 69.4% of the patients in the shull group were at menopause (p = .09). Operation time was significantly shorter in the shull group (p < .001), and the hospitalization period (p = .029) was significantly shorter in the vNOTES group. Ba, Bp, and D points and total vaginal length (TVL) were significantly behind the hymenal ring in patients who had vNOTES USLS procedure (p < .001). None of the patients who had intraoperative significant blood loss required transfusion. One patient in the vNOTES and two patients in the shull group had a postoperative cuff hematoma. CONCLUSION vNOTES USLS has a good safety profile, higher percentage of adnexal surgeries with better improvement on POP-Q points Ba, Bp, D, and TVL compared with classic USLS in patients with subtotal uterine prolapse. Studies evaluating short- and long-term results of vNOTES versus conventional USLS are needed.
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Affiliation(s)
- Murat Ekin
- Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Cengiz Dura
- Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Sukru Yildiz
- Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Berk Gürsoy
- Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Yagmur Yucebas Yildiz
- Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Keziban Dogan
- Department of Obstetrics and Gynecology, University of Health Sciences Turkey, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Cihan Kaya
- Department of Obstetrics and Gynecology, Istanbul Aydın University, Istanbul, Turkey
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Minaglia SM. Small Bowel Obstruction After Colpopexy-Case Report and Images of the Mechanism. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:457-460. [PMID: 37737744 DOI: 10.1097/spv.0000000000001407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Affiliation(s)
- Steven Michael Minaglia
- From the Queen's University Medical Group and John A. Burns School of Medicine, University of Hawaii, Honolulu, HI
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Vermeulen CKM, Schuurman B, Coolen ALWM, Meijs-Hermanns PR, van Leijsen SAL, Veen J, Bongers MY. The effectiveness and safety of laparoscopic uterosacral ligament suspension: A systematic review and meta-analysis. BJOG 2023; 130:1568-1578. [PMID: 37271736 DOI: 10.1111/1471-0528.17565] [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: 01/25/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Laparoscopic uterosacral ligament suspension (LUSLS) is a technique to correct apical pelvic organ prolapse (POP) by shortening the uterosacral ligaments with sutures. OBJECTIVE A systematic review with meta-analysis of the effectiveness and safety of LUSLS as treatment for apical POP. SEARCH STRATEGY PubMed and Cochrane search using 'pelvic organ prolapse', 'laparoscopy' and 'uterosacral', including synonyms. SELECTION CRITERIA All articles in English presenting outcome of an original series of women with LUSLS as treatment of apical POP. Case reports were excluded. DATA COLLECTION AND ANALYSIS Study enrollment was performed by two reviewers. Our primary outcome measures were objective and subjective effectiveness of the procedure. Secondary outcome measures regarded complications and recurrence. Bias was assessed with the Newcastle Ottawa Scale. MAIN RESULTS Of 138 hits, 13 studies were included with 933 LUSLS patients. The average follow-up was 22 months. All were nonrandomised cohort studies. The pooled anatomic success rate is 90% for all LUSLS procedures (95% confidence interval [CI] 83.3-95.5). LUSLS with hysterectomy resulted in an anatomic success rate of 96.6% (95% CI 87.5-100) and LUSLS with uterus preservation 83.4% (95% CI 67.7-94.6). The pooled subjective cure rate was 90.5% (95% CI 81.9-96.5). The rate of major complications was 1%. CONCLUSIONS Laparoscopic uterosacral ligament suspension (with or without uterus preservation) seems to be an effective and safe treatment for women with apical POP, but long-term prospective trials and randomised controlled trials are necessary to confirm these findings.
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Affiliation(s)
- Carolien K M Vermeulen
- Department of Gynaecology and Obstetrics, Máxima Medical Centre, Veldhoven, The Netherlands
- GROW, Research School of Oncology and Reproduction, University of Maastricht, Maastricht, The Netherlands
| | - Britt Schuurman
- Department of Gynaecology and Obstetrics, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Anne-Lotte W M Coolen
- GROW, Research School of Oncology and Reproduction, University of Maastricht, Maastricht, The Netherlands
- Department of Gynaecology and Obstetrics, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - Puck R Meijs-Hermanns
- Department of Gynaecology and Obstetrics, Máxima Medical Centre, Veldhoven, The Netherlands
- Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sanne A L van Leijsen
- Department of Gynaecology and Obstetrics, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Joggem Veen
- Department of Gynaecology and Obstetrics, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Marlies Y Bongers
- Department of Gynaecology and Obstetrics, Máxima Medical Centre, Veldhoven, The Netherlands
- GROW, Research School of Oncology and Reproduction, University of Maastricht, Maastricht, The Netherlands
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Ferrando CA, Bradley CS, Meyn LA, Brown HW, Moalli PA, Heisler CA, Murarka SM, Foster RT, Chung DE, Whitcomb EL, Gutman RE, Andy UU, Shippey SH, Anger J, Yurteri-Kaplan LA. Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:787-799. [PMID: 37733440 DOI: 10.1097/spv.0000000000001410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
OBJECTIVE The aim of the study was to compare 12-month subjective and objective outcomes between 3 approaches to apical pelvic organ prolapse (POP) surgery in patients presenting with uterovaginal or posthysterectomy vaginal prolapse enrolled in the Pelvic Floor Disorders Registry for Research. STUDY DESIGN This was an analysis of a multicenter, prospective registry that collected both patient- and physician-reported data for up to 3 years after conservative (pessary) and surgical treatment for POP. Twelve-month subjective and anatomic outcomes for patients who underwent surgical treatment were extracted from the registry for analysis. Pelvic organ prolapse recurrence was defined as a composite outcome and compared between the 3 apical surgery groups (native tissue repair, sacrocolpopexy, colpocleisis) as well as the 2 reconstructive surgery groups (native tissue repair and sacrocolpopexy). RESULTS A total of 1,153 women were enrolled in the registry and 777 (67%) opted for surgical treatment, of whom 641 underwent apical repair and were included in this analysis (404 native tissue repair, 187 sacrocolpopexy, and 50 colpocleisis). The overall incidence of recurrence was as follows: subjective 6.5%, anatomic 4.7%, retreatment 7.2%, and composite 13.6%. The incidence of recurrence was not different between the 3 surgical groups. When baseline patient characteristics were controlled for, composite POP recurrence between the native tissue and sacrocolpopexy groups remained statistically nonsignificant. Concurrent perineorrhaphy with any type of apical POP surgery was associated with a lower risk of recurrence (adjusted odds ratio, 0.43; 95% confidence interval, 0.25-0.74; P = 0.002) and prior hysterectomy was associated with a higher risk (adjusted odds ratio, 1.77, 95% confidence interval, 1.04-3.03; P = 0.036). CONCLUSION Pelvic Floor Disorders Registry for Research participants undergoing native tissue apical POP repair, sacrocolpopexy, and colpocleisis surgery had similar rates of POP recurrence 12 months after surgery.
