What Impacts the All Cause Risk of Reoperation after Pelvic Organ Prolapse Repair? A Comparison of Mesh and Native Tissue Approaches in 110,329 Women

Safety and Efficacy of Vaginal Implants in Pelvic Organ Prolapse Surgery: A Meta-analysis of 161 536 Patients

CONTEXT

Among the many surgical treatments for pelvic organ prolapse (POP), better results can be achieved with the use of vaginal implants. However, owing to perceived complications, vaginal implant surgeries have been restricted or banned in many countries.

OBJECTIVE

To assess the real value of vaginal implants in POP surgery and compare the safety and efficacy of operations with and without implants.

EVIDENCE ACQUISITION

A systematic search was performed in three medical databases. Randomised controlled trials and observational studies comparing the safety and efficacy of vaginal POP surgery with implants versus native tissue were included. Safety outcomes were defined as different types of complications (functional and non-functional) and reoperations for complications. Efficacy outcomes were parameters of anatomical success and the rate of reoperations due to recurrence. A multivariate meta-analysis framework was used to estimate pooled odds ratios (ORs) with confidence intervals (CIs) with simultaneous control for study correlations and estimation of multiple correlated outcomes.

EVIDENCE SYNTHESIS

We included 50 comparative studies in the analysis. Rates of reoperation for complications (OR 2.15, 95% CI 1.20-3.87), vaginal erosion (OR 14.05, 95% CI 9.07-21.77), vaginal bleeding (OR 1.67, 95% CI 1.25-2.23), and de novo stress urinary incontinence (OR 1.44, 95% CI 1.18-1.75) were significantly higher in the implant group. Rates of anatomical success (OR 3.22, 95% CI 2.06-5.0) and reoperation for recurrence (OR 0.55, 95% CI 0.36-0.85) were superior in the implant group.

CONCLUSIONS

POP surgeries with vaginal implants are more effective than surgeries without implants, with acceptable complication rates. Therefore, the complete prohibition of implants for POP surgeries should be reconsidered.

PATIENT SUMMARY

We compared vaginal surgery with and without implants for repair of pelvic organ prolapse. Despite higher complication rates, vaginal implants provide better long-term results overall than surgery without implants.

Review of Vaginal Approaches to Apical Prolapse Repair

PURPOSE OF REVIEW

To review recent literature and provide up-to-date knowledge on new and important findings in vaginal approaches to apical prolapse surgery.

RECENT FINDINGS

Overall prolapse recurrence rates following transvaginal apical prolapse repair range from 13.7 to 70.3% in medium- to long-term follow-up, while reoperation rates for prolapse recurrence are lower, ranging from 1 to 35%. Subjective prolapse symptoms remain improved despite increasing anatomic failure rates over time. The majority of studies demonstrated improvement in prolapse-related symptoms and quality of life in over 80% of patients 2-3 years after transvaginal repair, with similar outcomes with and without uterine preservation. Contemporary studies continue to demonstrate the safety of transvaginal native tissue repair with most adverse events occurring within the first 2 years. Transvaginal apical prolapse repair is safe and effective. It is associated with long-term improvement in prolapse-related symptoms and quality of life despite increasing rates of prolapse recurrence over time. Subjective outcomes do not correlate with anatomic outcomes.

Adverse outcomes after minimally invasive surgery for pelvic organ prolapse in women 65 years and older in the United States

INTRODUCTION AND HYPOTHESIS

To describe complications at the time of surgery, 90-day readmission and 1-year reoperation rates after minimally invasive pelvic organ prolapse (POP) in women > 65 years of age in the US using Medicare 5% Limited Data Set (LDS) Files.

METHODS

Medicare is a federally funded insurance program in the US for individuals 65 and older. Currently, 98% of individuals over the age of 65 in the US are covered by Medicare. We identified women undergoing minimally invasive POP surgery, defined as laparoscopic or vaginal surgery, in the inpatient and outpatient settings from 2011-2017. Patient and surgical characteristics as well as adverse events were abstracted. We used logistic regression for complications at index surgery and Cox proportional hazards regression models for time to readmission and time to reoperations.

RESULTS

A total of 11,779 women met inclusion criteria. The mean age was 72 (SD ± 8) years; the majority were White (91%). Most procedures were vaginal (76%) and did not include hysterectomy (68%). The rate of complications was 12%; vaginal hysterectomy (aOR 2.4, 95% CI 2.2-2.7) was the factor most strongly associated with increased odds of complications. The 90-day readmission rate was 7.3%. The most common reason for readmission was infection (2.0%), three quarters of which were urinary tract infections. Medicaid eligibility (aHR 1.5, 95% CI 1.3-1.8) and concurrent sling procedures (aHR 1.2, 95% CI 1.04-1.4) were associated with a higher risk of 90-day readmission. The 1-year reoperation rate was 4.5%. The most common type of reoperation was a sling procedure (1.8%). Obliterative POP surgery (aHR 0.6, 95% CI 0.4-0.9) was associated with a lower risk of reoperation than other types of surgery.

