Indications de la cure du prolapsus génital par voie vaginale avec prothèse : consensus d’experts du Collège national des gynécologues et obstétriciens français (CNGOF)

Effectiveness of Laparoscopic Pectopexy for Pelvic Organ Prolapse Compared with Laparoscopic Sacrocolpopexy

STUDY OBJECTIVE

To evaluate the clinical benefits of laparoscopic pectopexy vs laparoscopic sacrocolpopexy in women with pelvic organ prolapse (POP).

DESIGN

Prospective cohort study.

SETTING

A tertiary hospital.

PATIENTS

We included 203 patients with POP.

INTERVENTIONS

Laparoscopic pectopexy or laparoscopic sacrocolpopexy.

MEASUREMENTS AND MAIN RESULTS

Anatomic effectiveness was measured using the POP Quantification system, both before and after operation. Functional recovery effectiveness was evaluated using complications and recurrence rates within 1 year. Quality of life was assessed by the Pelvic Floor Distress Inventory-20 and Incontinence Quality of Life questionnaires at enrollment and postoperative months 3, 6, and 12. Comparisons between groups were performed using t test, chi-square test, and mixed-effects model with repeated measures. The analysis included 203 eligible patients (sacrocolpopexy, 101; pectopexy, 102). The proportion of robotic-assisted surgeries was lower in the pectopexy group than in the sacrocolpopexy group (15.7% vs 41.6%, p <.001). The average operation time of pectopexy was shorter than that of sacrocolpopexy (174.2 vs 187.7 minutes) with a mean difference of 13.5 minutes (95% confidence interval, 3.9-23.0; p = .006). Differences of intraoperative blood loss, length of hospital stay, and postoperative 7-day complications between groups were not significant. Anatomic successes were obtained in both groups with similar improvement in POP Quantification scores. The rate of urinary symptoms recurrence was higher in the pectopexy group (13.7%) than in the sacrocolpopexy group (5.0%) at the 1-year follow-up (odds ratio, 3.1; 95% confidence interval, 1.1-8.8, p = .032). The Pelvic Floor Distress Inventory-20 and Incontinence Quality of Life scores were better improved at postoperative months 3, 6, and 12 for laparoscopic pectopexy than for sacrocolpopexy.

CONCLUSION

Laparoscopic pectopexy revealed comparable anatomic success, shorter operation time, and better improvement in quality of life scores of prolapse, colorectal-anal, and urinary symptoms at 1-year follow-up, possibly being an alternative when sacrocolpopexy is not practicable. However, clinicians should pay more attention to the recurrence of urinary symptoms after pectopexy.

Evaluation of surgical treatment of genital prolapse using synthetic mesh in an outpatient procedure and patient satisfaction

OBJECTIVE

- To study a new strategy for one day prolapse surgery with mesh, to identify risk factors for one day procedure failure and patient satisfaction.

METHODS

- This retrospective observational study was conducted at Saint Etienne University Hospital, France. All patients who received a prolapse treatment by synthetic mesh between January 2016 and April 2019 in one day surgery procedure were included in the study. Exhaustive variables was collected and all patients were contacted for a satisfaction survey.

RESULTS

- During the periode patients were included. 6 of them required readmissions included 5 hospitalization for urinary retention and 1 for abnormal bleeding. Among the patients, 87% were satisfied. Only the anesthetic management was significantly associated with an ambulatory surgery success (p = 0,02) and satisfaction (p = 0,001).

CONCLUSION

- This study shows the technical feasibility and safety of prosthetic prolapse surgery during outpatient hospitalization. The success of a rapid pathway in one day surgery depends on a good selection of patients, proper planning of surgical procedures and optimization of anesthesia protocols. The prevention of outpatient failures is justified for medical and economic reasons respecting the quality and safety of patients.

Outpatient vaginal surgery for pelvic organ prolapse: a prospective feasibility study

BACKGROUND

In the light of recent progress in pelvic organ prolapse surgery, the modalities of hospital admission need reconsidering. This work aims to assess success rate of outpatient (ambulatory) vaginal mesh surgery for genital prolapse.

