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

Very long-term outcomes of robotic mesh sacrocolpopexy for pelvic organ prolapse repair

To assess the very long-term functional outcomes and complications of robot-assisted sacrocolpopexy (RASC) at our institution where this robotic technology for pelvic organ prolapse (POP) repair has been available since 2006. A retrospective review of a cohort of women who underwent a RASC was performed by an investigator not involved in the clinical care of these patients. Women with no electronic medical record follow-up in the last 2 years were contacted by telephone. The primary outcome was RASC success defined as (1) no self-report of vaginal bulge, (2) no prolapse beyond the hymen (POP-Q > 0), and (3) no retreatment for prolapse (surgery, pessary). Postoperative symptomatic urinary incontinence (UI), anorectal dysfunction, dyspareunia and any late complication were secondary outcomes. Of 100 women who underwent RASC between 2007 and 2018, 79 patients with a median age of 66 years (IQR 58-71) were included. Median follow-up was 69 months (28-117), with a last visit more than 5 years postoperatively in 48 patients and more than 10 years in 19 patients. A total of 59 patients (75%) met the definition of success. A bothersome vaginal bulge was reported in 18 patients (23%), prolapse beyond the hymen was observed in 12 patients (16%), and further surgery for POP was performed in 9 patients (12%). Twenty-three patients reported postoperative UI (32%) and 21 reported postoperative anorectal dysfunction (39%). RASC provided good long-term results with an unpredictable risk of recurrence independent of the timeline.

Recurrent pelvic prolapse after pelvic organ prolapse suspension (POPS): Analysis and treatment of an emerging clinical issue

OBJECTIVES

To investigate pelvic organ prolapse (POP) after a novel abdominal prosthetic surgical technique - 'pelvic organ prolapse suspension' (POPS) - that has been proposed recently as an easily reproducible laparoscopic technique for the treatment of multicompartmental POP and rectal prolapse. This study also aimed to analyse treatment strategies of recurrent POP after POPS, reporting on anatomical, subjective and functional outcomes following recurrence surgery.

METHODS

Patients with a symptomatic prolapse relapse after POPS were collected and analysed prospectively at a single tertiary care institution. Each patient was offered a multidisciplinary clinical and radiological evaluation pre-operatively.

RESULTS

Twenty-five women with a median age of 59 [interquartile range (IQR) 49-73] years were enrolled in the study. Of these, 88 % were menopausal. All patients had high-grade (Pelvic Organ Prolapse Quantification System stage > 2) recurrent posterior vaginal wall-predominant prolapse after POPS. Multicompartmental prolapse was found in 64 % of patients. All women complained of vaginal bulging associated with obstructed defaecation syndrome (ODS) symptoms. Surgical treatment consisted of laparoscopic ventral rectopexy (VR) in all 25 cases (100 %), and concomitant sacral colpopexy (SCP) with previous mesh removal in 16 cases (64 %). No anatomical recurrences were observed after median follow-up of 12 (IQR 3-18) months. Overall subjective improvement after surgery was high in all patients (Patient Global Improvement Index ≤ 2).

CONCLUSIONS

Recurrent POP following POPS appears to predominantly involve the posterior vaginal wall, with associated ODS symptoms. A multidisciplinary approach is advisable for treatment of these patients. Minimally invasive VR alone or in combination with SCP seems to represent an effective treatment.

Safety and medium-term outcome of redo laparoscopic sacrocolpopexy: a matched case-control study

INTRODUCTION AND HYPOTHESIS

In the case of recurrent apical prolapse following laparoscopic sacrocolpopexy (LSCP), one may consider a "redo" procedure. We hypothesized that redo LSCP may carry an increased complication risk and less favorable outcomes when compared with primary procedures.

METHODS

This is a single-center, matched case-control (1:4) study, comparing all 39 women who had a redo LSCP and 156 women who had a primary LSCP for symptomatic apical prolapse between 2002 and 2020 with a minimum follow-up of 12 months. Matching was based on proximity to the operation date. The primary outcome was the occurrence of intraoperative and early postoperative complications within 3 months. Secondary outcomes included subjective (Patient Global Impression of Change [PGIC] ≥4) and objective (Pelvic Organ Prolapse Quantification [POP-Q] stage <2) success rates, surgical variables, graft-related complications and reinterventions.

