Comprehensive Evaluation of Anterior Elevate System for the Treatment of Anterior and Apical Pelvic Floor Descent: 2-Year Followup

Unilateral levator avulsion increases the risk of de novo stress urinary incontinence after cystocele repair

INTRODUCTION

Patients without concurrent baseline stress urinary incontinence (SUI) can develop de novo SUI after transvaginal mesh surgery (TVM) for cystocele repair. Surgeons should be aware of de novo SUI risk factors after TVM.

METHODS

A total of 1124 women who were underwent TVM surgeries were recruited and assessed for eligibility from January 1, 2012 to April 30, 2021. All data related to patients and surgeries was collected, which included general conditions, clinical examination, surgery records, and follow-up results. Patients were divided into three groups according to follow-up results and data were compared with each group. The relative risk (RR) of de novo SUI with levator avulsion was also calculated.

RESULTS

Three hundred thirty-six patients were included in this study. They were divided into no complication group (n = 249), de novo SUI group (n = 68), and other complications group (n = 19). It seemed elder or obese women had a higher risk of de novo SUI after TVM (p < 0.05). In de novo SUI group, incidence of levator avulsion before surgery were higher than the other two groups (p = 0.001). TVM can significantly change a prolapse to point Aa and Ba on POP-Q quantification system (p < 0.05). RR ratios of de novo SUI with unilateral avulsion group is 2.60 (95% confidence interval [CI] 1.39-4.87), and 2.58 (95%CI 0.82-8.15) for bilateral group.

CONCLUSION

Unilateral levator avulsion, instead of bilateral levator avulsion, is a risk factor of de novo SUI after cystocele repair surgery.

Effect of anterior vaginal wall prolapse repair by modified transvaginal mesh surgery: a retrospective cohort study

OBJECTIVE

To explore clinical outcomes and complications of modified Transvaginal mesh (M-TVM) for advanced anterior vaginal wall prolapse in 1 year follow-up.

METHODS

574 patients underwent TVM surgeries from 2019 to 2020 were collected and divided into TVM group and M-TVM group, all preoperative and postoperative data was obtained and compared between the two groups.

RESULTS

285 women were involved eventually, including 181 in TVM group and 104 in M-TVM group. No significant difference of general conditions was found between these two groups. After long-term follow-up, patients in TVM group were more likely to suffer from pelvic pain than M-TVM group (P = 0.046). Meshes seemed much wider in M-TVM group (4.5 ± 0.69 cm) than in TVM group (3.0 ± 0.91 cm). No matter TVM or M-TVM, surgeries can significantly change point Aa and Ba when compared to preoperative data. Compared to TVM group, point C and D were significant changed in patients in M-TVM group after surgery (P < 0.001) CONCLUSION: M-TVM is a commendable procedure that can significant correct anterior prolapse with mesh extended wider, and also supply stable apical support at the same time.

Anterior/Apical single incision mesh (Elevate™): Surgical experience, anatomical and functional results, and long-term complications

OBJECTIVE

Pelvic organ prolapse is a common condition among post-menopausal women, and surgery is often the standard treatment proposed. Native tissue vaginal surgery is burdened by a high rate of recurrence, and mesh vaginal surgery has become current practice. The purpose of this study was to evaluate the safety and the effectiveness of the vaginal kit Anterior/Apical single incision mesh Elevate™ for the correction of anterior and apical compartment prolapse.

STUDY DESIGN

Data of patients with symptomatic anterior vaginal prolapse stage ≥ II, receiving mesh repair with the Anterior/Apical Elevate single incision system between January 2010 and January 2015 were retrieved. Prolapse was classified according to the POP-Q system. The main outcome measure was anatomical success, while subjective and safety outcomes were secondary outcomes.

RESULTS

Anatomical success rate was 87.2 % for anterior compartment prolapse and 84.6 % for combined anterior and apical prolapse, while overall functional success rate was 96.2 % after a median follow-up of 33.6 months. The most frequent short-term complications were urinary bladder injury (3.0 %) and transient urinary retention (6.9 %). The most common long-term complications were de novo or persistent symptomatic stress urinary incontinence (10.8 %) and vaginal mesh extrusion (3.8 %).

