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Delu AA, Terrani KF, Funk JT, Twiss CO. Harvest of large fascia lata autograft: Outcomes in 108 patients. Neurourol Urodyn 2024; 43:1179-1184. [PMID: 38587269 DOI: 10.1002/nau.25464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/14/2024] [Accepted: 03/25/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE Due to the reclassification of transvaginal mesh as a high-risk device, there has been renewed interest in the use of fascia lata in pelvic floor reconstruction. Here we report our experience in 108 patients who underwent large fascia lata harvest for pelvic organ prolapse (POP) repair. Our primary objective was to highlight the postoperative morbidity of the large fascia lata harvest in patients who underwent POP repair using fascia lata autograft. METHODS Surgery involved harvesting a fascia lata graft through a small lateral upper thigh incision and was used for either autologous transvaginal POP repair or autologous sacrocolpopexy. To prevent seroma, a temporary Jackson-Pratt drain was intraoperatively placed and a mild compression wrap was applied to the area for 4-6 weeks postoperatively. Patient demographics were obtained preoperatively, while physical exam findings and postoperative outcomes related to the fascia lata harvest were collected at sequential follow up visits. RESULTS One-hundred eight patients underwent 111 large fascia lata harvests for either transvaginal or abdominal/robotic POP repair from July 2016 to January 2022. Mean follow-up was 19.6 months (range: 1-65) with 38 patients having 24 months or more of follow-up. Mean Visual Analog Pain (VAP) score was 1 (range: 0-10). Sixteen patients developed asymptomatic thigh bulges, 16 patients developed harvest site seromas (of which 14 resolved), and 59 patients experienced mild, non-bothersome paresthesia near the incision. CONCLUSION Large fascia lata harvest offers a robust autograft for transvaginal or transabdominal POP repair with minimal morbidity. Harvest site complications are minor and typically resolve with expectant management. This technique can be safely utilized in patients who desire graft-augmented repair of POP without the use of synthetic mesh, allograft, or xenograft.
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Affiliation(s)
- Ava A Delu
- Department of Urology, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Kristina F Terrani
- Department of Urology, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Joel T Funk
- Department of Urology, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Christian O Twiss
- Department of Urology, University of Arizona College of Medicine, Tucson, Arizona, USA
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Daykan Y, Rotem R, O'Reilly BA. Robot-assisted laparoscopic pelvic floor surgery: Review. Best Pract Res Clin Obstet Gynaecol 2023; 91:102418. [PMID: 37776580 DOI: 10.1016/j.bpobgyn.2023.102418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 07/22/2023] [Accepted: 08/26/2023] [Indexed: 10/02/2023]
Abstract
Minimally invasive surgical techniques have become more common in pelvic floor reconstructive urogynaecological surgery, specifically, robotic-assisted pelvic floor surgery. Female pelvic floor anatomy is complex, and some repairs require highly experienced surgical skills that can be gained more easily using robotic-assisted surgery. A common application of the robotic platform in urogynaecological surgeries includes sacrocolpopexy, which has become the gold standard approach in the last decade for the correction of apical prolapse. Additional procedures include sacrohysteropexy, sacrocervicopexy, fistula repair, and complex procedures involving the bladder and other pelvic organs. Despite its increasing use and clear benefit in our field, data in the literature and, in particular, randomised controlled trials are sparse. This review provides an update, incorporating recently published literature and our personal experience in that field.
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Affiliation(s)
- Yair Daykan
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Reut Rotem
- Department of Urogynaecology, Cork University Maternity Hospital, Cork, Ireland; Department of Obstetrics & Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Barry A O'Reilly
- Department of Urogynaecology, Cork University Maternity Hospital, Cork, Ireland
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Maher C, Yeung E, Haya N, Christmann-Schmid C, Mowat A, Chen Z, Baessler K. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev 2023; 7:CD012376. [PMID: 37493538 PMCID: PMC10370901 DOI: 10.1002/14651858.cd012376.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND Apical vaginal prolapse is the descent of the uterus or vaginal vault (post-hysterectomy). Various surgical treatments are available, but there are no guidelines to recommend which is the best. OBJECTIVES To evaluate the safety and efficacy of any surgical intervention compared to another intervention for the management of apical vaginal prolapse. SEARCH METHODS We searched the Cochrane Incontinence Group's Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings and ClinicalTrials.gov (searched 14 March 2022). SELECTION CRITERIA We included randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS We used Cochrane methods. Our primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse (any site). MAIN RESULTS We included 59 RCTs (6705 women) comparing surgical procedures for apical vaginal prolapse. Evidence certainty ranged from very low to moderate. Limitations included imprecision, poor methodology, and inconsistency. Vaginal procedures compared to sacral colpopexy for vault prolapse (seven RCTs, n=613; six months to f four-year review) Awareness of prolapse was more common after vaginal procedures (risk ratio (RR) 2.31, 95% confidence interval (CI) 1.27 to 4.21, 4 RCTs, n = 346, I2 = 0%, moderate-certainty evidence). If 8% of women are aware of prolapse after sacral colpopexy, 18% (10% to 32%) are likely to be aware after vaginal procedures. Surgery for recurrent prolapse was more common after vaginal procedures (RR 2.33, 95% CI 1.34 to 4.04; 6 RCTs, n = 497, I2 = 0%, moderate-certainty evidence). The confidence interval suggests that if 6% of women require repeat prolapse surgery after sacral colpopexy, 14% (8% to 25%) are likely to require it after vaginal procedures. Prolapse on examination is probably more common after vaginal procedures (RR 1.87, 95% CI 1.32 to 2.65; 5 RCTs, n = 422; I2 = 24%, moderate-certainty evidence). If 18% of women have recurrent prolapse after sacral colpopexy, between 23% and 47% are likely to do so after vaginal procedures. Other outcomes: Stress urinary incontinence (SUI) was more common after vaginal procedures (RR 1.86, 95% CI 1.17 to 2.94; 3 RCTs, n = 263; I2 = 0%, moderate-certainty evidence). The effect of vaginal procedures on dyspareunia was uncertain (RR 3.44, 95% CI 0.61 to 19.53; 3 RCTs, n = 106, I2 = 65%, low-certainty evidence). Vaginal hysterectomy compared to sacral hysteropexy/cervicopexy (six RCTS, 554 women, one to seven year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.01 95% CI 0.10 to 9.98; 2 RCTs, n = 200, very low-certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 0.85, 95% CI 0.47 to 1.54; 5 RCTs, n = 403; I2 = 9%, low-certainty evidence). Prolapse on examination- there was little or no difference between the groups for this outcome (RR 0.78, 95% CI 0.54 to 1.11; 2 RCTs n = 230; I2 = 9%, moderate-certainty evidence). Vaginal hysteropexy compared to sacral hysteropexy/cervicopexy (two RCTs, n = 388, 1-four-year review) Awareness of prolapse - No difference between the groups for this outcome (RR 0.55 95% CI 0.21 to 1.44; 1 RCT n = 257, low-certainty evidence). Surgery for recurrent prolapse - No difference between the groups for this outcome (RR 1.34, 95% CI 0.52 to 3.44; 2 RCTs, n = 345; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 0.99, 95% CI 0.83 to 1.19; 2 RCTs n =367; I2 =9%, moderate-certainty evidence). Vaginal hysterectomy compared to vaginal hysteropexy (four RCTs, n = 620, 6 months to five-year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.0 95% CI 0.44 to 2.24; 2 RCTs, n = 365, I2 = 0% moderate-quality certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 1.32, 95% CI 0.67 to 2.60; 3 RCTs, n = 443; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 1.44, 95% CI 0.79 to 2.61; 2 RCTs n =361; I2 =74%, low-certainty evidence). Other outcomes: Total vaginal length (TVL) was shorter after vaginal hysterectomy (mean difference (MD) 0.89cm 95% CI 0.49 to 1.28cm shorter; 3 RCTs, n=413, low-certainty evidence). There is probably little or no difference between the groups in terms of operating time, dyspareunia and stress urinary incontinence. Other analyses There were no differences identified for any of our primary review outcomes between different types of vaginal native tissue repair (4 RCTs), comparisons of graft materials for vaginal support (3 RCTs), pectopexy versus other apical suspensions (5 RCTs), continuous versus interrupted sutures at sacral colpopexy (2 RCTs), absorbable versus permanent sutures at apical suspensions (5 RCTs) or different routes of sacral colpopexy. Laparoscopic sacral colpopexy is associated with shorter admission time than open approach (3 RCTs) and quicker operating time than robotic approach (3 RCTs). Transvaginal mesh does not confer any advantage over native tissue repair, however is associated with a 17.5% rate of mesh exposure (7 RCTs). AUTHORS' CONCLUSIONS Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, and postoperative SUI than a variety of vaginal interventions. The limited evidence does not support the use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse. There were no differences in primary outcomes for different routes of sacral colpopexy. However, the laparoscopic approach is associated with a shorter operating time than robotic approach, and shorter admission than open approach. There were no significant differences between vaginal hysteropexy and vaginal hysterectomy for uterine prolapse nor between vaginal hysteropexy and abdominal hysteropexy/cervicopexy. There were no differences detected between absorbable and non absorbable sutures however, the certainty of evidence for mesh exposure and dyspareunia was low.