CONCLUSIONS

US women 65 years and older who are also eligible to receive Medicaid are at higher risk of 90-day readmission following minimally invasive surgery for POP with the most common reason for readmission being UTI.

Outcomes of a fixed skeletonised mini mesh implant for pelvic organ prolapse repair with uterine preservation

Mesh repair of pelvic organ prolapse (POP) is complicated, causing erosions, postoperative pain and surgical failure. We hypothesised that reducing the mesh size and fixating it would result in significant cure rates and reduce complication rates. Here, we present the effectiveness of mini mesh implants in POP reconstruction. Sixty women who underwent repair of stage III and IV apical prolapse with cystocele or rectocele using skeletonised mesh implant Seratom PA MR MN® were evaluated. Anatomical outcomes were assessed using modified POP-quantification (POP-Q) staging and functional outcomes were self-reported by patients - one and three months post-operatively. Apical support with anterior and/or posterior colporrhaphy was performed, resulting in 96.6% success rate. Follow-up conducted one and three months post-operatively revealed significant improvement on the modified POP-Q (p < .001) and no complaints of dyspareunia. Para-vesicular fixation using a skeletonised mini mesh implant is feasible and effective in POP repair and has low surgical complication risk.Impact StatementWhat is already known on this subject? Mesh repair for pelvic organ prolapse (POP) is currently under scrutiny as it may result in erosions, postoperative pain, and surgical failure.What do the results of this study add? The use of an apical support with mini-mesh implants resulted in a 96.6% (58/60) success rate and excellent outcomes at 1- and 3-month follow-up.What are the implications of these findings for clinical practice and/or further research? Reconstruction using skeletonised and fixated mini-mesh implants may be safe and effective for POP treatment.

Impact of high-intensity interval training on cardiorespiratory fitness, body composition, physical fitness, and metabolic parameters in older adults: A meta-analysis of randomized controlled trials

High-intensity interval training (HIIT) can effectively increase peak oxygen consumption, body composition, physical fitness, and health-related characteristics of adults; however, its impact in the older population remains highly debated. This review and meta-analysis aimed to evaluate the effects of high-intensity interval training on cardiorespiratory fitness, body composition, physical fitness, and health-related outcomes in older adults. Four electronic databases (PubMed, Scopus, Medline, and Web of Science) were searched (until July 2020) for randomized trials comparing the effect of HIIT on physical fitness, metabolic parameters, and cardiorespiratory fitness in older adults. The Cochrane risk of bias assessment tool was used to evaluate the methodological quality of the included studies; Stata 14.0 software was used for statistical analysis. HIIT significantly improved the maximum rate of oxygen consumption (VO_2peak) as compared to a moderate-intensity continuous training (MICT) protocol (HIIT vs. MICT: weighted mean difference = 1.74, 95% confidence interval: 0.80-2.69, p < 0.001). Additional subgroup analyses determined that training periods >12 weeks, training frequencies of 2 sessions/week, session lengths of 40 min, 6 sets and repetitions, training times per repetition of >60 s, and rest times of <90 s were more effective for VO_2peak. This systematic review and meta-analysis showed that HIIT induces favorable adaptions in cardiorespiratory fitness, physical fitness, muscle power, cardiac contractile function, mitochondrial citrate synthase activity, and reduced blood triglyceride and glucose levels in older individuals, which may help to maintain aerobic fitness and slow down the process of sarcopenia.

LeFort colpocleisis for recurrent pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The causes of recurrence of pelvic organ prolapse (POP) are sufficiently understood. However, few studies are available evaluating reoperation for recurrence of POP. This study evaluates the efficacy and safety of LeFort colpocleisis for recurrent POP.

METHODS

We reviewed data from patients with recurrent POP who underwent LerFort colpocleisis at a center between March 2012 and April 2017. Quality of life was assessed using the Pelvic Floor Distress Inventory Questionnaire (PFDI-20) scores. The Patient Global Impression of Improvement scale (PGI-I) was used to assess self-perceived success and subjective measures of satisfaction. The Clavien-Dindo classification (CD) was used to assess the safety of the procedure. Chi-square and paired t-tests were used to compare the same patients before and after treatment in the follow-up.

RESULTS

Twenty-six patients with recurrent POP after previous prolapse surgery underwent LeFort colpocleisis. Most of these patients had at least one comorbidity. The mean age (years) was 71.8 (7.3). The mean time to recurrent POP was 5.602 (3.643) years. There were no intraoperative bladder lesions or rectal lesions. At mean follow-up of 33.1 months, all patients had no recurrence (< stage 2), significant resolution of awareness of prolapse (P < 0.05), and significantly improved satisfaction on PGI-I after surgery. Minor complications were classified as CD II level in four cases (15.4%).

CONCLUSION

This study suggests that LeFort colpocleisis is feasible and safe for recurrent POP, especially in older women with comorbidities.