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Affiliation(s)
- Cecile A Ferrando
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Catherine S Bradley
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Leslie A Meyn
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee Womens Research Institute, University of Pittsburgh, Pittsburgh, PA
| | - Heidi W Brown
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Pamela A Moalli
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee Womens Research Institute, University of Pittsburgh, Pittsburgh, PA
| | - Christine A Heisler
- Division of Female Pelvic Medicine and Reconstructive Surgery, University of Wisconsin, Madison, WI
| | - Shivani M Murarka
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Raymond T Foster
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology, and Women's Health, University of Missouri School of Medicine, Columbia, MO
| | - Doreen E Chung
- Department of Urology, Columbia University Irving Medical Center, New York, NY
| | - Emily L Whitcomb
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Southern California Permanente Medical Group, Irvine, CA
| | - Robert E Gutman
- National Center for Advanced Pelvic Surgery, Department of Obstetrics and Gynecology, MedStar Washington Hospital Center/Georgetown University, Washington, DC
| | - Uduak U Andy
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Stuart H Shippey
- Urogynecology Division, University of Florida Obstetrics and Gynecology Residency; Ascension Sacred Heart, Pensacola, FL
| | - Jennifer Anger
- Departments of Urology and Obstetrics and Gynecology, UC San Diego Health, San Diego, CA
| | - Ladin A Yurteri-Kaplan
- Division of Gynecologic Specialty Surgery, Section of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology; Columbia University Irving Medical Center, New York, NY
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Assessment of Adverse Events in a Matched Cohort of Women Undergoing Concurrent Midurethral Sling at the Time of Minimally Invasive Benign Gynecologic Surgery. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:862-871. [PMID: 36409644 DOI: 10.1097/spv.0000000000001249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE Procedures for stress urinary incontinence and benign gynecologic surgery are often performed concurrently, and associated complication rates have previously been unexplored. OBJECTIVE The aim of this study was to compare postoperative complication rates between women undergoing midurethral sling (MUS) placement at the time of benign gynecologic surgery and those undergoing MUS alone. STUDY DESIGN This was a retrospective matched cohort study of women undergoing MUS with or without concurrent minimally invasive benign gynecologic surgery from January 2010 through December 2020. Eligible women undergoing concurrent surgery were matched to a cohort of women undergoing MUS placement alone. The electronic medical record was queried for demographic and perioperative/postoperative data up to 12 months after surgery. RESULTS Thirty-eight women met inclusion criteria for the concurrent group, and 152 women were matched accordingly. The overall adverse event rate was 39.5% (95% confidence interval [CI], 0.25-0.55) for the concurrent group and 24.3% (95% CI, 0.18-0.32) for the MUS-only group ( P = 0.05). Adverse events with Clavien-Dindo grade ≤ 2 were higher in the concurrent group (Clavien-Dindo Grade 1: 5% vs 0%, P = 0.04; Clavien-Dindo Grade 2: 16% vs 6%, P = 0.04), as was composite postoperative resource utilization (76% vs 49%, P = 0.003). Mesh exposure ( P = 0.03) and sling lysis/excision rates ( P = 0.02) were higher in the concurrent group. On logistic regression, concurrent surgery cases remained significantly associated with sling mesh erosion (adjusted odds ratio, 12.6; 95% CI, 1.4-116.4). CONCLUSIONS Midurethral sling placement at the time of minimally invasive benign gynecologic surgery is safe but is associated with a higher incidence of postoperative hospital resource utilization and sling mesh extrusion, and a need for revision.
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Hendrickson WK, Havrilesky L, Siddiqui NY. Cost-effectiveness of bacteriuria screening before urogynecologic surgery. Am J Obstet Gynecol 2022; 226:831.e1-831.e12. [PMID: 34922920 DOI: 10.1016/j.ajog.2021.11.1375] [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: 09/04/2021] [Revised: 11/17/2021] [Accepted: 11/25/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Currently, there is controversy over who requires preoperative screening for bacteriuria in the urogynecologic population and whether treating asymptomatic bacteriuria reduces postoperative urinary tract infection rates. OBJECTIVE To evaluate the cost-effectiveness of selective, universal, and no preoperative bacteriuria screening protocols in women undergoing surgery for prolapse or stress urinary incontinence. STUDY DESIGN A simple decision tree model was created from a societal perspective to evaluate cost and effectiveness of 3 strategies to prevent postoperative urinary tract infection: (1) a universal protocol where all women undergoing urogynecologic surgery are screened for bacteriuria and receive preemptive treatment if bacteriuria is identified; (2) a selective protocol, where only women with a history of recurrent urinary tract infection are screened and treated for bacteriuria; and (3) a no-screening protocol, where no women are screened for bacteriuria. Our primary outcome was the incremental cost-effectiveness ratio, calculated in cost per quality-adjusted life-years. Secondary outcomes were the number of urine cultures, postoperative urinary tract infections, and pyelonephritis associated with each strategy. Costs were derived from the Centers for Medicare & Medicaid Services, Healthcare Cost and Utilization Project, and Medical Expenditure Panel Survey. Clinical estimates were derived from published literature and data from a historic surgical cohort. Quality-of-life-associated utilities for urinary tract infection (0.73), pyelonephritis (0.66), and antibiotic use (0.964) were derived from the published literature using the HALex scale, reported directly by affected patients. One-way sensitivity analyses were performed over the range of reported values. RESULTS In the base case scenario, selective screening is more costly (no screen: $101.69, selective: $101.98) and more effective (no screen: 0.096459 quality-adjusted-life-year, selective: 0.096464 quality-adjusted-life-year) than no screening, and is cost-effective, with an incremental cost-effectiveness ratio of $49,349 per quality-adjusted-life-year. Both selective screening and no screening dominate universal screening in being less costly (universal: $111.92) and more effective (universal: 0.096446 quality-adjusted-life-year), with a slightly higher rate of postoperative urinary tract infection (no screen: 17.1%, selective: 16.9%, universal: 16.6%). In 1-way sensitivity analyses, selective screening is no longer cost-effective compared with no screening when the cost of a urine culture exceeds $12, cost of a preoperative urinary tract infection exceeds $93, the cost of a postoperative urinary tract infection is below $339, the specificity of a urine culture is less than 96%, or preoperative bacteriuria rates in those without symptoms but a history of recurrent urinary tract infection is <23%. Universal screening only becomes cost-effective when the postoperative urinary tract infection rate increases to >50% in those without risk factors and untreated preoperative bacteriuria. When compared with no screening, selective screening costs an additional $104 per urinary tract infection avoided and $2607 per pyelonephritis avoided. Compared with selective screening, universal screening costs $4609 per urinary tract infection avoided and $115,223 per pyelonephritis avoided. CONCLUSION Implementation of a selective preoperative bacteriuria protocol is cost-effective in most scenarios and associated with only a <1% increase in the 30-day postoperative urinary tract infection rate. No screening is cost-effective when cost of a preoperative urinary tract infection is high and the rate of preoperative bacteriuria in those without risk factors is low.
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Evaluation and Management of Common Intraoperative and Postoperative Complications in Gynecologic Endoscopy. Obstet Gynecol Clin North Am 2022; 49:355-368. [DOI: 10.1016/j.ogc.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Lu Z, Chen Y, Wang X, Li J, Hua K, Hu C. Transvaginal natural orifice transluminal endoscopic surgery for uterosacral ligament suspension: pilot study of 35 cases of severe pelvic organ prolapse. BMC Surg 2021; 21:286. [PMID: 34103032 PMCID: PMC8185939 DOI: 10.1186/s12893-021-01280-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 05/28/2021] [Indexed: 11/17/2022] Open
Abstract
Background To describe the short-term outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for uterosacral ligament suspension (USLS) in patients with severe prolapse. Methods This was a retrospective study of patients with severe prolapse (≥ stage 3) who underwent vNOTES for USLS between May 2019 and July 2020. The Pelvic Organ Prolapse Quantification (POP-Q) score, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) and Pelvic Floor Inventory-20 (PFDI-20) were used to evaluate physical prolapse and quality of life before and after vNOTES for USLS. Results A total of 35 patients were included. The mean operative duration was 111.7 ± 39.4 min. The mean blood loss was 67.9 ± 35.8 ml. Statistically significant differences were observed between before and after vNOTES USLS in Aa (+ 0.6 ± 1.7 versus − 2.9 ± 0.2), Ba (+ 1.9 ± 2.2 versus − 2.9 ± 0.3), C (+ 1.5 ± 2.2 versus − 6.9 ± 0.9), Ap (− 1.4 ± 1.0 versus − 3.0 ± 0.1) and Bp (− 1.1 ± 1.4 versus − 2.9 ± 0.1) (P < 0.05 for all). The mean pre- and postoperative PFDI-20 score was 19.9 ± 6.7 and 3.2 ± 5.4, respectively, and the mean pre- and postoperative PISQ-12 score was 24.8 ± 2.3 and 38.3 ± 4.1, respectively (P < 0.05 for both). During 1–13 months of follow-up, there were no cases of severe complications or recurrence. Conclusions vNOTES for USLS may be a feasible technique to manage severe prolapse, with promising short-term efficacy and safety. Larger studies with more patients and longer follow-up periods should be performed to evaluate the long-term efficacy and safety profile of vNOTES for USLS.
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Affiliation(s)
- Zhiying Lu
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang RD, Shanghai, 200090, China
| | - Yisong Chen
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang RD, Shanghai, 200090, China
| | - Xiaojuan Wang
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang RD, Shanghai, 200090, China
| | - Junwei Li
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang RD, Shanghai, 200090, China
| | - Keqin Hua
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang RD, Shanghai, 200090, China.
| | - Changdong Hu
- Department of Gynecology, The Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang RD, Shanghai, 200090, China.
