Surgery for pelvic organ prolapse: current status and future perspectives

Clinical effect and prognostic factor of electric stimulation and biofeedback therapy on postpartum pelvic organ prolapse

OBJECTIVE

To explore the effects of electric stimulation and biofeedback therapy in patients with postpartum pelvic organ prolapse and to identify factors that can affect therapeutic efficacy outcomes.

METHOD

This retrospective study analysed clinical data about patients with postpartum pelvic organ prolapse. A total of 328 women with pelvic organ prolapse at 6 weeks postpartum were recruited from one tertiary hospitals in Sichuan province in China, between March 2019 and March 2022. The prognostic factors of therapeutic efficacy were analysed using logistic regression and decision tree model.

RESULTS

Overall, 259 women showed clinical benefits from the treatment. The logistic regression model showed that parity, pelvic floor muscle training at home, and the pelvic organ prolapse quantitation stage before treatment were independent prognostic factors. The decision tree model showed that the pelvic organ prolapse quantitation stage before treatment was the main prognostic factor, followed by parity. There was no significant difference in the area under the receiver operating characteristic curve between the two models.

CONCLUSION

Parity, pelvic floor muscle training at home, and the pelvic organ prolapse quantitation stage before treatment were important prognostic factors of electric stimulation and biofeedback therapy on postpartum pelvic organ prolapse.

Effects of Surgical Anatomical Correction of Pelvic Anterior Compartment Defect on Lower Urinary Tract Symptoms

OBJECTIVE

To evaluate the effects of surgical anatomical correction on lower urinary tract symptoms (LUTS) in patients with a pelvic anterior compartment defect (PACD).

METHODS

This prospective study was carried out on 30 women who had stage II-IV PACD. The women were questioned regarding LUTS symptoms such as urgency, urge incontinence, frequency, hesitancy, abnormal emptying, nocturia and dysuria pre and postoperatively. After a 7-month follow up, the comparison of LUTS symptoms with respect to their healing, existence or de novo appearance was performed using the McNemar and Bowner and Wilcoxon signed-rank tests.

RESULTS

For the repair of ACD, 15, 8 and 7 women were operated on using site-specific surgery, transvaginal mesh placement and anterior colporrhaphy, respectively. Surgery has significantly improved the LUTS: urgency (100 vs 26.7%, urge incontinence (70 vs 16.7%), frequency (76.7 vs 13.3%), abnormal emptying (56.7 vs 10%), hesitancy (30 vs 6.7%), nocturia (83.3 vs 60%) and dysuria (30 vs 6.7%). The differences were statistically significant (P < 0.05).

CONCLUSIONS

The correctional surgery on anterior compartment defects not only maintains the anatomy but also significantly heals the LUTS.

Long-term results of robotic sacral hysteropexy for pelvic organ prolapse in China Single medical center

OBJECTIVE

To evaluate the long-time clinical outcomes of robotic sacral hysteropexy for pelvic organ prolapse (POP).

METHODS

Five women who underwent robotic sacral hysteropexy for the treatment for POP. Blood loss, operative time, length of stay, blood transfusion, pulmonary embolus, gastrointestinal or genitourinary tract injury, ileus, bowel obstruction, post-operative fever, and urinary retention were recorded for all patients.

RESULTS

All the operative procedures were successfully performed using the robotic approach. In one case with perineal laceration, perineal repair was simultaneously performed, and in one patient with combined leiomyoma, myomectomy was performed first. The other three cases underwent no additional procedures during the surgery. Neither intra-nor post-operative complications occurred in all 5 cases. After follow-up one year, all patients declared their satisfaction with the achieved anatomical and functional results.

CONCLUSIONS

The robotic sacral hysteropexy is a minimally invasive technique for POP repair. We found low complication rates and high patient satisfaction with a minimum of 1 year followup. Larger series with longer follow-up data are needed to justify its widespread use.

The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Our objective was to assess the effectiveness of pelvic floor muscle training (PFMT) as a treatment for women with pelvic organ prolapse (POP) or as an adjunct to prolapse surgery.

METHODS

Relevant literature sources were searched using databases including PubMed, Ovid, Web of Science, Scopus, ClinicalTrials.gov, EBSCO, CINAHL, the Cochrane Central Register of Controlled Trials, CNKI, VIP, Wanfang, and CBM until 5 July 2015. Eligible studies were restricted to randomized controlled trials (RCT). The available data were pooled using Review Manager version 5.2. For data deemed not appropriate for synthesis, a narrative overview was conducted.