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Affiliation(s)
- Christopher Maher
- Wesley and Royal Brisbane and Women's Hospitals, Brisbane, Australia
| | - Ellen Yeung
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Nir Haya
- Rambam Medical Center, and the Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Alex Mowat
- Greenslopes Hospital, Brisbane, Australia
| | | | - Kaven Baessler
- Franziskus and St Joseph Hospitals Berlin, Berlin, Germany
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Permanent Compared With Absorbable Suture in Apical Prolapse Surgery: A Systematic Review and Meta-analysis. Obstet Gynecol 2023; 141:268-283. [PMID: 36649334 PMCID: PMC9838735 DOI: 10.1097/aog.0000000000005032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/08/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To explore how permanent compared with absorbable suture affects anatomic success in native tissue vaginal suspension (uterosacral ligament suspension and sacrospinous ligament suspension) and sacrocolpopexy with mesh. DATA SOURCES MEDLINE, EMBASE, and ClinicalTrials.gov were searched through March 29, 2022. METHODS OF STUDY SELECTION Our population included women undergoing apical prolapse surgery (uterosacral ligament suspension and sacrospinous ligament suspension and abdominal sacrocolpopexy). Our intervention was permanent suture for apical prolapse surgery, and our comparator was absorbable suture. We determined a single anatomic success proportion per study. Adverse events collected included suture and mesh exposure, surgery for suture and mesh complication, dyspareunia, and granulation tissue. Abstracts were doubly screened, full-text articles were doubly screened, and accepted articles were doubly extracted. Quality of studies was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. In single-arm studies using either permanent or absorbable suture, random effects meta-analyses of pooled proportions were used to assess anatomic success. In comparative studies investigating both suture types, random effects meta-analyses of pooled risk ratios were used. TABULATION, INTEGRATION, AND RESULTS Of 4,658 abstracts screened, 398 full-text articles were assessed and 63 studies were included (24 vaginal suspension [13 uterosacral ligament suspension and 11 sacrospinous ligament suspension] and 39 sacrocolpopexy). At 2-year follow-up, there was no difference in permanent compared with absorbable suture in uterosacral ligament suspension and sacrospinous ligament suspension (proportional anatomic success rate 88% [95% CI 0.81-0.93] vs 88% [95% CI 0.82-0.92]). Similarly, at 18-month follow-up, there was no difference in permanent compared with absorbable suture in sacrocolpopexy (proportional anatomic success rate 92% [95% CI 0.88-0.95] vs 96% [95% CI 0.92-0.99]). On meta-analysis, there was no difference in relative risk (RR) of success for permanent compared with absorbable suture for uterosacral ligament suspension and sacrospinous ligament suspension (RR 1.11, 95% CI 0.93-1.33) or sacrocolpopexy (RR 1.00, 95% CI0.98-1.03). CONCLUSION Success rates were similarly high for absorbable and permanent suture after uterosacral ligament suspension, sacrospinous ligament suspension, and sacrocolpopexy, with medium-term follow-up. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42021265848.
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Sharifiaghdas F. Autologous rectus fascia graft in the treatment of high-stage apical vaginal prolapse: preliminary results of a new surgical approach with native tissue. Int Urol Nephrol 2022; 54:1017-1022. [DOI: 10.1007/s11255-022-03167-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/26/2022] [Indexed: 10/18/2022]
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Comparative analyses of attitude, knowledge, and recollection of preoperative counseling regarding pelvic mesh among women with or without a mesh-related complication. Arch Gynecol Obstet 2021; 303:1263-1270. [PMID: 33392720 DOI: 10.1007/s00404-020-05919-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Our objective was to compare the recollection of preoperative counseling regarding mesh for pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI) among women with or without a mesh-related complication (MRC). We hypothesized that the patients who had MRC would better recollect counseling regarding complications associated with mesh. METHODS We conducted a retrospective cohort study among women who had prior implantation of synthetic, non-absorbable mesh for POP and/or SUI at least 3 months prior who presented with or without a MRC. The primary outcome was the proportion of women who recalled being counseled preoperatively about the risk of mesh exposure. RESULTS Ninety-six women were included in the final analysis (50 MRC; 46 no MRC). MRC women presented further in time from the index surgery [median 69 months [IQR 26-115] vs 12 months (IQR 6-64), p < 0.01]. After adjustment for time since surgery and age, MRC women were significantly less likely to recall being counseled about the possibility of any MRC [19/50 (38%) vs 32/44 (73%), aOR 0.29, 95% CI 0.11-0.79, p = 0.01]. They were also less likely to report they would undergo the same surgery again 5-point Likert scale [median 3 (IQR 1-4) vs 5 (IQR 3-5), 5-point Likert scale, p < 0.01], less satisfied with their mesh surgery [median 1 (IQR 1-3) vs 5 (IQR 3-5), 5-point Likert scale, p < 0.01] and recommended improved preoperative counseling [27/50 (54%) vs 6/46 (13%), p < 0.01]. CONCLUSION Women who experienced MRC were less likely to recall being counseled about the possibility of MRC and report more unmet needs regarding perioperative counseling than women without MRC.
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Bock ME, Nagle R, Soyster M, Song L, Tachibana I, Hathaway JK, Powell CR. Robotic Sacral Colpopexy Using Autologous Fascia Lata Compared with Mesh. J Endourol 2020; 35:801-807. [PMID: 33107334 DOI: 10.1089/end.2020.0537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: The objective is to compare robotic sacral colpopexy (RSC) utilizing autologous fascia lata with RSC with synthetic mesh in the treatment of pelvic organ prolapse (POP). Methods: We performed a prospective nonrandomized case comparison trial at a single institution. We compared RSC utilizing either synthetic mesh or autologous fascia lata in women with symptomatic POP, stages II through IV. The primary outcome was anatomic prolapse recurrence determined by the Pelvic Organ Prolapse Quantification (POP-Q) examination. Secondary outcomes included patient-reported outcomes such as the Urogenital Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7). Complications were also recorded and categorized using the Clavien-Dindo (CD) system. The hypothesis is that autologous fascia lata would provide equivalent anatomic and patient-reported outcomes compared with mesh while eliminating mesh-related complications. Results: Sixty-four women underwent RSC with 19 (29.7%) receiving fascia lata graft. The overall operative time was greater in the fascia lata group with mean fascia lata harvest time of 24.8 ± 7.4 minutes. Intragroup comparisons of the fascia and mesh groups demonstrated significant improvement in pelvic measurements as well as patient-reported outcomes. Intergroup comparison demonstrated equivalent success rates at 12.1 ± 8.7 months follow-up. There was one apical failure in the fascia lata RSC group; however, the difference was not statistically significant (p = 0.30). Significant complications in the fascia lata harvest group included two CD-II and one CD-IIIb. In the mesh group there was one mesh erosion requiring surgical excision (CD-IIIb). Conclusion: This is the first comparison between RSC with autologous fascia lata and mesh. Short-term anatomic outcomes were similar with autologous fascia lata use without the risk of mesh erosion. Morbidity from graft harvest site was not trivial. These results emphasize the need for a randomized controlled trial.
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Affiliation(s)
- Megan E Bock
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ramzy Nagle
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mary Soyster
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Leo Song
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Isamu Tachibana
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jon K Hathaway
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Charles R Powell
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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It's not that mesh, is it? What providers should know about the transvaginal mesh controversy. Menopause 2020; 27:1330-1335. [PMID: 33110051 DOI: 10.1097/gme.0000000000001603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The U.S. Food and Drug Administration recent ban on surgical mesh intended for the transvaginal repair of pelvic organ prolapse has called into question the safety of surgical mesh implants in general. As the media firestorm around vaginal mesh kits has continued to grow, important details about the specific type of mesh involved have been lost in the public discourse surrounding the controversy. This has left healthcare providers across the nation in the difficult position of addressing patient anxieties about the use of mesh in gynecologic surgery. This review seeks to educate women's health providers on the historical background and various uses of the different types of mesh in gynecologic surgery.