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Surgical Assessment of Tissue Quality during Pelvic Organ Prolapse Repair in Postmenopausal Women Pre-Treated Either with Locally Applied Estrogen or Placebo: Results of a Double-Masked, Placebo-Controlled, Multicenter Trial. J Clin Med 2021; 10:jcm10112531. [PMID: 34200470 PMCID: PMC8201142 DOI: 10.3390/jcm10112531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/17/2021] [Accepted: 06/01/2021] [Indexed: 11/17/2022] Open
Abstract
The aim of this prospective randomized, double-masked, placebo-controlled, multicenter study was to analyze the surgeon’s individual assessment of tissue quality during pelvic floor surgery in postmenopausal women pre-treated with local estrogen therapy (LET) or placebo cream. Secondary outcomes included intraoperative and early postoperative course of the two study groups. Surgeons, blinded to patient’s preoperative treatment, completed an 8-item questionnaire after each prolapse surgery to assess tissue quality as well as surgical conditions. Our hypothesis was that there is no significant difference in individual surgical assessment of tissue quality between local estrogen or placebo pre-treatment. Multivariate logistic regression analysis was performed to identify independent risk factors for intra- or early postoperative complications. Out of 120 randomized women, 103 (86%) remained for final analysis. Surgeons assessed the tissue quality similarity in cases with or without LET, representing no statistically significant differences concerning tissue perfusion, tissue atrophy, tissue consistency, difficulty of dissection and regular pelvic anatomy. Regarding pre-treatment, the rating of the surgeon correlated significantly with LET (r = 0.043), meaning a correct assumption of the surgeon. Operative time, intraoperative blood loss, occurrence of intraoperative complications, total length of stay, frequent use of analgesics and rate of readmission did not significantly differ between LET and placebo pre-treatment. The rate of defined postoperative complications and use of antibiotics was significantly more frequent in patients without LET (p = 0.045 and p = 0.003). Tissue quality was similarly assessed in cases with or without local estrogen pre-treatment, but it seems that LET prior to prolapse surgery may improve vaginal health as well as tissue-healing processes, protecting these patients from early postoperative complications.
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Abstract
OBJECTIVE To evaluate the cost-effectiveness of surgical treatment pathways for apical prolapse. STUDY DESIGN We constructed a stochastic Markov model to assess the cost-effectiveness of vaginal apical suspension, laparoscopic sacrocolpopexy, and robotic sacrocolpopexy. We modeled over 5 and 10 years, with 9 pathways accounting for up to 2 separate surgical repairs, recurrence of symptomatic apical prolapse, reoperation, and complications, including mesh excision. We calculated costs from the health care system's perspective. RESULTS Over 5 years, compared with expectant management, all surgical treatment pathways cost less than the willingness-to-pay threshold of US $50,000 per quality adjusted life-years. However, among surgical treatments, all but 2 pathways were dominated. Of the remaining 2, laparoscopic sacrocolpopexy followed by vaginal repair for apical recurrence was not cost-effective compared with the vaginal-only approach (incremental cost-effectiveness ratio [ICER], >$500,000). Over 10 years, all but the same 2 pathways were dominated. However, starting with the laparoscopic approach in this case was more cost-effective with an ICER of US $6,176. If the laparoscopic approach was not available, starting with the robotic approach similarly became more cost-effective at 10 years (ICER, US $35,479). CONCLUSIONS All minimally invasive surgical approaches for apical prolapse repair are cost-effective when compared with expectant management. Among surgical treatments, the vaginal-only approach is the only cost-effective option over 5 years. However, over a longer period, starting with a laparoscopic (or robotic) approach becomes cost-effective. These results help inform discussions regarding the surgical approach for prolapse.
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Chang OH, Tewari S, Sun JY, Ferrando CA. Risk factors for ureteral obstruction and the diagnostic value of the "cysto-under-tension" technique at the time of uterosacral colpopexy. Int Urogynecol J 2021; 32:2985-2992. [PMID: 33449125 DOI: 10.1007/s00192-020-04650-5] [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: 09/15/2020] [Accepted: 12/10/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective is to determine the incidence of ureteral obstruction and delayed ureteral injury and to identify risk factors for ureteral obstruction following uterosacral colpopexy. The secondary objective is to evaluate the diagnostic value of the "cysto-under-tension" technique, when a cystoscopy is performed prior to vaginal cuff closure with the uterosacral sutures on tension. METHODS This was a retrospective review of patients undergoing uterosacral ligament colpopexy between 2007 and 2012 with a nested case-control analysis. Patients with documented ureteral obstruction on cystoscopy or a delayed ureteral injury were identified. Cases were defined as patients with a ureteral obstruction on cystoscopy and controls as those who did not; a multivariable regression analysis was performed. RESULTS A total of 551 patients underwent uterosacral ligament colpopexy. Twenty-four (4.3% [95% CI = 2.94-6.40]) patients had a ureteral obstruction on cystoscopy, and two (0.4% [95% CI = 0.09-1.31]) patients experienced a delayed ureteral injury. The "cysto-under-tension" technique was used in 40 (7.3%) cases, with a sensitivity of 50.0% (CI = 1.26-98.74) and specificity of 97.4% (CI = 86.2-99.9) to detect ureteral obstruction. On logistic regression for the case-control analysis, increased age remained associated with increased odds of ureteral obstruction (adjOR 1.06, 95% CI = 1.02-1.11) and a higher BMI had lower odds (adjOR 0.89, 95% CI = 0.79-0.98). CONCLUSIONS In this large cohort study, older age was associated with higher odds of obstruction at the time of colpopexy while a higher BMI might have been protective. The "cysto-under-tension" technique overall may not be that useful in detecting ureteral obstructions but has high negative predictive value.
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Affiliation(s)
- Olivia H Chang
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk A81, Cleveland, OH, 44195, USA.
| | - Surabhi Tewari
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jinger Y Sun
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk A81, Cleveland, OH, 44195, USA
- Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk A81, Cleveland, OH, 44195, USA
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Incidence of and Risk Factors for Postoperative Urinary Tract Infection After Abdominal and Vaginal Colpopexy. Female Pelvic Med Reconstr Surg 2021; 27:e75-e81. [PMID: 32205555 DOI: 10.1097/spv.0000000000000814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The aims of the study were to determine the rate of urinary tract infection (UTI) in women undergoing colpopexy and to evaluate risk factors and timing for postoperative UTI. METHODS This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2017. Patients were grouped into those with and without UTI. Pairwise analysis between groups was performed using χ2 and Fisher exact test. Multivariable logistic regression was used to identify independent predictors of UTI. RESULTS Of 23,097 women who underwent colpopexy, 1079 (4.7%) experienced a postoperative UTI. Urinary tract infection was most frequently diagnosed in the second week after surgery (38.2%), compared with week 1 (19.9%), 3 (22.8%), and 4 (19.1%) (P < 0.001). Patients diagnosed with a UTI were more likely to have insulin-dependent diabetes (2.8% vs 1.7%, P = 0.006), coagulopathy (1.3% vs 0.7%, P = 0.04), and chronic steroid use (2.7% vs 1.8%, P = 0.004). Patients with a UTI versus those without a UTI were more likely to have undergone an intraperitoneal or extraperitoneal vaginal colpopexy (37.8% vs 30.5%, P < 0.001) and (29.8% vs 25.6%, P = 0.003), respectively, and more likely to undergo combined anterior and posterior colporrhaphy (17.1% vs 12.2%, P < 0.001). After logistic regression, intraoperative cystotomy repair (adjusted odds ratio = 2.93, 95% confidence interval = 1.54-5.59) was the most significant risk factor. CONCLUSIONS Postoperative UTI after colpopexy occurred less frequently than previously reported. Vaginal colpopexy is associated with a higher risk of UTI than abdominal or laparoscopic colpopexy.