METHODS

A prospective observational study was conducted between January 2015 and July 2017, including all patients presenting with POP-Q stage ≥3 anterior and/or apical prolapse.

RESULTS

Sixty-nine of the 89 eligible patients were treated on an ambulatory basis (group A); 20 required overnight admission (group B): i.e., ambulatory success rate, 77.5%. Mean operative time was 44.9±2.5 min in group A and 62±6.5 min in group B. Reasons for ineligibility for ambulatory management comprised organizational issues at home (10.5%) and excessive home-to-hospital distance (5.7%). The postoperative urinary retention rate was 4.5%. Rates for successful cystocele correction (POP-Q <2) at 2 months were similar in the two groups: 94.2% in group A and 94.4% in group B (P=ns). Mean satisfaction score was 8.6±0.3/10.

CONCLUSIONS

Outpatient anterior vaginal mesh surgery for prolapse is safe and effective. The current medical-economic context favors ambulatory management. Patient selection, prior information and continuity of care seem primordial.

Complications and clinical outcomes of laparoscopic sacrocolpopexy for pelvic organ prolapse

Evidence on laparoscopic sacrocolpopexy (LSC) is lacking. Herein, we describe the complications and outcomes of LSC. This single-centre, retrospective cohort study included women with pelvic organ prolapse (POP) who underwent LSC between 2015 and 2017. Preoperative, intraoperative, postoperative, and demographic data were collected. We evaluated patients using the Pelvic Organ Prolapse Quantification system and questionnaires. The primary outcomes were operative characteristics, perioperative complications, early postoperative complications, and anatomical results at 12 months. Forty-six patients (median age: 71 years) underwent LSC. The median follow-up period was 12.0 ± 5.0 (range: 11-26) months. The perioperative complications were bladder perforation and vaginal injury (2.2%). Two (4.3%) patients required reoperation for port-site hernia. One (2.2%) patient developed a retroperitoneal abscess, and one (2.2%) had worsened stress urinary incontinence after LSC. Three (6.5%) patients presented with recurrence of prolapse. LSC is safe and effective for POP.IMPACT STATEMENTWhat is already known on this subject? Laparoscopic sacrocolpopexy (LSC) has become a widely used intervention strategy during the last decade; nevertheless, few studies have reported its outcomes and complications.What do the results of this study add? We demonstrate that LSC for pelvic organ prolapse (POP) has favourable anatomical and voiding functional results, and few perioperative complications. However, it is important to preoperatively inform patients regarding the incidence of mesh-related postoperative complications, although they are not life-threatening, and secure their informed consent.What are the implications of these findings for clinical practice and/or further research? We believe that the LSC procedure, because of its short-term and functional outcomes in the lower urinary tract discussed here, will be more commonly available in clinical practice as a feasible and safe surgical option for POP. However, prospective, large-sample studies should be performed to verify the efficacy of LSC, as further evaluation of the procedure is required.

The importance of using 3D ultrasound during pelvic organ prolapse surgery in relation to pre- and post-operative quality of life questionnaires

AIM

The main aim of this study is to evaluate the interest of three-dimensional ultrasound perineal in the measurement of the levator hiatus area as an objective reflection of the surgical correction of pelvic organ prolapse (POP). Our hypothesis is that POP surgery decreases the size of the levator hiatus area.

MATERIALS AND METHODS

A longitudinal and prospective study was conducted between April and July 2017 in the Department of Gynaecology & Obstetrics at University Hospital of Angers. Surgery was performed either by laparoscopy (sacrocolpopexy) or vaginal surgery (with or without the use of mesh). All patients were handed an information letter and signed an informed consent before being included in the study. A questionnaire was fullfilled before and one month after surgery. A clinical evaluation using the simplified POP-Q classification and a perineal 3D ultrasound were carried out before and after surgery by the same professional. The levator hiatus area was assessed before and after surgery in order to evaluate the impact of surgery on the levator hiatus area. Simplified POP-Q measurements and responses to PFDI-20 and PFDI-7 questionnaires were also collected.