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Cassis C, Mukhopadhyay S, Morris E. Standardizing abdominal sacrocolpopexy for the treatment of apical prolapse: One year on. Int J Gynaecol Obstet 2019; 147:49-53. [DOI: 10.1002/ijgo.12935] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 04/01/2019] [Accepted: 07/11/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Charlotte Cassis
- Gynaecology DepartmentNorfolk and Norwich University Hospital Norwich UK
| | | | - Edward Morris
- Gynaecology DepartmentNorfolk and Norwich University Hospital Norwich UK
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10
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Powers SA, Burleson LK, Hannan JL. Managing female pelvic floor disorders: a medical device review and appraisal. Interface Focus 2019; 9:20190014. [PMID: 31263534 DOI: 10.1098/rsfs.2019.0014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2019] [Indexed: 02/07/2023] Open
Abstract
Pelvic floor disorders (PFDs) will affect most women during their lifetime. Sequelae such as pelvic organ prolapse, stress urinary incontinence, chronic pain and dyspareunia significantly impact overall quality of life. Interventions to manage or eliminate symptoms from PFDs aim to restore support of the pelvic floor. Pessaries have been used to mechanically counteract PFDs for thousands of years, but do not offer a cure. By contrast, surgically implanted grafts or mesh offer patients a more permanent resolution but have been in wide use within the pelvis for less than 30 years. In this perspective review, we provide an overview of the main theories underpinning PFD pathogenesis and the animal models used to investigate it. We highlight the clinical outcomes of mesh and grafts before exploring studies performed to elucidate tissue level effects and bioengineering considerations. Considering recent turmoil surrounding transvaginal mesh, the role of pessaries, an impermanent method, is examined as a means to address patients with PFDs.
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Affiliation(s)
- Shelby A Powers
- Department of Physiology, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Mailstop 634, Greenville, NC 27834-4354, USA
| | - Lindsey K Burleson
- Department of Physiology, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Mailstop 634, Greenville, NC 27834-4354, USA
| | - Johanna L Hannan
- Department of Physiology, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Mailstop 634, Greenville, NC 27834-4354, USA
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11
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van Zanten F, van Iersel JJ, Paulides TJC, Verheijen PM, Broeders IAMJ, Consten ECJ, Lenters E, Schraffordt Koops SE. Long-term mesh erosion rate following abdominal robotic reconstructive pelvic floor surgery: a prospective study and overview of the literature. Int Urogynecol J 2019; 31:1423-1433. [PMID: 31222568 PMCID: PMC7306026 DOI: 10.1007/s00192-019-03990-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 05/16/2019] [Indexed: 01/25/2023]
Abstract
Introduction and hypothesis The use of synthetic mesh in transvaginal pelvic floor surgery has been subject to debate internationally. Although mesh erosion appears to be less associated with an abdominal approach, the long-term outcome has not been studied intensively. This study was set up to determine the long-term mesh erosion rate following abdominal pelvic reconstructive surgery. Methods A prospective, observational cohort study was conducted in a tertiary care setting. All consecutive female patients who underwent robot-assisted laparoscopic sacrocolpopexy and sacrocolporectopexy in 2011 and 2012 were included. Primary outcome was mesh erosion. Preoperative and postoperative evaluation (6 weeks, 1 year, 5 years) with a clinical examination and questionnaire regarding pelvic floor symptoms was performed. Mesh-related complications were assessed using a transparent vaginal speculum, proctoscopy, and digital vaginal and rectal examination. Kaplan–Meier estimates were calculated for mesh erosion. A review of the literature on mesh exposure after minimally invasive sacrocolpopexy was performed (≥12 months’ follow-up). Results Ninety-six of the 130 patients included (73.8%) were clinically examined. Median follow-up time was 48.1 months (range 36.0–62.1). Three mesh erosions were diagnosed (3.1%; Kaplan–Meier 4.9%, 95% confidence interval 0–11.0): one bladder erosion for which mesh resection and an omental patch interposition were performed, and two asymptomatic vaginal erosions (at 42.7 and 42.3 months) treated with estrogen cream in one. Additionally, 22 patients responded solely by questionnaire and/or telephone; none reported mesh-related complaints. The literature, mostly based on retrospective studies, described a median mesh erosion rate of 1.9% (range 0–13.3%). Conclusions The long-term rate of mesh erosion following an abdominally placed synthetic graft is low. Electronic supplementary material The online version of this article (10.1007/s00192-019-03990-1) contains supplementary material, which is available to authorized users
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Affiliation(s)
- Femke van Zanten
- Department of Gynecology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands.
- Faculty of Electrical Engineering, Mathematics & Computer Science, Twente University, Enschede, The Netherlands.
| | - Jan J van Iersel
- Faculty of Electrical Engineering, Mathematics & Computer Science, Twente University, Enschede, The Netherlands
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Tim J C Paulides
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Paul M Verheijen
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Ivo A M J Broeders
- Faculty of Electrical Engineering, Mathematics & Computer Science, Twente University, Enschede, The Netherlands
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Egbert Lenters
- Department of Gynecology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
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Lee W, Tam J, Kobashi K. Surgery for Apical Vaginal Prolapse After Hysterectomy: Abdominal Sacrocolpopexy. Urol Clin North Am 2018; 46:113-121. [PMID: 30466696 DOI: 10.1016/j.ucl.2018.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The number of surgeries for pelvic organ prolapse in the United States is increasing. Abdominal sacrocolpopexy has become the gold standard for women desiring a restorative repair of their apical pelvic organ prolapse. Despite the associated morbidity of abdominal sacrocolpopexy, advances in minimally invasive approaches have safely increased the number of these surgeries performed, especially among urologists. Moreover, a number of studies have demonstrated superior objective outcomes after abdominal sacrocolpopexy when compared with vaginal approaches. Variations in the technique are described, but no consensus exists on a standard approach.
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Affiliation(s)
- Wai Lee
- Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98111, USA.
| | - Justina Tam
- Department of Urology, Stony Brook Medicine, 101 Nicolls Road, HSC Level 9-040, Stony Brook, NY 11794, USA
| | - Kathleen Kobashi
- Virginia Mason Medical Center, 1100 Ninth Avenue, Seattle, WA 98111, USA
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Giannini A, Russo E, Malacarne E, Cecchi E, Mannella P, Simoncini T. Role of robotic surgery on pelvic floor reconstruction. ACTA ACUST UNITED AC 2018; 71:4-17. [PMID: 30318878 DOI: 10.23736/s0026-4784.18.04331-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Over the past two decades, minimally invasive surgery (MIS) abdominal surgery has increasingly been used to treat pelvic organ prolapse. Besides the several advantages associated with minimal invasiveness, this approach bridged the gap between the benefits of vaginal surgery and the surgical success rates of open abdominal procedures. The most commonly performed procedure for suspension of the vaginal apex for postoperative vaginal prolapse by robotic-assisted laparoscopy is the sacrocolpopexy. Conventional laparoscopic application of this procedure was first reported in 1994 by Nezhat et al. and had not gained widespread adoption due to lengthy learning curve associated with laparoscopic suturing. Since FDA approval of the da Vinci® robot for gynecologic surgery in 2005, minimally invasive abdominal surgery for pelvic organ prolapse has become increasingly popular, as robotic-assisted laparoscopic sacrocolpopexy is an option for those surgeons without experience or training in the conventional route. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the "gold standard" technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. In fact, repair of pelvic organ prolapse can be performed robotically, and sometimes surgeons can feel suturing and dissection during the procedures less challenging with the assistance of the robot. However, even if robotic surgery may confer many benefits over conventional laparoscopy, these advantages should continue to be weighed against the cost of the technology. To date, as long-term outcomes, evidence about robotic sacrocolpopexy for a repair of pelvic organ prolapse are not conclusive, and much more investigations are needed to evaluate subjective and objective outcomes, perioperative and postoperative adverse events, and costs associated with these procedures. It is plausible to think that the main advantage is that robotics may lead to a widespread adoption of minimally invasive techniques in the field of pelvic floor reconstructive surgery. The following review will address the development and current state of robotic assistance in treating pelvic floor reconstruction discussing available data about the techniques of robotic prolapse repair as well as morbidity, costs and clinical outcomes.