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Cost-effectiveness Analysis of Universal Cystoscopy at the Time of Benign Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2020; 28:1470-1483. [PMID: 33310171 DOI: 10.1016/j.jmig.2020.12.004] [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: 09/01/2020] [Revised: 11/06/2020] [Accepted: 12/06/2020] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To estimate the rate of lower urinary tract injury (LUTI) and percentage of LUTI needing to be recognized intraoperatively to make universal cystoscopy cost-effective and cost-saving during laparoscopic hysterectomy. DESIGN A decision tree model was used to estimate the costs and quality-adjusted life years associated with delayed or intraoperative recognition of LUTI at the time of laparoscopic hysterectomy. Probabilities and utilities were estimated from published literature. Costs were estimated from Medicare national reimbursement schedules. Threshold analyses estimated the LUTI rate and cystoscopy sensitivity that would make universal cystoscopy cost-effective or cost-saving. Monte Carlo simulations were performed. SETTING US healthcare system. PATIENTS Individuals undergoing laparoscopic hysterectomy for benign indications. INTERVENTIONS Theoretic implementation of a universal cystoscopy policy. MEASUREMENTS AND MAIN RESULTS The total direct medical costs of laparoscopic hysterectomy under usual care were $8831 to $9149 and under universal cystoscopy were $8944 to $9068. When low LUTI rates (0.44%; estimated using sample-weighted estimates of retrospective and prospective data) were assumed, universal cystoscopy was only cost-effective in 17.1% of the simulations; the incremental cost was estimated to be $111 to $131. With median LUTI rates (2.3%) or high LUTI rates (4.0%; estimated using only prospective data with universal screening), the universal cystoscopy strategy was cost-effective in 93.9% and 99.6% of the simulations, respectively, and potentially cost-saving if the sensitivity of intraoperative cystoscopy for ureteral injury exceeded 65% or 31%, respectively. The estimated potential savings were $18 to $95 per hysterectomy. In threshold analysis assuming the average cystoscopy sensitivity rate, universal cystoscopy is estimated to be cost-effective when the LUTI rate exceeds 0.80%. CONCLUSION In our model, universal cystoscopy is the preferred approach for laparoscopic hysterectomy and is estimated to be cost-effective in contemporary clinical settings where the LUTI rate is estimated to be 1.8% and potentially cost-saving among higher-risk populations, including those with endometriosis or pelvic organ prolapse. If the LUTI rates are less than 0.75%, the estimated incremental costs are modest-up to $131 per case. Administrators and providers should consider the local LUTI rates and practice patterns when planning implementation of a universal cystoscopy policy.
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Wang W, Zhang Y, Shen W, Niu K, Lu Y. Long-term efficacy of transvaginal high uterosacral ligament suspension for middle-compartment defect-based pelvic organ prolapse. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1645. [PMID: 33490157 PMCID: PMC7812174 DOI: 10.21037/atm-20-7296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/04/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND We aim to assess the long-term efficacy of transvaginal high uterosacral ligament suspension (HUS) procedure for middle compartment defect-based pelvic organ prolapse (POP). METHODS We performed a retrospective review of 84 women with middle-compartment defect-based POP who underwent transvaginal HUS as the primary surgical treatment without mesh augmentation from January 2007 to January 2019. All 84 patients manifested ≥ grade-II middle-compartment defect-based POP. Follow-up visits were performed 2, 6 and 12 months after surgery and then annually, including questionnaires and clinical examination using pelvic organ prolapse quantitation system (POP-Q). Surgical success required to fulfill all three of these criteria: (I) anterior or posterior vaginal wall prolapsed the leading edge of 0 cm or less and apex of 1/2 total vaginal length or less; (II) the absence of POP symptoms as reported on the PFDI-20 question No. 3 ("do you usually have a bulge or something falling out that you can see or feel in your vaginal area?"); and (III) no prolapse re-operations or pessary use during the study period. RESULTS Of 84 women, 56 cases (66.7%, 56/84) were evaluated at a ≥5-year follow-up. The 5-year recurrence rates for patients with prolapse of either the anterior vaginal wall, vaginal vault, or posterior vaginal wall, or prolapses in multiple sites, were 7.1% (4/56), 0, 1.8% (1/56), and 3.6% (2/56), respectively. The surgery success rate was 87.5% (49/56). None of the recurrent women underwent retreatment. The satisfaction rate was 91.1% (51/56). CONCLUSIONS Transvaginal HUS without mesh augmentation is a safe and effective procedure in the surgical treatment of patients with middle-compartment defects. Anatomical, functional, and subjective outcomes were very satisfactory.
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Affiliation(s)
- Wenying Wang
- Department of Obstetrics and Gynecology, Fourth Medical Center, General Hospital of People's Liberation Army, Beijing, China
| | - Yinghui Zhang
- Department of Obstetrics and Gynecology, Fourth Medical Center, General Hospital of People's Liberation Army, Beijing, China
| | - Wenjie Shen
- Department of Obstetrics and Gynecology, Fourth Medical Center, General Hospital of People's Liberation Army, Beijing, China
| | - Ke Niu
- Department of Obstetrics and Gynecology, Fourth Medical Center, General Hospital of People's Liberation Army, Beijing, China
| | - Yongxian Lu
- Department of Obstetrics and Gynecology, Fourth Medical Center, General Hospital of People's Liberation Army, Beijing, China
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Antibiotic Prophylaxis in Pelvic Floor Surgery. CURRENT BLADDER DYSFUNCTION REPORTS 2020. [DOI: 10.1007/s11884-020-00601-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Slopnick EA, Welles Henderson J, Chapman G, Sheyn DD, El-Nashar SA, Petrikovets A, Pollard R, Mangel JM. Cystoscopy with antibiotic irrigation during pelvic reconstruction and minimally invasive gynecologic surgery: A double-blind randomized controlled trial. Neurourol Urodyn 2020; 39:2386-2393. [PMID: 32886811 DOI: 10.1002/nau.24499] [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: 06/19/2020] [Revised: 07/22/2020] [Accepted: 08/24/2020] [Indexed: 11/08/2022]
Abstract
AIMS After pelvic reconstructive surgery, the risk of postoperative urinary tract infection (UTI) is significant; intraoperative cystoscopy may contribute to this risk. Intravesical antibiotics are used in the ambulatory setting and may be applied to the surgical arena. Our objective was to evaluate the efficacy of antibiotic irrigation during intraoperative cystoscopy to prevent postoperative UTI. METHODS This double-blind randomized controlled trial enrolled 216 women undergoing cystoscopy with elective surgery for pelvic organ prolapse, stress urinary incontinence, or laparoscopic gynecologic surgery at an academic medical center 2016-2019. Participants were randomized to cystoscopic irrigation fluid type: normal saline (control) or 200,000 U polymyxin B + 40 mg neomycin solution in normal saline (antibiotic). Patients and providers who treated UTIs were blinded. The primary outcome was treatment of UTI within 6 weeks postoperatively, defined as positive culture or treatment for a symptomatic UTI. χ2 and multivariable logistic regression analyses were performed. RESULTS We enrolled 216 women: 111 control (51.4%) and 105 antibiotic (48.6%). Mean age was 51.6 years. Groups were well matched in medical comorbidities and surgery type. Primary vaginal surgery was most common (n = 127, 58.8%). Overall, 10.7% of patients developed a postoperative UTI with no difference in incidence between groups: 9.9% of control (n = 11, 95% confidence interval [CI]: 4.0%-16.0%) versus 11.4% of antibiotic subjects (n = 12, 95% CI: 5.0%-18.0%), on χ2 (p = .718) and logistic regression analysis (adjusted odds ratio, 1.3; CI: 0.53-3.16; p = .569). CONCLUSION When cystoscopy is performed during elective pelvic surgery, use of antibiotic irrigation does not impact the rate of postoperative UTI.
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Affiliation(s)
- Emily A Slopnick
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA.,Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - J Welles Henderson
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA.,Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Graham Chapman
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA.,Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.,Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - David D Sheyn
- Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sherif A El-Nashar
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Andrey Petrikovets
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Robert Pollard
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Jeffrey M Mangel
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA
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Vaginal intraperitoneal versus extraperitoneal uterosacral ligament vault suspensions: a comparison of a standard and novel approach. Int Urogynecol J 2020; 32:913-918. [PMID: 32757022 DOI: 10.1007/s00192-020-04462-7] [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: 05/07/2020] [Accepted: 07/23/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Uterosacral ligament suspension surgery is commonly utilized to correct post-hysterectomy vaginal vault prolapse (VVP). Vaginal intraperitoneal uterosacral vault suspension (IUSVS) is a viable option, but intraperitoneal access can be challenging. An alternative approach is an extraperitoneal uterosacral vault suspension (EUSVS). The aim of our study was to compare surgical outcomes of IUSVS and EUSVS in patients with post-hysterectomy VVP. METHODS Retrospective cohort study of women who underwent treatment of post-hysterectomy VVP with an IUSVS and EUSVS from May 2016 to January 2019 at our institution. The primary outcome was surgical success that was assessed by a composite outcome for surgical failure, defined as ANY of the following: (1) apical descent > 1/3 of the TVL or anterior or posterior vaginal wall beyond the hymen, (2) retreatment of prolapse, or (3) bothersome vaginal bulge symptoms with a positive response to either of two questions on the PFDI questionnaire. Secondary outcomes included EBL, operative time, duration of hospitalization, and perioperative complications. Two-sample t-tests and chi-square tests were used for the bivariate analysis. RESULTS Eighty patients were included (36 IUSVS and 44 EUSVS) with a mean follow-up of 7 months. For our primary outcome, there was no difference in surgical success (IUSVS group 72.22% vs. EUSVS group 81.82%, p = 0.307). Operative time, duration of hospitalization, and EBL were significantly less in the EUSVS group than in the IUSVS group. CONCLUSIONS EUSVS demonstrated similar short-term success compared to IUSVS for post-hysterectomy VVP, with shorter operative time, EBL, and length of stay.
