Surgery for Pelvic Organ Prolapse

A national survey of UK practice for day-case vaginal prolapse surgery: Unrealistic expectations?

OBJECTIVE

The UK NHS Getting It Right First Time report (2021) recommended that a significant proportion of native tissue vaginal prolapse operations should be undertaken as day-case procedures (target: 80% anterior compartment, 70% posterior compartment, 60% combined anterior/posterior compartment). The evidence for perioperative care, options for anaesthesia and outcomes of day-case vaginal prolapse surgery is limited. This study aimed to establish current practice amongst UK gynaecologists and explore perceived barriers to implementing day-case surgery for pelvic organ prolapse. Study design A pre-tested 16-item survey was emailed to British Society of Urogynaecology members in July 2022. This survey recorded rates of day-case prolapse surgeries, barriers to implementation and practices for managing urethral catheters, vaginal packs, intraoperative anaesthetics and perioperative care. Responses to free-text questions were independently analysed by two of the authors and underwent thematic analysis.

RESULTS

121 eligible responses were received (28 % response-rate): 41 % never undertook day-case prolapse repair, 16 % undertook < 5 per year and 26 % undertook > 20 cases per year. There was no significant difference in training level or hospital setting between those groups. Reasons cited for not undertaking day-case prolapse surgery included concerns about vaginal packs and urinary catheters (92 %) postoperative complications (67 %), early discharge of elderly patients (60 %) and a lack of published evidence (39 %) or national guidance (35 %). For those currently undertaking day-case prolapse surgery; 67 % used general anaesthesia, 15 % spinal with short-acting local anaesthetic, 14 % spinal with long-acting local anaesthetic and 3 % local anaesthetic alone. Vaginal packs and self-retaining urethral catheters were used by 68 % and 70 % respectively. Concerns regarding the management of vaginal packs and urinary catheters were the most frequently cited barrier to implementing day-case surgery for pelvic organ prolapse amongst free-text responses. There were wide variations in managing catheters and packs, and in managing readmissions.

CONCLUSIONS

There is significant variation in uptake and practice for day-case prolapse surgery in the UK, with legitimate clinical concerns a barrier to its implementation. Further evaluation and development of robust, evidence-based management pathways are required to make day-case prolapse surgery consistent, feasible and defensible in clinical practice.

Same-day surgery for pelvic organ prolapse and hospital contact within 30 days

INTRODUCTION AND HYPOTHESIS

The practice of same-day surgery among urogynecologic surgeons is increasing worldwide, but the percentage fluctuates among nations. Our primary aim was to investigate the feasibility of same-day surgery for pelvic organ prolapse (POP) using native tissue repair and the reasons why same-day surgery was not possible. Secondarily, we aimed to investigate the cause of hospital contact within 30 days post surgery.

METHODS

This is a case-control study including 803 women who underwent POP surgery performed by vaginal approach intended as same-day surgery during a 3-year period. No patients were excluded. Patients were divided into two groups: successful same-day surgery (SDSS) and same-day surgery failure (SDSF).

RESULTS

Same-day surgery was performed successfully in 90.7% of the cases. Postoperative complications were the main cause of SDSF (76.0%), and most were caused by voiding dysfunction (VD) (42.7%). Patients receiving surgery in the apical compartment and/or surgery involving two compartments, receiving general anesthesia or having comorbidities equivalent to ASA score 3 had a greater tendency not to be able to complete same-day surgery. Regarding telephone contact with the hospital, the SDSS group was significantly less likely to call compared to the SDSF group (11.3% versus 26.7%) (p < 0.01) and the same regarding physical attendance in the department (8.9% and 24.0%) (p < 0.01). Only five patients were re-operated within 30 days because of bleeding.

CONCLUSIONS

This study demonstrates that same-day surgery for POP has high feasibility and is safe. Complications, hospitalizations and reoperations immediately after surgery and within 30 days were found to be minimal.

Anatomical and functional outcomes after hysterectomy and bilateral sacrospinous ligament fixation for stage IV uterovaginal prolapse: a prospective case series

Background

Aim of this study is to examine pelvic floor symptoms, anatomical results and patients’ satisfaction after sacrospinous vaginal fixation for stage 4 pelvic organ prolapse.

Methods

All patients with stage 4 pelvic organ prolapse were treated with vaginal hysterectomy, native tissue cystocele and rectocele repair and bilateral sacrospinous vaginal fixation. Anatomical and functional outcomes according to the POPq classification system and the German version of the Australian pelvic floor questionnaire were assessed. Changes between baseline, first follow-up and second follow-up were assessed by the paired Wilcoxon rank test using R, version 3.5.1.

Results

20 patients were included in the study. Scores in all four domains of the pelvic floor symptom questionnaire (bladder, bowel, prolapse, sexual function) were significantly improved at 6 and 12-months follow-up. One patient presented with a symptomatic stage 3 cystocele that needed a second surgical intervention and two patients needed surgery due to a de novo stress urinary incontinence. There were no perioperative adverse events and all patients reported full satisfaction after surgery.

Conclusions

The vaginal approach with hysterectomy, native tissue repair and bilateral sacrospinous vaginal fixation seems to be a safe and effective method for the treatment of advanced stage POP, offering excellent relief in all pelvic floor symptoms.

Trial registration

ClinicalTrials.gov (NCT 02998216), December 20th, 2016.

Prospectively registered.

Initial Experience of Laparoscopic Pectopexy for Apical Prolapse in South Korea

Pelvic organ prolapse (POP) is the herniation or bulging of the pelvic organs to or beyond the vaginal introitus. POP is a common condition affecting more than half of parous women. We recently performed POP surgery and repair in 37 patients using laparoscopic pectopexy, a new technique for apical prolapse surgery, in women with advanced POP. The surgery was performed by a single surgeon at a single institute. The methods of operation were divided into total laparoscopic hysterectomy with pectopexy, supracervical hysterectomy with pectopexy or pectopexy alone, with additional anterior or posterior colporrhaphy selectively performed. All patients were analyzed in terms of age, body mass index, parity, estimated blood loss (EBL), operation time, intraoperative complications, and postoperative complications. The patients were followed up for at least 6 months after surgery, and the short-term clinical outcomes were analyzed. All operations were performed successfully and without severe intraoperative or postoperative complications. The mean EBL was 84 mL, and the mean operation time was 121 minutes. The operation satisfaction rates were high in most patients. All patients had no recurrence of apical prolapse, de novo urgency, frequency, incontinence, de novo constipation, or ileus. In our experience, laparoscopic pectopexy is a feasible method for apical prolapse repair as it does not have severe intraoperative or postoperative complications and de novo gastrointestinal complications. Considerable follow-up period for possible postoperative events is warranted.