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Affiliation(s)
- Andrea Giannini
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Pisa, Italy
| | - Eleonora Russo
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Pisa, Italy
| | - Elisa Malacarne
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Pisa, Italy
| | - Elena Cecchi
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Pisa, Italy
| | - Paolo Mannella
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Pisa, Italy
| | - Tommaso Simoncini
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Medicine, University of Pisa, Pisa, Italy -
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Female Urology and Urogynecology: The Outcome of Patients Participating in Live Surgical Broadcasts. Female Pelvic Med Reconstr Surg 2018; 26:554-557. [DOI: 10.1097/spv.0000000000000634] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Moroni RM, Juliato CRT, Cosson M, Giraudet G, Brito LGO. Does sacrocolpopexy present heterogeneity in its surgical technique? A systematic review. Neurourol Urodyn 2018; 37:2335-2345. [DOI: 10.1002/nau.23764] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 06/26/2018] [Indexed: 12/31/2022]
Affiliation(s)
- Rafael M. Moroni
- Department of Gynecology and Obstetrics; Ribeirão Preto Medical School; University of São Paulo; São Paulo Brazil
| | - Cassia R. T. Juliato
- Department of Obstetrics and Gynecology; School of Medical Sciences; University of Campinas; Campinas Brazil
| | - Michel Cosson
- Hopital Jeanne de Flandres; CHRU Lille; Lille France
| | | | - Luiz G. O. Brito
- Department of Gynecology and Obstetrics; Ribeirão Preto Medical School; University of São Paulo; São Paulo Brazil
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Sentiment Analysis of Web Sites Related to Vaginal Mesh Use in Pelvic Reconstructive Surgery. Female Pelvic Med Reconstr Surg 2018; 25:434-438. [PMID: 29683885 DOI: 10.1097/spv.0000000000000584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The purpose of this study was to utilize sentiment analysis to describe online opinions toward vaginal mesh. We hypothesized that sentiment in legal Web sites would be more negative than that in medical and reference Web sites. METHODS We generated a list of relevant key words related to vaginal mesh and searched Web sites using the Google search engine. Each unique uniform resource locator (URL) was sorted into 1 of 6 categories: "medical", "legal", "news/media", "patient generated", "reference", or "unrelated". Sentiment of relevant Web sites, the primary outcome, was scored on a scale of -1 to +1, and mean sentiment was compared across all categories using 1-way analysis of variance. Tukey test evaluated differences between category pairs. RESULT Google searches of 464 unique key words resulted in 11,405 URLs. Sentiment analysis was performed on 8029 relevant URLs (3472 legal, 1625 "medical", 1774 "reference", 666 "news media", 492 "patient generated"). The mean sentiment for all relevant Web sites was +0.01 ± 0.16; analysis of variance revealed significant differences between categories (P < 0.001). Web sites categorized as "legal" and "news/media" had a slightly negative mean sentiment, whereas those categorized as "medical," "reference," and "patient generated" had slightly positive mean sentiments. Tukey test showed differences between all category pairs except the "medical" versus "reference" in comparison with the largest mean difference (-0.13) seen in the "legal" versus "reference" comparison. CONCLUSIONS Web sites related to vaginal mesh have an overall mean neutral sentiment, and Web sites categorized as "medical," "reference," and "patient generated" have significantly higher sentiment scores than related Web sites in "legal" and "news/media" categories.
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Berger AA, Abramowitch S, Moalli PA. 3D vascular anatomy of the presacral space: impact of age and adiposity. Int Urogynecol J 2018; 30:401-407. [PMID: 29299627 DOI: 10.1007/s00192-017-3542-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/06/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Defining patient characteristics that alter vascular anatomy at the sacrum is critical for avoiding life-threatening bleeding at the time of sacrocolpopexy. We tested the hypothesis that in thinner/older women, the bifurcations of the aorta and inferior vena cava (IVC) are lower relative to S1 resulting in less space accessible for suture/mesh placement, placing this group at increased risk of major vascular injury. METHODS In a retrospective cross-sectional study, CT scans were used to make 2D measurements and a 3D model of the aorta/IVC, intervertebral disc space, and bony anatomy using segmentation and modeling software. For analysis, Spearman's and Pearson's correlation, Student's t test and the Mann-Whitney U test were used along with multivariate analysis of variance. RESULTS Of eligible women who had undergone abdominal/pelvic CT, 107 were included. The median locations of the aortic and IVC bifurcations utilizing 2D analysis were at the inferior L4 and middle L5 vertebral body, respectively. In 10.2% of patients, the IVC was located at the L5-S1 disc space or lower; however, 3D modeling of this space which allowed assessment of the area below the S1 "drop off" showed that the amount of accessible space for suture/mesh placement was not decreased. Utilizing 2D analysis there was no statistically significant independent correlation between age or adiposity and the aortic or IVC bifurcation. Patients who were both elderly and thinner had a lower aortic bifurcation (p = 0.005) and a trend towards a lower IVC bifurcation (p = 0.082). CONCLUSIONS In 10.2% of women, the IVC bifurcation descended at or below the L5-S1 disc space, suggesting that this group of women is at increased risk of major vascular injury. Patients who were both thin and elderly had lower bifurcations, but there was no difference in accessible surface area for suture placement on 3D analysis. 3D modeling improved visualization of the anatomy beyond the S1 "drop off" and may provide a future tool for surgical planning once predictors of high-risk anatomy are defined.
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Affiliation(s)
- Alexander A Berger
- Department of Reproductive Medicine, Division of Female Pelvic Medicine and Reconstructive Surgery, UC San Diego Health System, 9500 Gilman Drive, MC 0971, La Jolla, CA, 92093-0971, USA.
| | - Steven Abramowitch
- Magee-Women's Research Institute, Department of Obstetrics and Gynecology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pamela A Moalli
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA, USA
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Coolen ALWM, Bui BN, Dietz V, Wang R, van Montfoort APA, Mol BWJ, Roovers JPWR, Bongers MY. The treatment of post-hysterectomy vaginal vault prolapse: a systematic review and meta-analysis. Int Urogynecol J 2017; 28:1767-1783. [PMID: 29038834 PMCID: PMC5705749 DOI: 10.1007/s00192-017-3493-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 09/13/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The treatment of post-hysterectomy vaginal vault prolapse (VVP) has been investigated in several randomized clinical trials (RCTs), but a systematic review of the topic is still lacking. The aim of this study is to compare the effectiveness of treatments for VVP. METHODS We performed a systematic review and meta-analysis of the literature on the treatment of VVP found in PubMed and Embase. Reference lists of identified relevant articles were checked for additional articles. A network plot was constructed to illustrate the geometry of the network of the treatments included. Only RCTs reporting on the treatment of VVP were eligible, conditional on a minimum of 30 participants with VVP and a follow-up of at least 6 months. RESULTS Nine RCTs reporting 846 women (ranging from 95 to 168 women) met the inclusion criteria. All surgical techniques were associated with good subjective results, and without differences between the compared technique, with the exception of the comparison of vaginal mesh (VM) vs laparoscopic sacrocolpopexy (LSC). LSC is associated with a higher satisfaction rate. The anatomical results of the sacrocolpopexy (laparoscopic, robotic [RSC]. and abdominal [ASC]) are the best (62-91%), followed by the VM. However, the ranges of the anatomical outcome of VM were wide (43-97%). The poorest results are described for the sacrospinal fixation (SSF; 35-81%), which also correlates with the higher reoperation rate for pelvic organ prolapse (POP; 5-9%). The highest percentage of complications were reported after ASC (2-19%), VM (6-29%), and RSC (54%). Mesh exposure was seen most often after VM (8-21%). The rate of reoperations carried out because of complications, recurrence prolapse, and incontinence of VM was 13-22%. Overall, sacrocolpopexy reported the best results at follow-up, with an outlier of one trial reporting the highest reoperation rate for POP (11%). The results of the RSC are too small to make any conclusion, but LSC seems to be preferable to ASC. CONCLUSIONS A comparison of techniques was difficult because of heterogeneity; therefore, a network meta-analysis was not possible. All techniques have proved to be effective. The reported differences between the techniques were negligible. Therefore, a standard treatment for VVP could not be given according to this review.
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Affiliation(s)
- Anne-Lotte W M Coolen
- Department of Obstetrics and Gynecology, Máxima Medical Centre, De Run 4600, 5500 MB, Veldhoven, The Netherlands.
| | - Bich Ngoc Bui
- Department of Obstetrics and Gynecology, Máxima Medical Centre, De Run 4600, 5500 MB, Veldhoven, The Netherlands
| | - Viviane Dietz
- Department of Obstetrics and Gynecology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Rui Wang
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Aafke P A van Montfoort
- Department of Obstetrics and Gynaecology, Maastricht University, Grow School for Oncology and Developmental Biology, Minderbroedersberg 4, 6211 LK, Maastricht, The Netherlands
| | - Ben Willem J Mol
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Jan-Paul W R Roovers
- Department of Gynecology and Obstetrics, Academic Medical Centre Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marlies Y Bongers
- Department of Obstetrics and Gynecology, Máxima Medical Centre, De Run 4600, 5500 MB, Veldhoven, The Netherlands
- Department of Obstetrics and Gynaecology, Maastricht University, Grow School for Oncology and Developmental Biology, Minderbroedersberg 4, 6211 LK, Maastricht, The Netherlands
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Gurland B, E Carvalho MEC, Ridgeway B, Paraiso MFR, Hull T, Zutshi M. Should we offer ventral rectopexy to patients with recurrent external rectal prolapse? Int J Colorectal Dis 2017; 32:1561-1567. [PMID: 28785819 DOI: 10.1007/s00384-017-2858-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND For patients with rectal prolapse undergoing Ventral Rectopexy (VR), the impact of prior prolapse surgery on prolapse recurrence is not well described. PURPOSE The purpose of this study was to compare recurrence rates after VR in patients undergoing primary and repeat rectal prolapse repairs. DESIGN This study is a prospective cohort study. METHODS IRB-approved prospective data registry of consecutive patients undergoing VR for full-thickness external rectal prolapse between 2009 and 2015. MAIN OUTCOME MEASURES Rectal prolapse recurrence was defined as either external prolapse through the anal sphincters or symptomatic rectal mucosa prolapse warranting additional surgery. Preoperative and postoperative morbidity and functional outcomes were analyzed. Actuarial recurrence rates were calculated using the Kaplan-Meier method. RESULTS A total of 108 VRs were performed during the study period. Seventy-two were primary and 36 repeat repairs. Seven cases were open, 23 laparoscopic, and 78 robotic. Six cases were converted from laparoscopic/robotic to open. In 63 patients, VR was combined with gynecological procedures. There were no statistical differences between primary or recurrent prolapse for the following: demographics, operative time, concomitant gynecologic procedures, complications, blood loss, and graft material type. Length of stay was longer in patients with a history of prior prolapse surgery (p = 0.01). Prolapse recurrence rates for primary repairs were reported at 1.4, 6.9, and 9.7% and for recurrent prolapse procedures 13.9, 25, and 25% at 1, 3, and 5 years (p = 0.13). Mean length of follow-up was similar between groups. Time to recurrence was significantly shorter in patients undergoing repeat prolapse surgery 8.8 vs 30.7 months (p = 0.03). CONCLUSIONS VR is a better option for patients undergoing primary rectal prolapse repair.