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Wherley SD, Chapman GC, Mahajan ST, Hijaz AK, Slopnick EA, Roberts K, El-Nashar S. Evaluation of the ACS NSQIP surgical risk calculator in patients undergoing pelvic organ prolapse surgery. Int Urogynecol J 2020; 31:2089-2094. [PMID: 32556848 DOI: 10.1007/s00192-020-04364-8] [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: 02/03/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The purpose of this study was to evaluate the accuracy of the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) surgical risk calculator in predicting postoperative complications in patients undergoing pelvic organ prolapse surgery. METHODS We performed a retrospective review of 354 patients who underwent surgery for pelvic organ prolapse from 2013 to 2017 at a single academic institution. Patient medical information and surgical procedure were entered into the calculator to obtain predicted complication rates, which were compared with observed complications. Logistic regression, C-statistic, and Brier score were used to assess the accuracy of the calculator. RESULTS Of 354 patients included in the analysis, 79.7% were under the age of 75, and 41.5% were classified as American Society of Anesthesiologists class ≥3. The majority of patients underwent robotic sacrocolpopexy (40.7%) or uterosacral ligament suspension (36.4%), followed by colpocleisis, abdominal sacrocolpopexy, and extraperitoneal suspension. Complications were experienced by 100 patients (28.3%). Most common complications were urinary tract infection (n = 57), surgical site infection (n = 42), and readmission (n = 16); other complications were rare. The surgical risk calculator displayed poor predictive ability for experiencing a complication (C-statistic = 0.547, Brier score = 0.25). CONCLUSIONS The NSQIP surgical risk calculator displayed poor predictive ability in our cohort of patients undergoing surgery for pelvic organ prolapse, suggesting that this tool might have limited clinical applicability to individual patients in this population.
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Affiliation(s)
- Susan D Wherley
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - Graham C Chapman
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - Adonis K Hijaz
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Emily A Slopnick
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kasey Roberts
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sherif El-Nashar
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Joint report on terminology for surgical procedures to treat pelvic organ prolapse. Int Urogynecol J 2020; 31:429-463. [DOI: 10.1007/s00192-020-04236-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Palmerola R, Rosenblum N. Prolapse Repair Using Non-synthetic Material: What is the Current Standard? Curr Urol Rep 2019; 20:70. [PMID: 31612341 DOI: 10.1007/s11934-019-0939-8] [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] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Due to recent concerns over the use of synthetic mesh in pelvic floor reconstructive surgery, there has been a renewed interest in the utilization of non-synthetic repairs for pelvic organ prolapse. The purpose of this review is to review the current literature regarding pelvic organ prolapse repairs performed without the utilization of synthetic mesh. RECENT FINDINGS Native tissue repairs provide a durable surgical option for pelvic organ prolapse. Based on recent findings of recently performed randomized clinical trials with long-term follow-up, transvaginal native tissue repair continues to play a role in the management of pelvic organ prolapse without the added risk associated with synthetic mesh. In 2019, the FDA called for manufacturers of synthetic mesh for transvaginal mesh to stop selling and distributing their products in the USA. Native tissue and non-synthetic pelvic organ prolapse repairs provide an efficacious alternative without the added risk inherent to the utilization of transvaginal mesh. A recent, multicenter, randomized clinical trial demonstrated no clear advantage to the utilization of synthetic mesh. Furthermore, transvaginal native tissue repairs have demonstrated good long-term efficacy, particularly when anatomic success is not the sole metric used to define surgical success.
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Affiliation(s)
- Ricardo Palmerola
- Departments of Urology and Obstetrics & Gynecology, New York University School of Medicine, 222 East 41st Street, 11th Floor, New York, NY, 10017, USA.
| | - Nirit Rosenblum
- Departments of Urology and Obstetrics & Gynecology, New York University School of Medicine, 222 East 41st Street, 11th Floor, New York, NY, 10017, USA
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Pedersen KD, Storkholm MH, Bek KM, Glavind-Kristensen M, Greisen S. Recurrent apical prolapse after high uterosacral ligament suspension - in a heterogenous cohort characterised by a high prevalence of previous pelvic operations. BMC WOMENS HEALTH 2019; 19:96. [PMID: 31299946 PMCID: PMC6626360 DOI: 10.1186/s12905-019-0800-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/05/2019] [Indexed: 11/10/2022]
Abstract
Background The apical prolapse is probably the most complex form of pelvic organ prolapse (POP). Adequate apical support is essential in the treatment of POP, as it contributes to the support in all vaginal compartments. This study aimed to evaluate the rate of symptomatic recurrent apical prolapse after high uterosacral ligament suspension (HUSLS), in a cohort of women characterised by a high prevalence of previous pelvic operations and a significant degree of prolapse. Methods This is a retrospective chart review of 95 women who underwent HUSLS for symptomatic apical prolapse from 2002 to 2009 at Aarhus University Hospital, Denmark. Of these women, 97% attended a six-month clinical control. Recurrence was defined as symptomatic vaginal vault prolapse stage 2 or more (according to the International Continence Society (ICS) quantification system). Medical charts were reviewed for a mean period of 7.2 years. Any new contacts due to prolapse were noted. Results Before the operation, 73% of the women were hysterectomised, and 52% had previous prolapse surgery. Stage 2 apical prolapse was reported in 71% of the women, whereas 26% had stage 3 or 4. At six-month follow-up, 19% of the women had recurrent symptomatic apical prolapse, and 9% of the women had symptomatic recurrent prolapse in other compartments 6 months after operation. In all, 35% of the women had a renewed prolapse operation during the long-term follow-up period. Perioperative adverse events were seen in 7%. Two women were re-operated due to postoperative complications. Conclusions This retrospective study of 95 women with a significant degree of prolapse and a high prevalence of previous pelvic operations demonstrates that the rate of recurrent prolapse associated with HUSLS might be higher than originally described. In conclusion, HUSLS may not be the optimal first choice of operation in this group of patients.
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Affiliation(s)
- Katrine Dahl Pedersen
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark. .,, Brabrand, Denmark.
| | | | - Karl Møller Bek
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Marianne Glavind-Kristensen
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Susanne Greisen
- Department of Gynaecology and Obstetrics, Regional Hospital in Horsens, Horsens, Denmark
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Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort of Absorbable and Permanent Suture Groups. Female Pelvic Med Reconstr Surg 2019; 24:207-212. [PMID: 28657988 DOI: 10.1097/spv.0000000000000451] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to compare anatomic results after vaginal uterosacral ligament suspension with absorbable versus permanent suture. METHODS We performed a retrospective cohort study of women who underwent vaginal uterosacral ligament suspension, from 2006 to 2015. We compared 2 groups: (1) absorbable suspension suture and (2) permanent suspension suture (even if accompanied by absorbable suture). Our primary outcome was composite anatomic failure defined as (1) recurrent prolapse in any compartment past the hymen or (2) retreatment for prolapse. Continuous variables were analyzed using the Student t test or Mann-Whitney U test, and categorical variables were analyzed using χ or Fisher exact test. Multivariable logistic regression analysis was performed to control for confounders. P < 0.05 was considered significant. RESULTS Of the 242 patients with medium-term follow-up (3 months to 2 years after surgery), 188 underwent vaginal uterosacral ligament suspension with only absorbable suture, and 54 underwent suspension with permanent suture. Compared with the absorbable suture cohort, the permanent suture cohort was more likely to have had advanced preoperative prolapse (P = 0.01), less likely to have had a prior hysterectomy (P = 0.01), and less likely to have undergone a concomitant posterior colporrhaphy/perineoplasty (P < 0.01). Overall, there were no differences in composite anatomic failure between the absorbable and permanent suture groups (17.0% vs 20.4%, P = 0.41). In multivariable logistic regression analyses, when controlling for covariates, there remained no difference in composite anatomic failure between permanent and absorbable suture groups. CONCLUSIONS Completion of vaginal uterosacral ligament suspension using only absorbable suture affords similar anatomic outcomes in the medium term as compared with suspension with additional permanent suture.