CONCLUSION

Mesh vaginal surgery with Anterior/Apical single incision mesh Elevate™ is a well-tolerated procedure with a very high anatomical and functional success rate. Short and long-term complications rate seem to be acceptable, and in most of cases, solvable. Further studies are needed to confirm our promising data.

Evaluation of single-incision apical vaginal suspension for treatment of pelvic organ prolapse

OBJECTIVE

To present a comprehensive evaluation of anterior/apical and/or posterior prolapse repair systems with a focus on safety and surgical efficacy.

METHODS

Two hundred and twenty women with pelvic organ prolapse (POP) stage II-IV were referred for single-incision transvaginal mesh procedures in a single institution. Pre- and postoperative assessments included pelvic examination, urodynamic studies, and personal interviews about patients' quality of life and urinary symptoms.

RESULTS

The anatomical success rate was 92.3 % (203/220), regardless of primary or de-novo POP, at 12-38 month follow-up. The POP quantification parameters, except total vaginal length, improved significantly after surgery (p < 0.05). Complications included bladder injury (one case), mesh exposure (six cases) and urinary retention that required intermittent catheterization (five cases). There were no cases of bowel injury during surgery. The results indicated that 29 % of patients had de-novo stress urinary incontinence and 7.7 % of patients had de-novo POP after surgery.

CONCLUSION

The apical vaginal suspension system is a safe and effective procedure, creating good anatomical restoration and significant improvement in quality of life. However, the rate of de-novo POP in the anterior compartment of the vagina (31.8 %) seems high after treatment with apical and posterior prolapse repair systems.

Long-term results of genital prolapse surgery with polypropylene mesh

INTRODUCTION AND OBJECTIVE

The risk of intervention due to urogenital prolapse in a woman's life is 11.1%. Recurrences after classic surgery reach up to 38%. With the aim of improving these results, transvaginal mesh kits are used. The purpose of the study is to describe the results of efficacy and long-term safety of vaginal prolapse surgery with polypropylene mesh, assess subjective symptoms before and after surgery and the level of satisfaction.

PATIENTS AND METHODS

A descriptive, retrospective study of 58 women with symptomatic genital prolapses operated with polypropylene mesh between September / 2011-November / 2016. Mean age: 66.53 years, 98.27% menopausal women, 77.59% overweight/obesity, 29.31% with previous gynaecological surgery and 55.17% with combined prolapse. 46 Elevate anterior and 12 posterior were inserted. The mean follow-up period was 34.02 months. The PFDI questionnaire was used pre and post-surgery, as well as the satisfaction questionnaire.

RESULTS

Healing rate of 91.38%. Recurrences were associated with a higher BMI and with background of recurrence of previous surgery. Mean length of stay: 2.5 days. 70.69% did not need analgesia at discharge. Clavien-Dindo complications: 1 type I (urinary retention), 5 type II (urinary tract infection) and 1 type IIIa (erosion). De novo stress urinary incontinence occurred in 3.44%, while de novo dyspareunia 14.28%. 89.36% patients improved subjective symptoms, and 95.92% were satisfied.

CONCLUSION

This surgery achieves high healing rates, with few complications, improvement of subjective symptoms and high level of satisfaction of the patients.

Long-term follow-up of patients treated by transvaginal mesh repair for anterior prolapse

OBJECTIVE

The aim of the study was to assess 5 years outcome of transvaginal single incision mesh surgery (SIMS) for anterior pelvic organ prolapse (POP).

STUDY DESIGN

This was a prospective study including all patients from January 2009 to December 2012 who underwent SIMS for symptomatic anterior prolapse stage ≥2, according to POP Quantification (POP-Q). Symptoms and quality of life were assessed using validated questionnaires: Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact questionnaire (PFIQ-7), and Prolapse/ Incontinence Sexual Questionnaire (PISQ-12). Main outcome was subjective success (question 3 of PFDI-20 score = 0). Mesh-related complications, objective and functional outcomes were used as the secondary outcomes.