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Affiliation(s)
- Brooke Gurland
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | | | - Beri Ridgeway
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Cleveland Clinic, Gynecology and Women's Health Institute, Cleveland, OH, USA
| | - Marie Fidela R Paraiso
- Section of Urogynecology and Reconstructive Pelvic Surgery, Obstetrics, Cleveland Clinic, Gynecology and Women's Health Institute, Cleveland, OH, USA
| | - Tracy Hull
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Massarat Zutshi
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Oliver JL, Chaudhry ZQ, Medendorp AR, Wood LN, Baxter ZC, Kim JH, Raz S. Complete Excision of Sacrocolpopexy Mesh With Autologous Fascia Sacrocolpopexy. Urology 2017; 106:65-69. [DOI: 10.1016/j.urology.2017.04.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 04/18/2017] [Accepted: 04/27/2017] [Indexed: 10/19/2022]
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Bergamin PA, Kiosoglous AJ. Surgical management of recurrent urinary tract infections: a review. Transl Androl Urol 2017; 6:S153-S162. [PMID: 28791234 PMCID: PMC5522803 DOI: 10.21037/tau.2017.06.17] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
There are many causes of recurrent urinary tract infections (rUTI) which are amenable to surgical management. This usually follows a lengthy trial of conservative management. Aetiological classification of rUTI requiring surgical management may be divided into congenital or acquired. Predisposing factors are classified into two groups; those providing a source for organisms, or by maintaining favourable conditions for the proliferation of organisms. Sources of infections include calculi, fistulae or abscesses. Conditions which predispose to bacterial proliferation include malignancies, foreign bodies, high post void residuals, and neuropathic bladders. Removal of identified sources, treating the obstruction, and improving urinary drainage, are all goals of surgical management. Surgical options for rUTI management can range from minimally invasive procedures such as endoscopic or percutaneous, through to more invasive requiring laparoscopic or an open approach. Surgery remains a very important and viable solution.
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Affiliation(s)
- Paul A Bergamin
- Department of Urology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,University of Queensland, School of Medicine and Surgery, Brisbane, Australia
| | - Anthony J Kiosoglous
- Department of Urology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia.,University of Queensland, School of Medicine and Surgery, Brisbane, Australia
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Abstract
PURPOSE OF REVIEW To review the use and efficacy of minimally invasive surgery in pelvic organ prolapse (POP) repair. This review summarizes surgical options for management of POP with special emphasis on minimally invasive surgical approach and discusses the recent experience and feasibility of integrating robot-assisted technology. RECENT FINDINGS Minimally invasive approaches have equal efficacy and less morbidity than laparotomy for POP repair, particularly apical prolapse. Robotics may facilitate the rate of minimally invasive surgery for POP repair with greater cost and as yet no proven superiority for conventional laparoscopy. SUMMARY Minimally invasive surgery is the preferred approach to POP repair. Conventional laparoscopic or robotic sacral colpopexy is recommended for apical defect and procidentia.
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Burch Retropubic Urethropexy Compared With Midurethral Sling With Concurrent Sacrocolpopexy: A Randomized Controlled Trial. Obstet Gynecol 2017; 128:828-35. [PMID: 27607858 DOI: 10.1097/aog.0000000000001651] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare efficacy and safety of retropubic Burch urethropexy and a midurethral sling in women with stress urinary incontinence (SUI) undergoing concomitant pelvic floor repair with sacrocolpopexy. METHODS Women were randomly assigned to Burch retropubic urethropexy (n=56) or retropubic midurethral sling (n=57) through dynamic allocation balancing age, body mass index, history of prior incontinence surgery, intrinsic sphincter deficiency, preoperative incontinence diagnosis, and prolapse stage. Overall and stress-specific continence primary outcomes were ascertained with validated questionnaires and a blinded cough stress test. RESULTS Enrollment was June 1, 2009, through August 31, 2013. At 6 months, no difference was found in overall (29 midurethral sling [51%] compared with 23 Burch [41%]; P=.30) (odds ratio [OR] 1.49, 95% confidence interval [CI] 0.71-3.13) or stress-specific continence rates (42 midurethral sling [74%] compared with 32 Burch [57%]; P=.06) (OR 2.10, 95% CI 0.95-4.64) between groups. However, the midurethral sling group reported greater satisfaction (78% compared with 57%; P=.04) and were more likely to report successful surgery for SUI (71% compared with 50%; P=.04) and to resolve pre-existing urgency incontinence (72% compared with 41%; P=.03). No difference was found in patient global impression of severity or symptom improvement, complication rates, or mesh exposures. CONCLUSION There was no difference in overall or stress-specific continence rates between midurethral sling and Burch urethropexy groups at 6 months. However, the midurethral sling group reported better patient-centered secondary outcomes.
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Le Normand L, Cosson M, Cour F, Deffieux X, Donon L, Ferry P, Fatton B, Hermieu JF, Marret H, Meurette G, Cortesse A, Wagner L, Fritel X. Clinical Practice Guidelines: Synthesis of the guidelines for the surgical treatment of primary pelvic organ prolapse in women by the AFU, CNGOF, SIFUD-PP, SNFCP, and SCGP. J Gynecol Obstet Hum Reprod 2017; 46:387-391. [DOI: 10.1016/j.jogoh.2017.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 05/10/2017] [Indexed: 11/26/2022]
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Gokmen-Karasu AF, Aydin S, Sonmez FC, Adanir I, Ilhan G, Ates S. A rat hysteropexy model for evaluating adhesion formation and comparison of two different structured meshes. Int Urogynecol J 2017; 28:1695-1700. [DOI: 10.1007/s00192-017-3328-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 03/27/2017] [Indexed: 12/12/2022]
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Le Normand L, Cosson M, Cour F, Deffieux X, Donon L, Ferry P, Fatton B, Hermieu JF, Marret H, Meurette G, Cortesse A, Wagner L, Fritel X. Recommandations pour la pratique clinique : synthèse des recommandations pour le traitement chirurgical du prolapsus génital non récidivé de la femme par l’AFU, le CNGOF, la SIFUD-PP, la SNFCP, et la SCGP. ACTA ACUST UNITED AC 2016; 45:1606-1613. [DOI: 10.1016/j.jgyn.2016.09.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Accepted: 09/19/2016] [Indexed: 11/17/2022]
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Maher C, Feiner B, Baessler K, Christmann‐Schmid C, Haya N, Brown J. Surgery for women with apical vaginal prolapse. Cochrane Database Syst Rev 2016; 10:CD012376. [PMID: 27696355 PMCID: PMC6457970 DOI: 10.1002/14651858.cd012376] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Apical vaginal prolapse is a descent of the uterus or vaginal vault (post-hysterectomy). Various surgical treatments are available and there are no guidelines to recommend which is the best. OBJECTIVES To evaluate the safety and efficacy of any surgical intervention compared to another intervention for the management of apical vaginal prolapse. SEARCH METHODS We searched the Cochrane Incontinence Group's Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched July 2015) and ClinicalTrials.gov (searched January 2016). SELECTION CRITERIA We included randomised controlled trials (RCTs). DATA COLLECTION AND ANALYSIS We used Cochrane methods. Our primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse (any site). MAIN RESULTS We included 30 RCTs (3414 women) comparing surgical procedures for apical vaginal prolapse. Evidence quality ranged from low to moderate. Limitations included imprecision, poor methodological reporting and inconsistency. Vaginal procedures versus sacral colpopexy (six RCTs, n = 583; one to four-year review). Awareness of prolapse was more common after vaginal procedures (risk ratio (RR) 2.11, 95% confidence interval (CI) 1.06 to 4.21, 3 RCTs, n = 277, I2 = 0%, moderate-quality evidence). If 7% of women are aware of prolapse after sacral colpopexy, 14% (7% to 27%) are likely to be aware after vaginal procedures. Repeat surgery for prolapse was more common after vaginal procedures (RR 2.28, 95% CI 1.20 to 4.32; 4 RCTs, n = 383, I2 = 0%, moderate-quality evidence). The confidence interval suggests that if 4% of women require repeat prolapse surgery after sacral colpopexy, between 5% and 18% would require it after vaginal procedures.We found no conclusive evidence that vaginal procedures increaserepeat surgery for stress urinary incontinence (SUI) (RR 1.87, 95% CI 0.72 to 4.86; 4 RCTs, n = 395; I2 = 0%, moderate-quality evidence). If 3% of women require repeat surgery for SUI after sacral colpopexy, between 2% and 16% are likely to do so after vaginal procedures. Recurrent prolapse is probably more common after vaginal procedures (RR 1.89, 95% CI 1.33 to 2.70; 4 RCTs, n = 390; I2 = 41%, moderate-quality evidence). If 23% of women have recurrent prolapse after sacral colpopexy, about 41% (31% to 63%) are likely to do so after vaginal procedures.The effect of vaginal procedures on bladder injury was uncertain (RR 0.57, 95% CI 0.14 to 2.36; 5 RCTs, n = 511; I2 = 0%, moderate-quality evidence). SUI was more common after vaginal procedures (RR 1.86, 95% CI 1.17 to 2.94; 3 RCTs, n = 263; I2 = 0%, moderate-quality evidence). Dyspareunia was also more common after vaginal procedures (RR 2.53, 95% CI 1.17 to 5.50; 3 RCTs, n = 106, I2 = 43%, low-quality evidence). Vaginal surgery with mesh versus without mesh (6 RCTs, n = 598, 1-3 year review). Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.08 95% CI 0.35 to 3.30 1 RCT n = 54, low quality evidence). The confidence interval was wide suggesting that if 18% of women are aware of prolapse after surgery without mesh, between 6% and 59% will be aware of prolapse after surgery with mesh. Repeat surgery for prolapse - There may be little or no difference between the groups for this outcome (RR 0.69, 95% CI 0.30 to 1.60; 5 RCTs, n = 497; I2 = 9%, low-quality evidence). If 4% of women require repeat surgery for prolapse after surgery without mesh, 1% to 7% are likely to do so after surgery with mesh.We found no conclusive evidence that surgery with mesh increases repeat surgery for SUI (RR 4.91, 95% CI 0.86 to 27.94; 2 RCTs, n = 220; I2 = 0%, low-quality evidence). The confidence interval was wide suggesting that if 2% of women require repeat surgery for SUI after vaginal colpopexy without mesh, 2% to 53% are likely to do so after surgery with mesh.We found no clear evidence that surgery with mesh decreases recurrent prolapse (RR 0.36, 95% CI 0.09 to 1.40; 3 RCTs n = 269; I2 = 91%, low-quality evidence). The confidence interval was very wide and there was serious inconsistency between the studies. Other outcomes There is probably little or no difference between the groups in rates of SUI (de novo) (RR 1.37, 95% CI 0.94 to 1.99; 4 RCTs, n = 295; I2 = 0%, moderate-quality evidence) or dyspareunia (RR 1.21, 95% CI 0.55 to 2.66; 5 RCTs, n = 501; I2 = 0% moderate-quality evidence). We are uncertain whether there is any difference for bladder injury (RR 3.00, 95% CI 0.91 to 9.89; 4 RCTs, n = 445; I2 = 0%; very low-quality evidence). Vaginal hysterectomy versus alternatives for uterine prolapse (six studies, n = 667)No clear conclusions could be reached from the available evidence, though one RCT found that awareness of prolapse was less likely after hysterectomy than after abdominal sacrohysteropexy (RR 0.38, 955 CI 0.15 to 0.98, n = 84, moderate-quality evidence).Other comparisonsThere was no evidence of a difference for any of our primary review outcomes between different types of vaginal native tissue repair (two RCTs), comparisons of graft materials for vaginal support (two RCTs), different routes for sacral colpopexy (four RCTs), or between sacral colpopexy with and without continence surgery (four RCTs). AUTHORS' CONCLUSIONS Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, postoperative SUI and dyspareunia than a variety of vaginal interventions.The limited evidence does not support use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse. Most of the evaluated transvaginal meshes are no longer available and new lighter meshes currently lack evidence of safetyThe evidence was inconclusive when comparing access routes for sacral colpopexy.No clear conclusion can be reached from the available data comparing uterine preserving surgery versus vaginal hysterectomy for uterine prolapse.
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Affiliation(s)
- Christopher Maher
- Royal Brisbane and Women's HospitalUniversity QueenslandBrisbaneQueenslandAustralia
| | - Benjamin Feiner
- Hillel Yaffe Medical Center, Technion UniversityDepartment of Urogynecology & Reconstructive Pelvic SurgeryHa‐Shalom StHaderaIsrael38100
| | - Kaven Baessler
- Pelvic Floor Centre ChariteUrogynaecology DepartmentHindenburgdamm 30BerlinGermany12200
| | | | - Nir Haya
- Lady Davis Carmel Medical Center, and the Ruth and Bruce Rappaport School of Medicine, Technion‐Israel Institute of TechnologyDepartment of Obstetrics and Gynaecology6 Michal StHaifaIsrael34364
| | - Julie Brown
- The University of AucklandLiggins InstitutePark RdGraftonAucklandNew Zealand1142
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Rajshekhar S, Mukhopadhyay S, Morris E. Early safety and efficacy outcomes of a novel technique of sacrocolpopexy for the treatment of apical prolapse. Int J Gynaecol Obstet 2016; 135:182-186. [PMID: 27498595 DOI: 10.1016/j.ijgo.2016.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 05/12/2016] [Accepted: 07/18/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of a modified technique of bilateral abdominal sacrocolpopexy in which both uterosacral ligaments are replaced with polyvinylidene fluoride mesh to provide support to the cervix (cervico-sacropexy [CESA]) or vaginal vault (vagino-sacropexy [VASA]). METHODS A retrospective observational study was undertaken of women with posthysterectomy vault prolapse or recurrent apical prolapse following previous prolapse repair who underwent bilateral sacrocolpopexy between July 1, 2013, and December 31, 2014, in a tertiary referral unit in the UK. Before surgery and 3 months afterwards, prolapse was assessed using the Pelvic Organ Prolapse Quantification scale and functional outcomes were recorded using the International Consultation on Incontinence Questionnaire for vaginal symptoms and urinary incontinence. RESULTS Fifty women were included. At 3 months, 47 (94%) patients reported no bulge symptoms and the mean point C was -7.6. Complications comprised bladder injury in 1 (2%) and minor wound problems in 3 (6%) patients. No mesh erosion was reported. CONCLUSION Bilateral abdominal sacrocolpopexy seems to be a safe and effective option for apical prolapse. Longer-term follow-up is needed to detect prolapse recurrence and mesh-related complications.
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Affiliation(s)
| | | | - Edward Morris
- Norfolk and Norwich University Hospital, Norwich, UK
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Ismail S, Duckett J, Rizk D, Sorinola O, Kammerer-Doak D, Contreras-Ortiz O, Al-Mandeel H, Svabik K, Parekh M, Phillips C. Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion. Int Urogynecol J 2016; 27:1619-1632. [DOI: 10.1007/s00192-016-3076-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/14/2016] [Indexed: 12/13/2022]
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Traitement du prolapsus génital par promontofixation laparoscopique : recommandations pour la pratique clinique. Prog Urol 2016; 26 Suppl 1:S27-37. [DOI: 10.1016/s1166-7087(16)30426-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Le Normand L, Cosson M, Cour F, Deffieux X, Donon L, Ferry P, Fatton B, Hermieu JF, Marret H, Meurette G, Cortesse A, Wagner L, Fritel X. Recommandations pour la pratique clinique : Synthèse des recommandations pour le traitement chirurgical du prolapsus génital non récidivé de la femme par l´AFU, le CNGOF, la SIFUD-PP, la SNFCP et la SCGP. Prog Urol 2016; 26 Suppl 1:S1-7. [DOI: 10.1016/s1166-7087(16)30424-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Transabdominal sacrocolpopexy with autologous rectus fascia graft. Int Urogynecol J 2016; 27:1273-5. [PMID: 26994768 DOI: 10.1007/s00192-016-2987-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 02/16/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Extrusion and infection are potential postoperative complications when using synthetic mesh for abdominal sacrocolpopexy. Long-term follow-up in the Colpopexy and Urinary Reduction Efforts (CARE) trial revealed an estimated 9.9 % risk of mesh extrusion. There are 26 reports of spondylodiscitis after sacrocolpopexy with synthetic mesh. These surgical risks may be decreased by using autologous fascia. To date, there have been no reports of extrusion or spondylodiscitis after using autologous fascia for sacrocolpopexy. METHODS This video demonstrates transabdominal sacrocolpopexy with an autologous rectus fascia graft. A 76-year-old woman with symptomatic stage 3 prolapse also had a history of diverticulitis and sigmoid abscess requiring sigmoid colectomy with end colostomy and incidental left ureteral transection with subsequent left nephrostomy tube placement. She presented for colostomy reversal, ureteral reimplantation, and prolapse repair. Given the need for concomitant colon and ureteral reconstruction, the risk of infection was potentially higher if synthetic mesh were used. The patient therefore underwent transabdominal sacrocolpopexy with autologous rectus fascia graft. RESULTS At 4 months' follow-up the patient reported resolution of her symptoms and on examination she had no pelvic organ prolapse. CONCLUSION Transabdominal sacrocolpopexy using autologous rectus fascia graft is a feasible option, especially in cases in which infection and synthetic mesh extrusion risks are potentially higher.