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Abstract
An estimated 300,000 women undergo pelvic organ prolapse (POP) surgery in the United States every year at a cost of more than 1 billion dollars per year. The prevalence of POP is approximately 2.9% to 8%, and increases with age. Apical support is required to achieve successful prolapse repair. As the search for the safest, most durable, surgical repair continues, transvaginal native tissue repairs have the advantage of providing minimally invasive surgical repairs without the added risk of abdominal, laparoscopic, or robotic surgery while avoiding the risk of mesh augmentation.
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Affiliation(s)
- Ekene A Enemchukwu
- Department of Urology, Stanford University, 300 Pasteur Drive, Grant Building, 2nd Floor, S287, Stanford, CA 94304, USA; Department of Obstetrics & Gynecology, 300 Pasteur Drive- HG332 Stanford, CA 94305, USA.
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Iwanoff C, Giannopoulos M, Salamon C. Follow-up postoperative calls to reduce common postoperative complaints among urogynecology patients. Int Urogynecol J 2018; 30:1667-1672. [PMID: 30413866 DOI: 10.1007/s00192-018-3809-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 10/25/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The purpose of our study was to identify the most common reasons why postoperative urogynecology patients called their surgeon within the first 6 weeks of surgery. We hypothesize that implementing a follow-up postoperative call (FPC) policy would decrease the number of patient-initiated calls within this postoperative period. METHODS This is a prospective before-and-after cohort study that was conducted in two phases. The initial phase identified the most common reasons why patients call within 6 weeks of their inpatient or outpatient urogynecological surgery. In the second phase, an intervention was implemented where each postoperative patient was called within 48 to 72 h of discharge: the intervention group. The primary outcome was the number of phone calls initiated by patients during the 6-week postoperative period. RESULTS There were 226 patients in the control group and 233 patients in the intervention group. Significantly fewer calls were initiated by patients in the intervention group, both groups having a median of 1 call per person, range 0-8 in the control group and 0-10 in the intervention group (p = 0.04). The five most common complaints were as follows: pain (20.4%), medication management (17.4%), disability paperwork (15.5%), and laboratory results (11.5%). There was a significant reduction in calls concerning constipation, laboratory/pathology results, and disability insurance claims after implementing the FPC policy. CONCLUSIONS The implementation of the FPC policy resulted in fewer patient-initiated calls. As such, there were significant reductions in postoperative complaints of constipation, vaginal bleeding, incomplete bladder emptying, and inquiries into laboratory results and disability paperwork.
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Affiliation(s)
- Christopher Iwanoff
- FPMRS, Atlantic Health System, 435 South Street, Suite 370, Morristown, NJ, 07960, USA.
| | - Maria Giannopoulos
- Obstetrics and Gynecology, Atlantic Health System, 100 Madison Ave, Morristown, NJ, USA
| | - Charbel Salamon
- FPMRS, Atlantic Health System, 435 South Street, Suite 370, Morristown, NJ, 07960, USA
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Abstract
PURPOSE OF REVIEW This article provides an update on the use of cystoscopy at the time of prolapse and incontinence surgery. RECENT FINDINGS Iatrogenic lower urinary tract injury is a known complication of antiincontinence procedures and surgical repair of pelvic organ prolapse. Intraoperative cystoscopy improves detection of lower urinary tract injuries in women undergoing pelvic floor surgery. The pelvic surgeon has a number of agents available to aid in the cystoscopic visualization of ureteral efflux. When injuries of the urinary tract are identified and treated intraoperatively, there is decreased morbidity, lower healthcare costs, and a lower risk of litigation than when detection is delayed. Therefore, many organizations, including the American College of Obstetricians and Gynecologists (ACOG), the American Urogynecologic Society (AUGS), and the American Urological Association (AUA) recommend cystoscopy at the time of pelvic floor surgery. SUMMARY Cystoscopy should be universally employed at the time of prolapse and incontinence surgery, except in instances of isolated repair of the posterior compartment.
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Houlihan S, Kim-Fine S, Birch C, Tang S, Brennand EA. Uterosacral vault suspension (USLS) at the time of hysterectomy: laparoscopic versus vaginal approach. Int Urogynecol J 2018; 30:611-621. [PMID: 30393822 DOI: 10.1007/s00192-018-3801-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/19/2018] [Indexed: 02/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS To compare laparoscopic and vaginal approaches to uterosacral ligament vault suspension (USLS) by perioperative data, short-term complications, rates of successful concomitant adnexal surgery and procedural efficacy. METHODS Retrospective cohort of USLS procedures performed at the time of hysterectomy at a tertiary care center over a 3-year period. Patient demographics, surgical data, concomitant adnexal procedures and complications were abstracted from a surgical database and compared using parametric or non-parametric tests as appropriate. Validated questionnaires (POPDI-6, UDI-6, PROMIS) were used to collect information on recurrence and long-term complications. Patients were analyzed according to both intention-to-treat analysis based on the intended approach and the completed route of surgery to deal with intraoperative conversions. RESULTS Two hundred six patients met the criteria for inclusion; 152 underwent vaginal USLS (V-USLS) and 54 laparoscopic USLS (L-USLS). No statistically significant differences in mean case time, postoperative length of stay or perioperative infection were found. While no ureteric obstructions occurred in the L-USLS group, in the V-USLS group 14 (9%) obstructions occurred (p = 0.023). Postoperative urinary retention was higher with V-USLS (31% vs. 15%, p = 0.024). Rates of successfully completed adnexal surgery differed (56% vs. 98%, p < 0.001) in favor of L-USLS. Patient-reported symptomatic recurrence of prolapse was higher in the V-USLS group (41% vs. 24%, p = 0.046); despite this, re-treatment did not differ between the groups (0% vs. 7%, p = 0.113). CONCLUSIONS Perioperative case time and complications did not differ between approaches. However, rates of completed adnexal surgery were significantly higher in the laparoscopic group, which could influence surgical decisions concerning approaches to prolapse surgery.
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Affiliation(s)
- Sara Houlihan
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, 4th Floor North Tower, Room 432, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada.
| | - Shunaha Kim-Fine
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, 4th Floor North Tower, Room 432, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada
| | - Colin Birch
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, 4th Floor North Tower, Room 432, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada
| | - Selphee Tang
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, 4th Floor North Tower, Room 432, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada
| | - Erin A Brennand
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, 4th Floor North Tower, Room 432, 1403 29 Street NW, Calgary, AB, T2N 2T9, Canada
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Perioperative adverse events in women undergoing concurrent urogynecologic and gynecologic oncology surgeries for suspected malignancy. Int Urogynecol J 2018; 30:1195-1201. [PMID: 30280203 DOI: 10.1007/s00192-018-3772-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/14/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS This study's objectives were to compare the incidence of adverse events after concurrent urogynecologic and gynecologic oncology surgery to gynecologic oncology surgery alone and to describe the frequency of modification in planned urogynecologic procedures. The authors hypothesized there would be no difference in major complications. METHODS This was a retrospective matched cohort study of women who underwent concurrent surgery at a large tertiary care center between January 2004 and June 2017. Cohorts were matched by surgeon, surgery route, date, and final pathologic diagnosis. Perioperative data and postoperative adverse events classified by Clavien-Dindo grade were compared. RESULTS One hundred and eight patients underwent concurrent surgeries, with 216 matched cohorts. Concurrent-case patients were more likely to be older, postmenopausal, have greater vaginal parity, have had preoperative chemotherapy, and have preoperative cardiac or pulmonary disease. There were no differences in intraoperative complications or Dindo grade ≥ 3 adverse events between groups, but there were more grade 2 adverse events in the concurrent cohort (44 vs 19%, p < 0.0001) including postoperative urinary tract infection (UTI) (26 vs 7%, p < 0.0001). Concurrent surgery remained associated with a higher incidence of grade ≥ 2 events on multivariate analysis [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.5-4.2, p = 0.0004). Discharge with a urinary catheter was more frequent after concurrent cases (35 vs 2%, p < 0.0001). Planned urogynecologic procedures were modified in 10% (n = 11) of cases. CONCLUSIONS Concurrent surgeries have an increased incidence of minor but not serious perioperative adverse events. One in ten planned urogynecologic procedures is either modified or abandoned during combined surgeries.