RESULTS

270 patients were included in the study. Median follow-up was 5,7 years [4,5-8,2]. Subjective success rate was 86,6% at 5 years. Objective success rate was 53,1% at 5 years. At 5 years, composite failure (subjective + objective) occurred for 17 patients (12%), 7 patients with direct recurrence and 10 with indirect recurrence. Re-treatment was performed in six patients (2,8%; 3 hysterectomies for apical recurrence and 3 posterior repairs for posterior recurrence). One case (0,4%) of asymptomatic mesh exposure occurred. The reoperation rate for mesh-related complications was 3,4%. At 5 years, de novo dyspareunia rate was 11,7%, 3,9% considered as mesh-related. A significant improvement was noted for symptoms and quality of life.

CONCLUSION

Five-year results demonstrate that vaginal mesh surgery provides a durable and safe repair of anterior compartment prolapse with a low rate of mesh-related complications and reoperations. Between the 2- and 5-year follow-up, patient satisfaction and associated improvements in prolapse-specific symptoms were sustained and minimal new morbidity occurred.

Long-term outcome after surgical repair of pelvic organ prolapse with Elevate Prolapse Repair System

Female pelvic organ prolapse (POP) is a common condition and the correction of prolapse remains a major challenge for the surgical community. A retrospective study of women with POP undergoing pelvic reconstructive surgery with the Elevate System followed-up for 48 months. A total of 138 women with POP were included in the study. We observed an objective cure rate of 94.9% for the anterior wall after 4 years' follow-up. The subjective cure rate was 97.1%. Improvement in the urinary symptoms was seen after the surgery: the number of asymptomatic patients increased from 14.5 to 77% after the 4 years of follow-up. We reported no cases of bleeding, haematoma, mesh infection and bowel injury, while we had four cases of bladder injury and one case of sepsis. The mesh extrusion rate was 7.3%, all cases interested the anterior compartment. Postoperative dyspareunia and pelvic pain were rare. In this cohort, the Elevate Prolapse Repair System was associated with excellent long-term results, for both anatomical corrections of prolapse, with a high objective and subjective cure rate and a functional urinary outcome. Impact statement What is already known on this subject? Female pelvic organ prolapse is a common condition and the correction of prolapse remains a major challenge for the surgical community. The optimal treatment of POP has still to be determined. What do the results of this study add? The findings from this study shows that the Elevate Prolapse Repair System had high anatomic results associated with a good durability, low morbidity and excellent subjective outcome. To the best of our knowledge, this is the first study that reports a follow-up up to 48 months. What are the implications of these findings for clinical practice and/or further research? The Elevate Prolapse Repair System was associated with excellent long terms results in terms of safety, durability and tolerability during the 4 years' follow-up. Despite the fact that the Elevate kit produced by AMS was withdrawn from the market and it is no longer available, we believe that it is helpful to have data about the outcomes of a transvaginal mesh implant.

Efficacy and safety of Elevate® system on apical and anterior compartment prolapse repair with personal technique modification

AIM

To evaluate the effectiveness and safety of Anterior Elevate® mesh kit system (AES) in woman with symptomatic stage 3 or 4 anterior and/or apical pelvic organ prolapse (POP).

MATERIALS AND METHODS

This retrospective, monocentric, single surgeon study enrolled between May 2010 and January 2013 fifty-six woman experiencing symptomatic anterior vaginal prolapse with or without apical descent (POP-Q stage 3 or 4). All women received a AES and 7 (12.5%) received a concomitant transvaginal hysterectomy. Primary endpoint was anatomic correction of prolapse; success was defined as POP-Q stage ≤ 1 or asymptomatic stage 2. Secondary endpoints were quality-of-life (QOL) results and patients' safety outcomes, which were assessed by 3 validated self-reporting questionnaires at baseline and annually: ICIQ-UI short form, ICIQ-VS and P-QOL. All patients completed 2-years and 28 women 3-years of follow-up. Surgical approach was modified in women with uterus, moving the two-propylene strips anteriorly around the cervix itself crossing one another, so the left will take place in the right side and the right on the opposite. This modification was made in order to better support the uterus.

RESULTS

Vaginal mesh exposure was present in 3 (5,3%) patients. Very good anatomical outcomes were seen, with one (1,8%) failure at 6-months, 4 (7,1%) at 1-year, 6 at 2-years (10,7%). Statistically significant improvements were seen in the ICIQ-VS and P-QOL questionnaires throughout follow-up.