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Henninger V, Reisenauer C, Brucker SY, Rall K. Laparoscopic Nerve-Preserving Colposacropexy for Surgical Management of Neovaginal Prolapse. J Pediatr Adolesc Gynecol 2015; 28:e153-5. [PMID: 26148788 DOI: 10.1016/j.jpag.2014.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/23/2014] [Accepted: 12/10/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Neovaginal prolapse occurs rarely, and a standard treatment has not yet been defined. CASE We report 2 cases of patients with vaginal agenesis with a symptomatic neovaginal prolapse; one occurring 25 years after self-dilation and another occurring 24 years after sigmoid vaginoplasty. At 48 and 18 months after surgical treatment with laparoscopic nerve-preserving colposacropexy using 2 types of mesh and 2 kinds of sutures to anchor the mesh at the neovaginal wall, both women are asymptomatic and highly satisfied with the result, without prolapse recurrence or mesh/suture erosion. SUMMARY AND CONCLUSION For the surgical management of neovaginal prolapse after sigmoid vaginoplasty and vagina creation after self-dilation, we recommend the nerve-preserving sacrocolpopexy as a safe method to achieve durable functional outcomes and good anatomic vaginal level I and II support.
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Affiliation(s)
- Verena Henninger
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Tübingen, Germany
| | - Christl Reisenauer
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Tübingen, Germany.
| | - Sara Y Brucker
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Tübingen, Germany
| | - Katharina Rall
- Department of Obstetrics and Gynecology, University Hospital Tübingen, Tübingen, Germany
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Fixation of Light Weight Polypropylene Mesh with n-Butyl-2-cyanocrylate in Pelvic Floor Surgery: Experimental Design Approach in Sheep for Effectiveness Evaluation. BIOMED RESEARCH INTERNATIONAL 2015. [PMID: 26221605 PMCID: PMC4499369 DOI: 10.1155/2015/737683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective. The aim of this study was to find a proper experimental design and to evaluate n-butyl-2-cyanoacrylate (Histoacryl) as a fixation method for a light-weight and large pore PP mesh (Synthetic PP Mesh-1) using the sheep as an animal model. Methods. Posterior vaginal implantation by means of episiotomy was used to implant 8 ewes which were evaluated macroscopically and histologically at 3 months (n = 4) and 6 months (n = 4) post-surgery. In previous pilot studies anterior vaginal implantation was evaluated, as well as different synthetic mesh materials, sizes and fixation methods (n = 1 to 3) during three weeks. In all cases a clinical evaluation of the animal was performed. Results. A reduction in the mesh size (Synthetic PP Mesh-1) together with precise application of the surgical glue Histoacryl to fix the mesh yielded significantly better histocompatibility results (P < 0.01) compared to larger size or other fixation methods. Conclusion. The combination of Synthetic PP Mesh-1 with Histoacryl offered a high degree of graft integration without vaginal ulceration and a minimal foreign body reaction, being the sheep a proper animal model to test these types of medical devices.
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Deng T, Liao B, Luo D, Shen H, Wang K. Risk factors for mesh erosion after female pelvic floor reconstructive surgery: a systematic review and meta-analysis. BJU Int 2015; 117:323-43. [PMID: 25906691 DOI: 10.1111/bju.13158] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Tuo Deng
- Department of Urology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - Banghua Liao
- Department of Urology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - Deyi Luo
- Department of Urology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - Hong Shen
- Department of Urology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
| | - Kunjie Wang
- Department of Urology; West China Hospital; Sichuan University; Chengdu Sichuan Province China
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Abstract
Pelvic organ prolapse (POP) is a major health issue with a lifetime risk of undergoing at least one surgical intervention estimated at close to 10%. In the 1990s, the risk of reoperation after primary standard vaginal procedure was estimated to be as high as 30% to 50%. In order to reduce the risk of relapse, gynecological surgeons started to use mesh implants in pelvic organ reconstructive surgery with the emergence of new complications. Recent studies have nevertheless shown that the risk of POP recurrence requiring reoperation is lower than previously estimated, being closer to 10% rather than 30%. The development of mesh surgery - actively promoted by the marketing industry - was tremendous during the past decade, and preceded any studies supporting its benefit for our patients. Randomized trials comparing the use of mesh to native tissue repair in POP surgery have now shown better anatomical but similar functional outcomes, and meshes are associated with more complications, in particular for transvaginal mesh implants. POP is not a life-threatening condition, but a functional problem that impairs quality of life for women. The old adage "primum non nocere" is particularly appropriate when dealing with this condition which requires no treatment when asymptomatic. It is currently admitted that a certain degree of POP is physiological with aging when situated above the landmark of the hymen. Treatment should be individualized and the use of mesh needs to be selective and appropriate. Mesh implants are probably an important tool in pelvic reconstructive surgery, but the ideal implant has yet to be found. The indications for its use still require caution and discernment. This review explores the reasons behind the introduction of mesh augmentation in POP surgery, and aims to clarify the risks, benefits, and the recognized indications for its use.
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Affiliation(s)
- Patrick Dällenbach
- Department of Gynecology and Obstetrics, Division of Gynecology, Urogynecology Unit, Geneva University Hospitals, Geneva, Switzerland
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Colaco M, Mettu J, Badlani G. The scientific basis for the use of biomaterials in stress urinary incontinence (SUI) and pelvic organ prolapse (POP). BJU Int 2014; 115:859-66. [DOI: 10.1111/bju.12819] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Marc Colaco
- Department of Urology; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Jayadev Mettu
- Department of Urology; Wake Forest School of Medicine; Winston-Salem NC USA
| | - Gopal Badlani
- Department of Urology; Wake Forest School of Medicine; Winston-Salem NC USA
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Giarenis I, Robinson D. Prevention and management of pelvic organ prolapse. F1000PRIME REPORTS 2014; 6:77. [PMID: 25343034 PMCID: PMC4166938 DOI: 10.12703/p6-77] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pelvic organ prolapse is a highly prevalent condition in the female population, which impairs the health-related quality of life of affected individuals. Despite the lack of robust evidence, selective modification of obstetric events or other risk factors could play a central role in the prevention of prolapse. While the value of pelvic floor muscle training as a preventive treatment remains uncertain, it has an essential role in the conservative management of prolapse. Surgical trends are currently changing due to the controversial issues surrounding the use of mesh and the increasing demand for uterine preservation. The evolution of laparoscopic and robotic surgery has increased the use of these techniques in pelvic floor surgery.
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Abstract
INTRODUCTION AND HYPOTHESIS The aim was to determine the incidence and prevalence of pelvic organ prolapse surgery and describe how outcomes are reported. METHODS Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews, level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. A grade A recommendation usually depends on consistent level 1 evidence. A grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. A grade C recommendation usually depends on level 4 studies or "majority evidence" from level 2/3 studies or Delphi processed expert opinion. A grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi . RESULTS Pelvic organ prolapse (POP) when defined by symptoms has a prevalence of 3-6% and up to 50% when based upon vaginal examination. Surgery for prolapse is performed twice as commonly as continence surgery and prevalence varies widely from 6 to 18%. The incidence of POP surgery ranges from 1.5 to 1.8 per 1,000 women years and peaks in women aged 60-69. When reporting outcomes of the surgical management of prolapse, authors should include a variety of standardised anatomical and functional outcomes. Anatomical outcomes reported should include all POP-Q points and staging, utilising a traditional definition of success with the hymen as the threshold for success. Assessment should be prospective and assessors blinded as to the surgical intervention performed if possible and without any conflict of interest related to the assessment undertaken (grade C). Subjective success postoperatively should be defined as the absence of a vaginal bulge (grade C). Functional outcomes are best reported using valid, reliable and responsive symptom questionnaires and condition-specific HRQOL instruments (grade C). Sexual function is best reported utilising validated condition-specific HRQOL that assess sexual function or validated sexual function questionnaires such as the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire (PISQ) or the Female Sexual Function Index (FSFI). The sexual activity status of all study participants should be reported pre- and postoperatively under the following categories: sexually active without pain, sexually active with pain or not sexually active (grade C). Prolapse surgery should be defined as primary surgery, and repeat surgery sub-classified as primary surgery different site, repeat surgery, complications related to surgery and surgery for non-prolapse-related conditions (grade C). CONCLUSION Significant variation exists in the prevalence and incidence of pelvic organ prolapse surgery and how the outcomes are reported. Much of the variation may be improved by standardisation of definitions and outcomes of reporting on pelvic organ prolapse surgery.
