Concomitant trocar-guided transvaginal mesh surgery with a midurethral sling in treating advanced pelvic organ prolapse associated with stress or occult stress urinary incontinence

Role of Hysteropexy in the Management of Pelvic Organ Prolapse

PURPOSE OF REVIEW

To discuss considerations for hysteropexy for apical pelvic organ prolapse (POP) and summarize available literature comparing various hysteropexy techniques to analogous procedures involving hysterectomy.

RECENT FINDINGS

Hysteropexy for apical POP has increased in popularity in recent years, although anatomic factors and gynecologic cancer risk must be taken into account. Native tissue hysteropexy options include the LeFort colpocleisis, sacrospinous hysteropexy, and uterosacral hysteropexy. Although vaginal mesh was banned by the Food and Drug Administration in 2019, abdominal mesh sacrohysteropexy done either open or laparoscopically remains an option in the USA. Overall, short-term prolapse outcomes appear to be comparable between uterus-sparing approaches and hysterectomy, with less blood loss and shorter operating room time observed with the uterine-sparing approaches, although long-term outcome data remains variable and limited. Uterine-sparing apical POP repair may be offered to appropriate patients without certain risk factors, although longer-term data will be required to evaluate durability.

Short-term results of stress urinary incontinence in women undergoing laparoscopic sacrocolpopexy with and without midurethral sling

OBJECTIVES

This study aimed to assess the short-term results of stress urinary incontinence (SUI) in women undergoing laparoscopic sacrocolpopexy (LSC) with and without midurethral sling (MUS).

METHODS

This retrospective study was conducted from July 2012 to December 2017. Women with stage 3 or 4 in the Pelvic Organ Prolapse Quantification (POP-Q) who underwent LSC were recruited. Multichannel urodynamic studies were performed in all women. Assessment included pre- and postoperative POP-Q stages, urodynamic parameters, peri- and postoperative complications, and symptoms.

RESULTS

One hundred and eighteen patients met the inclusion criteria in total. A total of 19.5% (23/118) of them had concomitant MUS. The mean follow-up duration was 16.9 ±  16.0 (range 3-69) months. Meanwhile, 33.9% (40/118) of the patients were diagnosed with overt SUI, and 50% (20/40) underwent MUS. In the concomitant MUS group, the rate of having postoperative SUI was only 5% (1/20). Patients diagnosed with SUI and without concomitant MUS had a 45% rate (9/20), and 25% of them (5/20) received MUS later. Preoperatively, 16.1% (19/118) of the patients were diagnosed with occult SUI. Among the patients without anti-incontinence sling during prolapse surgery, 25% (4/16) of them complained about having SUI during the follow-up. However, none of the women required subsequent anti-incontinence surgery. Postoperative de novo SUI occurred to 13.6% (16/118) of them. None of the patients received further operation. Based on the preoperative and postoperative urodynamic studies in the combination surgery group, a significant improvement was observed in the pad test.

CONCLUSIONS

The combination of LSC with MUS procedure is likely to be beneficial in selected patients.

Management of Urinary Incontinence before and after Total Pelvic Reconstruction for Advanced Pelvic Organ Prolapse with and without Incontinence

Background:

The effectiveness of an anti-incontinence procedure concomitant with prolapse reconstruction for pelvic organ prolapse (POP) in preventing urinary incontinence (UI) after surgery remains controversial. Our study aimed to describe the incidence of pre- and postoperative UI for pelvic reconstructive surgery and evaluate the management of POP associated with UI.

Methods:

A total of 329 patients who underwent total pelvic reconstruction between June 2009 and February 2015 at a single institution were identified. These patients were divided into two groups (Group A [Prolift reconstruction]: n = 190 and Group B [modified total pelvic reconstruction]: n = 139). Data regarding surgical procedures and patient demographic variables were recorded. Chi-square and Student's t-tests were used for two independent samples.

Results:

A total of 115 patients presented with UI preoperatively. The average follow-up time was 46.5 months, with 20 patients lost to follow-up (6.1%). The cure rates of stress UI (SUI), urgency UI (UUI), and mixed UI (MUI) were 51% (30/59), 80% (16/20), and 48% (14/29), respectively. The cure rate of UUI after total pelvic reconstruction (80% [16/20]) was higher than that of SUI (50.8% [30/59], χ²= 5.219, P = 0.03), and the cure rate of MUI (48%, 14/29) was the lowest. The cure rate of patients with UI symptoms postoperatively was lower than that of those with symptoms preoperatively (9.1% [28/309] vs. 16.2% [50/309], χ²= 7.101, P = 0.01). There was no difference in the incidence of UI postoperatively between Groups A and B (P > 0.05). The cure rate of SUI in patients undergoing tension-free vaginal tape-obturator was not higher than that in those who did not undergo the procedure (42.9% [6/14] vs. 53.3% [24/45], χ²= 0.469, P = 0.49). There were no differences in the cure rate for POP or UI between these two types of reconstructions (P > 0.05).