RESULTS

A total of 18 patients were included in the study and four were excluded. Seven underwent laparoscopic surgery and seven underwent vaginal surgery. The levator hiatus area decreased substantially from 20.87 to 16.55cm² on mean (p=0.0001) at rest. Regarding patient satisfaction, the PFDI-20 score improved after surgery from 89.36 to 37.87 on mean (p=0.006), but the PFIQ-7 score did not reveal any significant changes (p=0.096). For the clinical examination, we used the simplified POP-Q with Ba measurement from 2.3 to -1.92cm (p=0.005) or Bp from -1.5 to -2.46cm, which is not a significant change (p=0.14). Points C (or D in cases with a history of hysterectomy) changed from -3.1 to -6.15cm (p=0.03).

CONCLUSION

The levator hiatus area seems to decrease after POP surgery. 3D ultrasound seems a new and complementary procedure that allowed to evaluate objectively the levator hiatus area and thus the clinical findings of the surgery.

Comparative mid-term anatomical and functional outcomes following laparoscopic sacrocolpopexy in women under and over 65: results from a prospective study

PURPOSE

To compare mid-term anatomical and functional outcomes following laparoscopic sacrocolpopexy (LS) between women under and over 65.

METHODS

Prospective and observational study involving patients with symptomatic pelvic organ prolapse (POP) undergoing LS. Study population was stratified according to patients' age at the time of surgery. POP symptoms and impact on quality of life were assessed by PFIQ-7 and PFDI-20 questionnaires at baseline and during follow-up.

RESULTS

Among our study population (n = 72), 26 women were over 65 and 46 under 65. Mean follow-up duration was 17.6 months, and complete follow-up was available in 90% of patients. No differences between study groups were observed regarding surgery duration, length of stay, and peri-operative complications. Recurrence rate was 1.4% at 18 months of follow-up. Questionnaires analysis revealed a significant improvement in PFIQ-7 and PFDI-20 scores. We found no differences in post-operative scores between control and elderly groups. Sixteen patients experienced de novo stress urinary incontinence (22.2%), with no difference between groups (p = 0.7). Among them, seven required surgical management.

CONCLUSIONS

LS was associated with high anatomical success rate and good functional outcomes, regardless of age at the time of surgery. LS should thus be considered in women over 65. Beyond age, the route of surgery should be driven by patient's choice and medical condition.

[Laparoscopic sacrocolpopexy for exteriorized pelvic organ prolapse: Mid-term functional results]

OBJECTIVES

To assess feasibility and postoperative outcomes associated with laparoscopic sacrocolpopexy in patients presenting with exteriorized pelvic organ prolapse (stage>3).

METHODS

Prospective study involving patients undergoing laparoscopic sacrocolpopexy for advanced stage pelvic organ prolapse. Symptoms and quality of life were evaluated at baseline and at 1, 4 and 18 months after surgery using validated questionnaires (PFDI-20 and PFIQ-7).

RESULTS

Sixty-three patients were included between September 2012 and January 2014. Sub-total hysterectomy and sub-urethral sling were performed at the time of surgery in 36% and 34% of patients, respectively. We observed 1 per-operative complication (bladder wound). De novo stress urinary incontinence and de novo dyspareunia persisting at 18 months occurred in 10% and 3% of cases, respectively. Recurrence rate was 1.6% at 18 months. The follow-up also revealed a significant and prolonged improvement in PFDI-20 and PFIQ-7 scores: from 98.8 at baseline to 33.9 at 18 months (P<0.01) and from 89.6 to 26.5 (P<0.001), respectively.

CONCLUSION

Laparoscopic sacrocolpopexy seems feasible and safe in patients suffering from exteriorized pelvic organ prolapse, leading to high anatomic success rate. It is also associated with a prolonged improvement in quality of life and a positive impact on symptoms related to prolapse.

[Are there selection criteria between abdominal approach and vaginal route for genital prolapse surgical management?]

INTRODUCTION

The never ending debate over the surgical approach of genital prolapse repair (abdominal versus vaginal route) is as passionate as ever. The available literature may support a multidisciplinary analysis of our expert daily practice.

OBJECTIVE

Our purpose was to define selection criteria for surgical approach between abdominal and vaginal route in the management of genital prolapse by reviewing the literature.