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Peacock LM, Young A, Rogers RG. Universal cystoscopy at the time of benign hysterectomy: a debate. Am J Obstet Gynecol 2018; 219:75-77. [PMID: 29941279 DOI: 10.1016/j.ajog.2018.04.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 02/11/2018] [Accepted: 04/10/2018] [Indexed: 11/24/2022]
Abstract
Injury to the bladder and/or ureters is the cause of significant morbidity, and efforts to reduce these injuries are important. This debate presents arguments that both support, and refute, the value of routine cystoscopy at the time of benign hysterectomy. Proponents of routine cystoscopy state that injuries are more likely to be detected and repaired when cystoscopy is routinely performed. Dissenters counter that the available evidence does not support routine cystoscopy at the current rates of lower urinary tract injury, and the cystoscopy should be performed only when injury is suspected or when performing hysterectomy with concurrent procedures that increase the risk of lower urinary tract injury.
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RCT of vaginal extraperitoneal uterosacral ligament suspension (VEULS) with anterior mesh versus sacrocolpopexy: 4-year outcome. Int Urogynecol J 2018; 29:1607-1614. [DOI: 10.1007/s00192-018-3687-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 06/06/2018] [Indexed: 11/26/2022]
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Symptom Relief and Retreatment After Vaginal, Open, or Robotic Surgery for Apical Vaginal Prolapse. Female Pelvic Med Reconstr Surg 2018; 23:297-309. [PMID: 28118173 DOI: 10.1097/spv.0000000000000389] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this work was to determine the degree of symptom relief and survival free of retreatment after Mayo-McCall culdoplasty (MMC), open abdominal sacrocolpopexy (ASC), and robotic sacrocolpopexy (RSC) for posthysterectomy vaginal vault prolapse. METHODS We retrospectively studied patients who had undergone surgery for posthysterectomy apical vaginal prolapse from January 1, 2000, through June 30, 2012, at our institution. Baseline characteristics and perioperative outcomes were abstracted from electronic health records. Cross-sectional data for current pelvic floor symptoms were collected by using validated questionnaires. Survival free of retreatment was estimated with the Kaplan-Meier method. To account for selection bias, adjusted analyses using inverse probability weighting (IPW) were performed to compare outcomes for MMC versus ASC, MMC versus RSC, and ASC versus RSC. RESULTS Of 512 patients, 337 completed at least a validated or abbreviated questionnaire. Among MMC, ASC, and RSC groups, overall Pelvic Floor Distress Inventory 20, Pelvic Floor Impact Questionnaire Short Form 7, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire 12 summary scores were not significantly different. There was no significant difference in 5-year survival free of retreatment for MMC (94.0%) versus RSC (95.5%) and ASC (94.8%) versus RSC (92.1%). However, patients who had MMC were more likely to have retreatment than patients who had ASC during the first 10 years (10-year survival free of retreatment: 81.1% vs 95.4%; hazard ratio, 3.68 [95% confidence interval, 1.51-8.98]); the 10-year data were not available for RSC comparisons, given the later initiation of RSC. CONCLUSIONS Symptom relief was comparable after MMC, ASC, and RSC. Among all groups, most patients were free of retreatment for prolapse at 5 years. Between the MMC and ASC groups, survival free of retreatment (%) within 10 years was still favorable, but ASC had greater durability, particularly after accounting for selection bias.
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Eftekhar T, Forooghifar T, Alizadeh S, Shabihkhani S, Forooghifar T, Hajhashemy M. Apical Prolapse Surgical Treatment Outcomes: Transabdominal Versus Transvaginal Approach. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tahereh Eftekhar
- Department of Pelvic Floor, Tehran University of Medical Sciences, Tehran, Iran
| | - Tahereh Forooghifar
- Department of Pelvic Floor, Tehran University of Medical Sciences, Tehran, Iran
| | - Shima Alizadeh
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
| | - Sarah Shabihkhani
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
| | - Tayebeh Forooghifar
- Student of Marketing Management, Islamic Azad University of Rudehen, Tehran, Iran
| | - Maryam Hajhashemy
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
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Erekson E, Murchison RL, Gerjevic KA, Meljen VT, Strohbehn K. Major postoperative complications following surgical procedures for pelvic organ prolapse: a secondary database analysis of the American College of Surgeons National Surgical Quality Improvement Program. Am J Obstet Gynecol 2017; 217:608.e1-608.e17. [PMID: 28578172 DOI: 10.1016/j.ajog.2017.05.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/19/2017] [Accepted: 05/23/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Surgical approaches to the correction of pelvic organ prolapse include abdominal, vaginal, and obliterative approaches. These approaches require vastly different anatomical dissections, surgical techniques, and operative times and are often selected by the patient and surgeon to match preoperative multimorbidity and ability of the patient to tolerate the stress of surgery. OBJECTIVE We sought to describe the occurrence of postoperative complications occurring after 3 different surgical approaches to treat pelvic organ prolapse: vaginal, abdominal, and obliterative. STUDY DESIGN We conducted a secondary database analysis of the 2006 through 2014 American College of Surgeons National Surgical Quality Improvement Program participant use data files to analyze patients undergoing procedures for pelvic organ prolapse based on Current Procedural Terminology codes. Women were categorized into 3 surgical approaches to prolapse: vaginal, abdominal, and obliterative. Concomitant hysterectomy and sling were also examined. The primary outcome was a composite of 30-day major postoperative complications. RESULTS A total of 33,416 women were included in our final analysis: 24,928 vaginal procedures, 6834 abdominal (4461 minimally invasive) procedures, and 1654 obliterative procedures. Concomitant hysterectomies and slings were performed in 17,380 (52.0%) and 10,896 (32.6%) of prolapse procedures. The overall prevalence of composite 30-day major postoperative complications was 3.1% (n/N = 1028/33,416). There were 13 perioperative deaths (0.04%) with no difference in the surgical approaches (P = .55). There were no differences in major postoperative complications between vaginal and abdominal procedures (3.0% vs 3.0%; P = .71). Women undergoing obliterative procedures had an occurrence of major postoperative complications of 5.0% (n/N = 83/1654), P < .001. CONCLUSION The occurrence of major postoperative complications after prolapse surgery is rare. We did not find a significant difference in major postoperative complications between vaginal and abdominal surgeries for pelvic organ prolapse. In this well-characterized cohort of patients who self-selected surgical approach, women undergoing obliterative surgery had more postoperative complications, likely attributed to increased age and multimorbidity.
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Affiliation(s)
- Elisabeth Erekson
- Department of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth, Hanover, NH; Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH.
| | - Regan L Murchison
- Department of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Kristen A Gerjevic
- Department of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - Kris Strohbehn
- Department of Obstetrics and Gynecology, Geisel School of Medicine at Dartmouth, Hanover, NH
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Abstract
OBJECTIVE The aim of this study was to describe the relationship of the uterosacral ligament (USL) to the ureter and rectum along a surgeon's target location for suture placement under conditions simulating live surgery. METHODS Dissections were performed in 11 unembalmed female cadavers. Steps were taken to identify the USL simulating USL colpopexy. Pins were placed in the midportion of the USL at the level of the IS, and at 1-cm, 2-cm, and 3-cm increments traveling proximally toward the sacrum (Fig. 1). We measured minimum distances from the USL to the ureter and rectum at each target location. RESULTS In general, the ureters range from 1.3 to 2.0 cm lateral to the USLs along the target length. The rectum ranges from 1.9 to 2.6 cm from the right USL and remains 1.5 cm from the left USL. The mean change in distance between the ureter and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% confidence interval [CI], 0.19-0.24) on the right and 0.2 cm (95% CI, 0.18-0.27) on the left. The mean change in distance between the rectum and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% CI, 0.19-0.24) on the right and 0.0 cm (95% CI, 0-0) on the left. CONCLUSIONS For every centimeter traveled along the bilateral USLs from the IS toward the sacrum, the ureter moves 0.2 cm laterally away from the ligament, the rectum moves 0.2 cm medially away from the right USL, but maintains its position from the left USL.
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Ajao MO, Kohli N. CystoSure™: A Unique Catheter-Based Instrument for Cystoscopy and Bladder Diagnostics in the Operating Room and Office. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0209-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Surgical treatments for vaginal apical prolapse. Obstet Gynecol Sci 2016; 59:253-60. [PMID: 27462591 PMCID: PMC4958670 DOI: 10.5468/ogs.2016.59.4.253] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/16/2016] [Accepted: 03/23/2016] [Indexed: 11/29/2022] Open
Abstract
Pelvic organ prolapse is a common condition, occurring in up to 11% of women in the United States. Often, pelvic organ prolapse recurs after surgery; when it recurs after hysterectomy, it frequently presents as vaginal apical prolapse. There are many different surgical treatments for vaginal apical prolapse; among them, abdominal sacral colpopexy is considered the gold standard. However, recent data reveal that other surgical procedures also result in good outcome. This review discusses the various surgical treatments for vaginal apical prolapse including their risks and benefits.