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Affiliation(s)
- Matthew D Barber
- Urogynecology and Pelvic Reconstructive Surgery, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Abstract
INTRODUCTION AND HYPOTHESIS The aim was to review the safety and efficacy of pelvic organ prolapse surgery for vaginal apical prolapse. METHODS Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials (RCT) or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. RESULTS Abdominal sacral colpopexy (ASC) has a higher success rate than sacrospinous colpopexy with less SUI and postoperative dyspareunia for vault prolapse. ASC had greater morbidity including operating time, inpatient stay, slower return to activities of daily living and higher cost (grade A). ASC has the lowest inpatient costs compared with laparoscopic sacral colpopexy (LSC) and robotic sacral colpopexy (RSC). LSC has lower inpatient costs than RSC (grade B).In single RCTs the RSC had longer operating time than both ASC and LSC (grade B). In small trials objective outcomes appear similar although postoperative pain was greater in RSC. LSC is as effective as ASC with reduced blood loss and admission time (grade C). The data relating to operating time are conflicting. ASC performed with polypropylene mesh has superior outcomes to fascia lata (level I), porcine dermis and small intestine submucosa (level 3; grade B). In a single RCT, LSC had a superior objective and subjective success rate and lower reoperation rate compared with polypropylene transvaginal mesh for vault prolapse (grade B).Level 3 evidence suggests that vaginal uterosacral ligament suspension, McCall culdoplasty, iliococcygeus fixation and colpocleisis are relatively safe and effective interventions (grade C). CONCLUSION Sacral colpopexy is an effective procedure for vault prolapse and further data are required on the route of performance and efficacy of this surgery for uterine prolapse. Polypropylene mesh is the preferred graft at ASC. Vaginal procedures for vault prolapse are well described and are suitable alternatives for those not suitable for sacral colpopexy.
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de Tayrac R, Sentilhes L. Complications of pelvic organ prolapse surgery and methods of prevention. Int Urogynecol J 2014; 24:1859-72. [PMID: 24142061 DOI: 10.1007/s00192-013-2177-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The aim was to review complications associated with pelvic organ prolapse surgery. METHODS Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. RESULTS AND CONCLUSIONS Transvaginal mesh has a higher re-operation rate than native tissue vaginal repairs (grade A). If a synthetic mesh is placed via the vaginal route, it is recommended that a macroporous polypropylene monofilament mesh should be used. At sacral colpopexy mesh should not be introduced or sutured via the vaginal route and silicone-coated polyester, porcine dermis, fascia lata and polytetrafluoroethylene meshes are not recommended as grafts. Hysterectomy should also be avoided (grade B). There is no evidence to recommend routine local or systemic oestrogen therapy before or after prolapse surgery using mesh. The first cases should be undertaken with the guidance of an experienced surgeon in the relevant technique (grade C). Expert opinion suggests that by whatever the surgical route pre-operative urinary tract infections are treated, smoking is ceased and antibiotic prophylaxis is undertaken. It is recommended that a non-absorbable synthetic mesh should not be inserted into the rectovaginal septum when a rectal injury occurs. The placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after a bladder injury has been repaired, if the repair is considered to be satisfactory. It is possible to perform a hysterectomy in association with the introduction of a non-absorbable synthetic mesh inserted vaginally, but this is not recommended routinely.
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Affiliation(s)
- Renaud de Tayrac
- Department of Obstetrics and Gynecology, Caremeau University Hospital, Place du Prof Robert Debré, 30900, Nîmes, France,
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Neovaginal prolapse in male-to-female transsexuals: an 18-year-long experience. BIOMED RESEARCH INTERNATIONAL 2014; 2014:240761. [PMID: 24895556 PMCID: PMC4033431 DOI: 10.1155/2014/240761] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 03/29/2014] [Indexed: 11/18/2022]
Abstract
Neovaginal prolapse is a rare and distressing complication after male-to-female sexual reassignment surgery. We retrospectively analysed the prevalence of partial and total neo-vaginal prolapses after sexual reassignment surgery in our institute. During the years, two different techniques have been adopted with the aim of fixing the neovaginal cylinder. In the first, two absorbable sutures are placed at the top of the penoscrotal cylinder and fixed to the Denonvilliers fascia. In the second, two additional sutures are added from the posterior/midpoint of the flap to the prerectal fascia. We enrolled 282 consecutive transsexual patients. 65 (23.04%) out of the 282 were treated with the first technique and the following 217 (76.96%) with the last technique. In the first technique, 1 case (1.53%) of total prolapse and 7 cases (10.76%) of partial prolapse were observed, while in the other 217 patients treated with the second technique only 9 cases of partial prolapse were observed (4.14%) and no cases of total prolapse. All prolapses occurred within 6 months from the procedure. In our experience, the use of 4 stitches and a more proximal positioning of the sutures to fix the penoscrotal apex with the Denonvilliers fascia guarantees a lower risk of prolapse.
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Akyol A, Akca A, Ulker V, Gedikbasi A, Kublay A, Han A, Ark HC, Numanoglu C. Additional surgical risk factors and patient characteristics for mesh erosion after abdominal sacrocolpopexy. J Obstet Gynaecol Res 2014; 40:1368-74. [DOI: 10.1111/jog.12363] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 11/25/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Alpaslan Akyol
- Department of Obstetrics and Gynecology; Firat University Faculty of Medicine; Elazig Turkey
| | - Aysu Akca
- Department of Obstetrics and Gynecology; Kanuni Sultan Süleyman Training and Research Hospital; Istanbul Turkey
| | - Volkan Ulker
- Department of Obstetrics and Gynecology; Kanuni Sultan Süleyman Training and Research Hospital; Istanbul Turkey
| | - Ali Gedikbasi
- Department of Obstetrics and Gynecology; Kanuni Sultan Süleyman Training and Research Hospital; Istanbul Turkey
| | - Arzu Kublay
- Department of Obstetrics and Gynecology; Kanuni Sultan Süleyman Training and Research Hospital; Istanbul Turkey
| | - Agahan Han
- Department of Obstetrics and Gynecology; Kanuni Sultan Süleyman Training and Research Hospital; Istanbul Turkey
| | - Hasan Cemal Ark
- Department of Obstetrics and Gynecology; Kanuni Sultan Süleyman Training and Research Hospital; Istanbul Turkey
| | - Ceyhun Numanoglu
- Department of Obstetrics and Gynecology; Kanuni Sultan Süleyman Training and Research Hospital; Istanbul Turkey
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Investigating the clinical significance of mesh peritonization in abdominal vault suspension surgery using a comparative rabbit model. Eur J Obstet Gynecol Reprod Biol 2014; 175:199-204. [DOI: 10.1016/j.ejogrb.2014.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 12/21/2013] [Accepted: 01/02/2014] [Indexed: 11/17/2022]
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Abstract
Pelvic organ prolapse is highly prevalent, and negatively affects a woman’s quality of life. Women with bothersome prolapse may be offered pessary management or may choose to undergo corrective surgery. In choosing the most appropriate surgical procedure, there are many factors to consider. These may include the location(s) of anatomic defects, the severity of prolapse symptoms, the activity level of the woman, and concerns regarding the durability of the repair. In many instances, women and their surgeons are challenged to weigh the risks and benefits of native tissue versus mesh-augmented repairs. Though mesh-augmented repairs may offer better durability, they are also associated with unique complications, such as mesh erosion. Furthermore, newer surgical techniques of mesh placement via abdominal or vaginal routes may result in different outcomes compared to traditional techniques. Biologic grafts may also be considered to improve durability of a surgical repair, while avoiding potential complications of synthetic mesh. In this article, we review many of the clinical challenges that gynecologic surgeons face in the surgical management of vaginal prolapse. Furthermore, we review data that can help guide decision making when treating women with pelvic organ prolapse.
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Affiliation(s)
- Nazema Y Siddiqui
- Division of Urogynecology and Reconstructive Surgery, Duke University Medical Center, Durham, NC, USA
| | - Autumn L Edenfield
- Division of Urogynecology and Reconstructive Surgery, Duke University Medical Center, Durham, NC, USA
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Indications, contraindications, and complications of mesh in surgical treatment of pelvic organ prolapse. Clin Obstet Gynecol 2013; 56:276-88. [PMID: 23563869 DOI: 10.1097/grf.0b013e318282f2e8] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Women are seeking care for pelvic organ prolapse in increasing numbers and a significant proportion of them will undergo a second repair for recurrence. This has initiated interest by both surgeons and industry to utilize and design prosthetic mesh materials to help augment longevity of prolapse repairs. Unfortunately, the introduction of transvaginal synthetic mesh kits for use in women was done without the benefit of level 1 data to determine its utility compared with native tissue repair. This report summarizes the potential benefit/risks of transvaginal synthetic mesh use for pelvic organ prolapse and recommendations regarding its continued use.
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Chinthakanan O, Miklos JR, Moore RD. Laparoscopic Mesh Sacrohysteropexy With Concurrent Laparoscopic Myomectomy for Treatment of Multiple Myomas: Case Report and Literature Review. J Minim Invasive Gynecol 2013; 20:903-6. [DOI: 10.1016/j.jmig.2013.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/16/2013] [Accepted: 04/23/2013] [Indexed: 10/26/2022]
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