Conclusions:

No correlation between the incidence of UI and POP was identified. The results suggest that UI treatment should be performed after POP surgery for patients with both conditions.

Uterine preservation vs hysterectomy in pelvic organ prolapse surgery: a systematic review with meta-analysis and clinical practice guidelines

OBJECTIVE

We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines.

DATA SOURCES

The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017.

STUDY ELIGIBILITY CRITERIA

We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed.

RESULTS

We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation.

CONCLUSION

Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.

Does anchoring vaginal mesh increase the potential for correcting stress incontinence?

Background

This study aims to explore the feasibility of anchoring a four-arm transvaginal mesh (TVM) to the mid-urethra to correct an anterior compartment POP–Quantification stage II–III (Q II–III) and concomitant genuine SUI.

Methods

We analysed clinical data from 248 patients with stage II–III anterior prolapse and concomitant SUI who had undergone surgery at a tertiary referral centre in Hungary between January 2008 and June 2010. One hundred and twenty-four women treated with anterior colporrhaphy and 62 patients implanted with a conventional permanent TVM were selected as historical matched controls. Sixty-two patients received a modified permanent TVM, where the mesh was fixed to the mid-urethra with two stitches for the purpose of potentially correcting SUI. Surgical complications were classified using the Clavien–Dindo (CD) classification system.

Results

The anti-SUI efficacy was minimally higher in the mTVM group than in the original TVM group (p = 0.44, 96.8% vs 91.9%, respectively), while prosthesis surgery was more effective than anterior colporrhaphy in improving the anterior compartment POP–Q status (96.8, 90.3% vs 64.5%, respectively). Anchoring the mesh did not increase the extrusion rate (p = 0.11). The de novo urge symptoms were not more prevalent among those who had received additional periurethral stitches (p = 1.00, 11.3% vs 12.9%). The incidence of reoperation observed in the mTVM group was non-significantly lower than that in the TVM group (p = 0.15, 6.5% vs 16.1%); however, the difference did not reach the level of significance. The early postoperative complication profile was more favourable among the mTVM patients (classified as CD I: 8.1%; CD II: 1.6%; and CD IIIb: 1.6%) as compared to the TVM group (p = 0.013).

Conclusions

The new, modified mesh surgery represents an effective procedure for prolapse and concomitant SUI with a decreased risk of short- and long-term complications.

Effect of Concurrent Prolapse Surgery on Stress Urinary Incontinence Outcomes After TVTO

OBJECTIVES

A variety of pelvic organ prolapse (POP) surgeries are performed concomitant to midurethral sling (MUS) placement. It is unknown whether differing POP surgeries may affect stress urinary incontinence outcomes after MUS placement.

METHODS

We performed a retrospective cohort analysis of patients undergoing TVT obturator system in conjunction with a variety of POP repair (cystocele with mesh graft, cystocele with cadaveric fascia, colpocleisis, and sacrocolpopexy). Primary outcomes included validated measures of stress urinary incontinence (International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms), measured preoperatively and at 6 week, 1 year, and 2 years postoperatively. Secondary outcomes included validated questionnaire items focused on obstructive and irritative symptoms. Multivariate analyses using mixed-effects regressions were used to assess for differences in outcomes based on POP repair type.

RESULTS

A total of 102 patients were identified for study analysis (cystocele with mesh graft, n = 45; cystocele with cadaveric fascia, n = 37; sacrocolpopexy, n = 16; colpocleisis, n = 4). Four patients undergoing colpocleisis were excluded from primary analysis given lack of sufficient cohort size. When adjusted for effects of covariates, significant improvements in primary and secondary outcomes were seen throughout follow-up in comparison with baseline. In general, multivariate analysis demonstrated no significant differences between surgeries when assessing primary and secondary outcomes. The only statistically significant difference in change over time comprised CM, which demonstrated superior improvement in International Consultation on Incontinence Questionnaire-Female Lower Urinary Tract Symptoms (preoperative vs 2 year, P = 0.04).

CONCLUSIONS

Regardless of POP surgery type, patients demonstrate improvements in validated SUI outcomes through 2 years. Multivariate analysis suggests that there is little difference in SUI outcomes after TVT obturator system across several different POP repair types.