CONCLUSION

Our data suggest that AES is a minimally-invasive transvaginal procedure to repair anterior and apical POP, with good evidence related to mid-term safety and efficacy.

Factors that affect outcomes of prolapse repair using single-incision vaginal mesh procedures

AIMS

Single-incision vaginal mesh (SIVM) procedures for pelvic organ prolapse (POP) differed in mesh fabrication and implantation that may affect treatment outcomes. We aim to evaluate and compare the safety and effectiveness of two SIVM procedures, and explore factors that may have associations with surgical effectiveness.

METHODS

Our data of using two SIVM procedures for a total (anterior and posterior) vaginal mesh repair were studied. Patients who had ≧stage 2 POP and underwent either Elevate (n = 85) using anchored, lightweight meshes or Prosima procedures (n = 95) using non-anchored, original meshes were assessed. A detailed comparison of 1 year outcomes was made.

RESULTS

Of the 180 patients, 172 (95.6%) attended the 1-year follow-up. Demographic data were similar between groups except a higher average age (64.5 vs 60.4, P = 0.001) was noted in the Elevate (n = 84) group compared to the Prosima (n = 88) group. Surgical results were also similar except a significantly higher objective cure (POP stage ≦1) rate (89.3% vs 78.4%, P = 0.042) was noted in the Elevate group. The safety profile favored Elevate with a lower, but not statistically significant, rate (4.7% vs 12.5%, P = 0.106) of vaginal mesh exposure. After a statistical analysis, we found anatomic recurrence (POP stage ≧2) after the SIVM procedures had strong (P < 0.05) associations with "early surgical cases," "Prosima procedure," "advanced cystocele (Ba > +3 cm)," and "prior prolapse repair," respectively.

CONCLUSIONS

Beyond a learning curve, Elevate performed better than Prosima in POP repair regarding surgical effectiveness. Meanwhile, several predisposing factors that may affect recurrence after SIVM procedures were found.

The hybrid technique of pelvic organ prolapse treatment: apical sling and subfascial colporrhaphy

INTRODUCTION AND HYPOTHESIS

The majority of patients with cystocele undergoing reconstructive surgery have combined defects of pubocervical fascia and uterosacral/cardinal ligament complex. In this regard, the simultaneous correction of both defects is rational. Furthermore, decreasing the use of synthetic materials in pelvic floor surgery is an important goal. The aim was to evaluate the objective and subjective cure rate of a hybrid technique: bilateral sacrospinous fixation using modern monofilament synthetic tape (apical sling) combined with the original technique of subfascial colporrhaphy.

MATERIALS AND METHODS

This prospective study involved 148 women suffering from cystocele combined with apical prolapse. We used the following criteria to evaluate the results of surgical treatment: results of the vaginal examination (POP-Q system), urodynamic tests, bladder ultrasound, special questionnaires (Pelvic Floor Distress Inventory [PFDI-20], Pelvic Floor Impact Questionnaire [PFIQ-7], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire [PISQ-12], International Consultation on Incontinence Modular Questionnaire Short Form [ICIQ-SF]). All listed parameters were determined before the surgery and at control examinations at 1, 6, and 12 months after the treatment.

RESULTS

At the 1-year follow-up, the objective cure rate for prolapse was 97.8%. The rate of anatomical recurrence was 2.2% (3 out of 138). The following long-term complications were noted: de novo urgency and stress urinary incontinence de novo in 2 (1.4%) and 4 (2.9%) patients, respectively. Comparison of the scores by the questionnaires also revealed a significant improvement in the quality of life in the postoperative period. Patient satisfaction rate was 97.1%.