MATERIAL AND METHODS

Systematically review of the literature concerning comparative anatomical and functionnal results of surgery of pelvic organ prolaps by vaginal or abdominal route.

RESULTS

We were confronted to the lack of data in the literature, with few prospective randomized comparative studies. Many limitations were identified such as small populations in the studies, no description of sub-population, multiplicity of surgical procedures. Moreover, vaginal route was compared to sacral colpopexy by open abdominal approach, whereas laparoscopic sacrocolpopexy is now recommended. Only one prospective randomized comparative trial assessed laparoscopic sacrocolpopexy and vaginal approach, in which was used a mesh withdrawn from the market.

CONCLUSION

The lack of available randomized trials makes it impossible to define HAS compliant guidelines on this topic. However, selection criteria for each surgical approach and technique were drawn from experts' advices. © 2016 Published by Elsevier Masson SAS.

[Vaginal mesh exposure after prolapse surgery. A descriptive study of 43 cases: Epidemiology and therapeutic management]

OBJECTIVE

To describe the prevalence and time of occurrence of vaginal mesh exposure based on the initial surgical approach of prolaps. To describe their therapeutic management.

MATERIAL

Descriptive retrospective study of 43 women followed for vaginal mesh exposure diagnosed during a follow-up visit or motivated by symptoms. The initial surgery was performed abdominally (promontofixation) or vaginally. The therapeutic management was carried out by medical and/or surgical (prosthetic resection partial or complete).

RESULTS

The prevalence of vaginal exposure was 7.3% in case of vaginal initial surgery and 2.8% in case of promontofixation initial (P=0.02). Mesh exposure have appeared earlier in case of vaginal initial surgery compared to promontofixation (14.9 months vs. 45.2 months). After vaginal initial surgery, vaginal mesh exposure appeared to third within 6 months postoperatively (9/29). The success rate of medical treatment was 21.4%. In total, 31% of women initially made vaginally and 64.9% of women initially made abdominally required at least two surgeries to get a cure.

CONCLUSION

Vaginal mesh exposure may be away from the initial surgery, especially when the first initial surgery was abdominal. The medical treatment of vaginal mesh exposure led to poor results. The overall rate of healing in our experience was good but at the cost of considerable morbidity as a significant proportion of patients required two or more surgical interventions.

[Management of genito-urinary prolapse]

Genito-urinary prolapse is a common condition that is not always symptomatic. Only bothersome prolapse should be treated. The treatment is essentially surgical. Two surgical approaches can be used: abdominal, usually laparoscopic or vaginal. A rigorous analysis of anatomical and functional defect is necessary to indicate the most appropriate treatment.

[Transvaginal repair of genital prolapse using a light-weight mesh by the vaginal route]

OBJECTIVE

To evaluate the results associated with the transvaginal repair of genital prolapse using a tension free light-weight polypropylene mesh.

PATIENTS AND METHODS

One hundred and fifteen patients have been treated in a single centre. Pre-operative and operative data and complications were recorded. Patients were examined at 1, 6 and 12 months. Anatomical failure was defined as follows: Pelvic Organ Prolapse Quantification (POP-Q) stage II or more.

RESULTS

Seventy-seven (67%) patients completed 6 months follow-up and 45 (39%) patients completed 12 months follow-up. Finally, 70 (61%) patients were lost to follow-up, including 2 deaths (not related to surgery). Mean age was 66 years. All patients were treated with an anterior and apical and 20 patients were additionally treated with a posterior mesh. Among the 77 patients who completed 6 months follow-up, the complications reported were: 2 (2%) bladder injuries, 1 (1%) hematoma, 1 (1%) bleeding>200 mL and 1 (1%) vaginal mesh exposure. At one year, 6 (7%) patients suffered from urinary stress incontinence, 5 (4%) suffered from urgency and 4 (5%) had dyspareunia. Among the 45 patients who completed 12 months follow-up, functional success was 95% and anatomical success was 77%.

CONCLUSION

In this series, the placement of a light-weight transvaginal polypropylene mesh was associated with good functional results and a moderate prevalence of complications.

LEVEL OF EVIDENCE

4.