RESULTS

There was no difference in the rate of intraoperative and early postoperative complications (redo: 21.1% vs control: 29.8%, OR: 0.63, 95% CI 0.27-1.48). The conversion rate was higher in redo patients (redo: 10.3% vs control: 0.6, OR: 17.71, 95% CI 1.92-163.39). Early postoperative complications were comparable: they were mainly infectious and managed by antibiotics. At a comparable follow-up (redo: 81 months (IQR: 54) vs control: 71.5 months (IQR: 42); p=0.37), there were no differences in graft-related complications (redo: 17.9% vs control: 9.6%, p=0.14) and reinterventions for complications (redo: 12.8% vs control: 5.1%, p=0.14) or prolapse (redo: 15.4% vs control: 8.3%, p=0.18). Subjective (redo: 88.5% vs control: 80.2%, p=0.41) and objective (redo: 31.8% vs control: 24.7%, p=0.50) success rates were also comparable.

CONCLUSIONS

In our experience, redo LSCP is as safe and effective as a primary LSCP, but there is a higher risk of conversion.

Laparoscopic sacrocolpopexy mesh excision step-by-step

INTRODUCTION AND HYPOTHESIS

The objective was to demonstrate the surgical procedure of laparoscopic mesh removal after sacrocolpopexy to aid clinicians facing mesh complications.

METHODS

Video footage shows the laparoscopic management of mesh failure and mesh erosion after sacrocolpopexy with narrated video sequences of two patients.

RESULTS

Laparoscopic sacrocolpopexy represents the gold standard in advanced prolapse repair. Mesh complications occur infrequently but infections, failure of prolapse repair and mesh erosions necessitate mesh removal and repeat sacrocolpopexy if applicable. The video deals with two women referred to our tertiary referral urogynecology unit in the University Women's Hospital of Bern, Switzerland, after laparoscopic sacrocolpopexies that were carried out in remote hospitals. Both patients were asymptomatic more than 1 year after surgery.

CONCLUSIONS

Complete mesh removal after sacrocolpopexy and repeat prolapse surgery can be challenging but is feasible and is aimed at improving patients' complaints and symptoms.

Measurement of extraction forces of non-absorbable suture and different anchoring systems used for pelvic organ prolapse surgery using soft-embalmed cadavers: A feasibility study

OBJECTIVE

Success of pelvic organ prolapse (POP) mesh procedures also depends on reliable anchoring systems (AS). Our primary aim was to assess the use of soft-embalmed cadavers in testing of different AS and our secondary aim was to compare extraction forces (EF) of different AS and non-absorbable suture (NAS).

STUDY DESIGN

IRB approval was obtained. NAS (Ti-cron®) and different AS were attached to force-measuring instrument (Dynamometer SS25LA) and anchored to anterior longitudinal (ALL) and pectineal ligament (PL) (Protack®, Uplift®, NAS), and sacrospinous ligament (SSL) (Surelift®, Elevate PC®, NAS) of Thiel soft-embalmed cadavers. EF were measured 2-4 times in each cadaver. Data were compared using non-parametric tests. Statistical significance was set at p < 0.05.

RESULTS

Three female cadavers (age 59, 77 and 87) were used. NAS EF were significantly higher than AS EF for ALL and SSL, but not PL. Thiel soft-embalmed cadavers proved to be useful in testing of different AS.

CONCLUSIONS

Use of soft-embalmed cadavers in testing of different AS is feasible. According to our results, the NAS provides most reliable intra-corporeal fixation. However, significant inter- and intra-subject variability indicates that results may also be dependent on the tissue properties and anchoring procedure. Further testing using soft-embalmed cadavers could help optimise mesh procedures and establish a threshold EF necessary for reliable fixation.

Revision sacrocolpopexy: tips and tricks for optimal outcomes

INTRODUCTION AND HYPOTHESIS

The aim of this video is to highlight important considerations and techniques for revision sacrocolpopexy in women with symptomatic recurrence of pelvic organ prolapse after sacrocolpopexy.

METHODS

In this video, we show five patients who presented with recurrent symptomatic pelvic organ prolapse after prior sacrocolpopexy. We demonstrate techniques for robotic-assisted laparoscopic sacrocolpopexy revision including surgical dissection, revision of existing mesh, and/or addition of new mesh.

CONCLUSIONS

Overall, revision sacrocolpopexy requires an individualized approach. These surgeries are often challenging because of adhesions and altered anatomy from the prior sacrocolpopexy. The reviewed considerations and techniques can be useful for ensuring a safe and effective outcome.