CONCLUSION

The hybrid technique is an effective and safe uterus-sparing method for patients with advanced forms of cystocele combined with apical prolapse. This technique improves voiding function, quality of life, and provides a high satisfaction rate.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Management of apical pelvic organ prolapse

Pelvic organ prolapse is a prevalent condition, with up to 12 % of women requiring surgery in their lifetime. This manuscript reviews the treatment options for apical prolapse, specifically. Both conservative and surgical management options are acceptable and should be based on patient preferences. Pessaries are the most commonly used conservative management options. Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, though may not be effective for high stage or apical prolapse. Surgical treatment options include abdominal and vaginal approaches, the latter of which can be performed open, laparoscopically, and robotically. A systematic review has demonstrated that sacrocolpopexy has better long-term success for treatment of apical prolapse than vaginal techniques, but vaginal surgery can be considered an acceptable alternative. Recent data has demonstrated equal efficacy between uterosacral ligament suspension and sacrospinous ligament suspension at 1 year. To date, two randomized controlled trials have demonstrated equal efficacy between robotic and laparoscopic sacrocolpopexy. Though abdominal approaches may have increased long-term durability, when counseling their patients, surgeons should consider longer operating times and increased pain and cost with these procedures compared to vaginal surgery.

KEY POINTS

• Pelvic floor physical therapy (PFPT) with a physical therapist is the best approach to conservative management of apical prolapse [10]. • Pessaries should be managed with regular follow-up care to minimize complications [14•]. • Minimally invasive sacrocolpopexy appears as effective as the gold standard abdominal sacrocolpopexy (ASC) [42•]. • Robotic assisted sacrocolpopexy (RASC) and laparoscopic assisted sacrocolpopexy (LASC) are equally effective and should be utilized by pelvic floor surgeons based on their skill level and expertise in laparoscopy [44, 45•]. • Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are considered equally effective procedures and can be combined with a vaginal hysterectomy. • Obliterative procedures are effective but are considered definitive surgery [24••]. • The use of transvaginal mesh has been shown in some studies to be superior to native tissue repairs with regard to anatomic outcomes, but complication rates are higher. Transvaginal mesh should be reserved for surgeons with adequate training so that complications are minimized.

Apical prolapse repair: weighing the risks and benefits

PURPOSE OF REVIEW

This article reviews the current literature regarding surgical repair of vaginal apical prolapse and discusses the risks and benefits of various surgical approaches.

RECENT FINDINGS

Vaginal uterosacral ligament suspension has similar anatomic and subjective outcomes to sacrospinous ligament fixation at 1 year. Native tissue vaginal repairs offer decreased morbidity compared with mesh-augmented sacrocolpopexy; however, sacrocolpopexy has greater anatomic success. Minimally invasive sacrocolpopexy appears to be equivalent to open abdominal sacrocolpopexy. Native tissue repairs and transvaginal mesh kits support the vaginal apex with similar results; however, long-term follow-up is needed. Robotic and laparoscopic sacrocolpopexy are equally effective in restoring the vaginal apex.

SUMMARY

Surgical restoration of the vaginal apex can be accomplished via a variety of approaches and techniques. When deciding on the proper surgical intervention, the surgeon must carefully calculate the risks and benefits of each procedure while incorporating the patient's individual medical and surgical risk factors. Lastly, a discussion regarding the patient's overall goals of care is paramount to the decision-making process.

Comparison of clinical outcomes using "elevate anterior" versus "Perigee" system devices for the treatment of pelvic organ prolapse

OBJECTIVE

This study aims to compare clinical outcomes using the Perigee versus Elevate anterior devices for the treatment of pelvic organ prolapse (POP).

STUDY DESIGN

One hundred and forty-one women with POP stages II to IV were scheduled for either Perigee (n = 91) or Elevate anterior device (n = 50). Preoperative and postoperative assessments included pelvic examination, urodynamic study, and a personal interview about quality of life and urinary symptoms.

RESULTS

Despite postoperative point C of Elevate group being significantly deeper than the Perigee group (median: -7.5 versus -6; P < 0.01), the 1-year success rates for two groups were comparable (P > 0.05). Apart from urgency incontinence, women with advanced POP experienced significant resolution of irritating and obstructive symptoms after both procedures (P < 0.05), generating the improvement in postoperative scores of Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) (P < 0.01). On urodynamics, only the residual urine decreased significantly following these two procedures (P < 0.05). Women undergoing Perigee mesh experienced significantly higher visual analogue scale (VAS) scores and vaginal extrusion rates compared with the Elevate anterior procedure (P < 0.05).

CONCLUSIONS

With comparable success rates, the Elevate procedure has advantages over the Perigee surgery with lower extrusion rate and postoperative day 1 VAS scores.

[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.