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Siff LN, Unger CA, Jelovsek JE, Paraiso MFR, Ridgeway BM, Barber MD. Assessing ureteral patency using 10% dextrose cystoscopy fluid: evaluation of urinary tract infection rates. Am J Obstet Gynecol 2016; 215:74.e1-6. [PMID: 26875949 DOI: 10.1016/j.ajog.2016.02.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/19/2016] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intravenous indigo carmine has routinely been used to confirm ureteral patency after urogynecologic surgery. Recent discontinuation of the dye has altered clinical practice. In the absence of indigo carmine, we have used 10% dextrose in sterile water (D10) as cystoscopic fluid to evaluate ureteral patency. Glucosuria has been associated with urinary tract infection (UTI) in vivo and significantly enhanced bacterial growth in vitro. The concern is that the use of D10 would mimic a state of glucosuria albeit transient and increase the risk of postoperative UTI. OBJECTIVES The objectives of this study were to compare the rates of postoperative UTI and lower urinary tract (LUT) injuries between patients who underwent instillation of D10 vs normal saline at the time of intraoperative cystoscopy after urogynecological surgery. STUDY DESIGN This was a retrospective cohort study of all women who underwent cystoscopic evaluation of ureteral patency at the time of urogynecological surgery from May through December 2014 at a tertiary care referral center. We compared patients who received D10 cystoscopy fluid vs those who used normal saline. Outcomes included UTI and diagnosis of ureteral or LUT injuries. UTI was diagnosed according to Centers for Disease Control and Prevention guidelines by symptoms alone, urine dipstick, urinalysis, or urine culture. Descriptive statistics compared the rates of UTI between the 2 groups, and a multivariable model was fit to the data to control for potential confounders and significant baseline differences between the groups. RESULTS A total of 303 women were included. D10 was used in 113 cases and normal saline (NS) was used in 190. The rate of UTI was higher in the D10 group than the NS group: 47.8% (95% confidence interval [CI], 38.3-57.4) vs 25.9% (95% CI, 19.8-32.8, P < .001). After adjusting for age, pelvic organ prolapse stage, use of perioperative estrogen, days of postoperative catheterization, menopausal status, diabetes mellitus, and history of recurrent UTI, the UTI rate remained significantly higher with the use of D10 (adjusted odds ratio, 3.4 [95% CI, 1.6-7.5], P = .002) compared with NS. Overall, 3 cases of transient ureteral kinking (1.0%) and one cystotomy (0.3%) were identified intraoperatively. However, ureteral and LUT injuries were not different between groups. No unidentified injuries presented postoperatively. CONCLUSION Although the use of D10 cystoscopy fluid has been successful in identifying ureteral patency in the absence of indigo carmine, it is associated with an increased rate of postoperative UTI compared with NS.
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Postoperative appointments: which ones count? Int Urogynecol J 2016; 27:1873-1877. [PMID: 27311601 DOI: 10.1007/s00192-016-3052-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 05/11/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Although postoperative complications in women undergoing reconstructive pelvic surgery (RPS) have been characterized, little is known regarding the timeline of these occurrences. We aimed to determine the timeframe after RPS during which the majority of complications occur, to assist with planning intervals between postoperative visits. METHODS Women undergoing RPS were identified through billing information. Demographic, surgical, and complications data were extracted from electronic medical records. The Pelvic Floor Complication scale is a surgical scale tailored to women undergoing RPS. It contains three subscales: intraoperative, immediately postoperative, and delayed complications. We applied this scale to each postoperative visit (at 2, 6, and 13 weeks). RESULTS 396 women underwent RPS and 125 patients had 179 complications, most of which (66 %) were identified by the 2-week visit. Complications at the 2-week visit consisted of urinary tract infection (UTI; 46 %), wound infection (10.0 %), and urinary retention (9.4 %). The majority of serious complications (venous thromboembolism [VTE], ileus, small bowel obstruction [SBO], readmission, and reoperation [1 incarcerated hernia and 1 sling release]) were diagnosed by 2 weeks. One patient was readmitted for ileus at between 2 and 6 weeks. At between 6 and 13 weeks, 1 patient was readmitted with SBO; 1 VTE was diagnosed; and 1 required reoperation for a prolapsed fallopian tube. In contrast, two thirds of the complications seen at the 13-week visit were due to granulation tissue, suture erosion or mesh erosion. CONCLUSIONS The majority of non-mesh-related complications occur within the first 2 weeks after RPS, whereas mesh and suture complications are more likely to be identified at the 13-week visit.
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Maldonado PA, Stuparich MA, McIntire DD, Wai CY. Proximity of uterosacral ligament suspension sutures and S3 sacral nerve to pelvic landmarks. Int Urogynecol J 2016; 28:77-84. [DOI: 10.1007/s00192-016-3039-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/02/2016] [Indexed: 11/24/2022]
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Fairchild PS, Kamdar NS, Berger MB, Morgan DM. Rates of colpopexy and colporrhaphy at the time of hysterectomy for prolapse. Am J Obstet Gynecol 2016; 214:262.e1-262.e7. [PMID: 26366666 PMCID: PMC4744488 DOI: 10.1016/j.ajog.2015.08.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/06/2015] [Accepted: 08/28/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND It has been shown that addressing apical support at the time of hysterectomy for pelvic organ prolapse (POP) reduces recurrence and reoperation rates. In fact, national guidelines consider hysterectomy alone to be inadequate treatment for POP. Despite this, anterior and posterior colporrhaphy are frequently performed without a colpopexy procedure and hysterectomy alone is often utilized for treatment of prolapse. OBJECTIVE The objectives of this study were to: (1) determine rates of concomitant procedures for POP in hysterectomies performed with POP as an indication, (2) identify factors associated with performance of a colpopexy at the time of hysterectomy for POP, and (3) identify the influence of surgical complexity on perioperative complication rates. STUDY DESIGN This is a retrospective cohort study of hysterectomies performed for POP from Jan. 1, 2013, through May 7, 2014, in a statewide surgical quality database. Patients were stratified based on procedures performed: hysterectomy alone, hysterectomy with colporrhaphy and without apical suspension, and hysterectomy with colpopexy with or without colporrhaphy. Demographics, medical history and intraoperative care, and perioperative care were compared between the groups. Multivariable logistic regression models were created to identify factors independently associated with use of colpopexy and factors associated with increased rates of postoperative complications. RESULTS POP was an indication in 1557 hysterectomies. Most hysterectomies were vaginal (59.6%), followed by laparoscopic or robotic (34.1%), and abdominal (6.2%). Hysterectomy alone was performed in 43.1% (95% confidence interval [CI], 40.6-45.6) of cases, 32.8% (95% CI, 30.4-35.1) had a colporrhaphy without colpopexy, and 24.1% (95% CI, 22-26.3) had a colpopexy with or without colporrhaphy. Use of colpopexy was independently associated with patient age >40 years, POP as the only indication for surgery (odd ratio [OR], 1.6; 95% CI, 1.185-2.230), laparoscopic surgery (OR, 3.2; 95% CI, 2.860-5.153), and a surgeon specializing in urogynecology (OR, 8.2; 95% CI, 5.156-12.923). The overall perioperative complication rate was 6.6%, with the majority being considered minor. Complications were more likely when the procedure was performed with an abdominal approach (OR, 2.3; 95% CI, 1.088-4.686), with the use of a colpopexy procedure (OR, 3.1; 95% CI, 1.840-5.194), and by a surgeon specializing in urogynecology (OR, 2.2; 95% CI, 1.144-4.315). CONCLUSION Colpopexy and colporrhaphy may be underutilized and are potential targets for quality improvement. Performance of additional procedures at the time of hysterectomy increased the rate of perioperative complications. Long-term consequences of these surgical practices deserve additional study.
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Affiliation(s)
- Pamela S Fairchild
- Female Pelvic Medicine and Reconstructive Surgery, University of Michigan, Ann Arbor, MI.
| | - Neil S Kamdar
- Female Pelvic Medicine and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Mitchell B Berger
- Female Pelvic Medicine and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
| | - Daniel M Morgan
- Female Pelvic Medicine and Reconstructive Surgery, University of Michigan, Ann Arbor, MI
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Mearini L, Nunzi E, Di Biase M, Costantini E. Laparoscopic Management of Vaginal Vault Prolapse Recurring after Pelvic Organ Prolapse Surgery. Urol Int 2016; 97:158-64. [DOI: 10.1159/000443337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 12/12/2015] [Indexed: 11/19/2022]
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