RESULTS

In total, 13 studies with 2,340 patients were included. Our results indicated women receiving PFMT gained a greater improvement than controls in prolapse symptom score [mean difference (MD) -3.07, 95 % confidence interval (CI) -3.91 to -2.23] and POP stages [risk ratio (RR) 1.70, 95 % CI 1.19-2.44]. The number of women who said their prolapse was getting better was higher (RR 5.48, 95 % CI 2.19-13.72) and other discomfort syndromes, such as vaginal, bladder, and rectum, were lower in the PFMT groups than in controls. Meanwhile, women after PFMT had greater improvement in muscle strength and endurance but did not show a significant difference for further treatment needs. In addition, the results evaluating PFMT as an adjunct to prolapse surgery were inconclusive because of the variability in methods of measuring outcome.

CONCLUSIONS

Our meta-analysis demonstrated women who received PFMT showed a greater subjective improvement in prolapse symptoms and an objective improvement in POP severity.

Meta-analysis of the efficacy and safety of the application of adjuvant material in the repair of anterior vaginal wall prolapsed

INTRODUCTION

This study is a meta-analysis of the efficacy and safety of the application of adjuvant material in the repair of anterior vaginal wall prolapse and a sub-category analysis of the use of nonabsorbable synthetic mesh, biological graft and absorbable synthetic mesh.

METHOD

Pubmed, Embase and Ovid databases were searched for published randomized controlled trials from 1980 to February 2012 on the treatment of anterior vaginal wall prolapse with adjuvant materials. A comprehensive meta-analysis applying Revman5.1 analysis software was performed.

RESULTS

A total of 20 randomized controlled trials including 2,313 participants were recognized. The result showed that repair with adjuvant materials was better and more effective; nevertheless, use of adjuvant materials resulted in longer duration of surgery and more peri-operative bleeding when compared with the control group, but no significant differences were observed between the two groups regarding visceral injury, postoperative pain, urinary tract infection rate, new stress incontinence and new dyspareunia.

CONCLUSION

Adjuvant material is worthy of clinical popularization, especially the biological graft type because of its lower anatomy failure rate and no difference in safety compared with the control group. However, exposure to adjuvant materials and erosion rate are high, which are the most important aspects to be improved.

Trans-vaginal total pelvic floor repair using customized prolene mesh: A safe and cost-effective approach for high-grade pelvic organ prolapse

AIMS

To assess safety, efficacy, and cost-effectiveness of trans-vaginal total pelvic floor repair with customized prolene mesh in patients with high-grade pelvic organ prolapse.

MATERIALS AND METHODS

A total of 32 patients, who underwent trans-vaginal total pelvic floor repair using a customized prolene mesh from January 2007 to June 2010 for grade III and IV pelvic organ prolapse, were analyzed retrospectively. Prolapse was graded using Pelvic Organ Prolapse Quantification system of International Continence Society. Patients were evaluated for symptoms associated with prolapse pre- and postoperatively.

RESULTS

Of the 32 patients, 18 were grade IV uterine prolapse, 10 were grade III uterine prolapse, and 4 were grade IV vault prolapse. Twenty-eight patients underwent vaginal hysterectomy at the time of repair. All the patients had associated anterior and posterior prolapse of varying degree. Follow-up ranged from 6 to 42 months. All patients had symptomatic relief after surgery. There were no intraoperative rectal or bladder injuries. Early complications were perineal pain (30), de novo urgency (4), vaginal discharge (3), vaginal wall hematoma (2), and failure to void (2). Two patients had vaginal erosion of mesh.

CONCLUSIONS

Trans-vaginal total pelvic floor repair using a customized prolene mesh is safe and effective treatment for comprehensive repair of high-grade pelvic organ prolapse. The use of this custom-made prolene mesh makes the procedure very cost-effective and affordable. The reduction in cost is about 25-30 times with the use of this mesh when compared with commercially available variety.

Robotic sacrocolpopexy: an observational experience at mayoclinic, USA

Although there are many studies the ongoing debate on the management of posthysterectomy vault prolapse whether it should be abdominal, vaginal, or laparoscopic still continues. However there is no clear consensus. Though the incidence of vaginal vault prolapse is said to range from 0.2 to 45%, the choice of the optimal treatment depends on the surgeon's experience, suitability for surgery, age, symptoms, quality of life impairment, and prolapse grade. Abdominal sacrocopopexy (ASCP) with mesh interposition is the traditional surgical procedure for treating pelvic organ prolapse and has been shown to have one of the highest long-term success rates for vaginal vault prolapse. The laparoscopic approach offers reduced morbidity, shorter hospitalization, and decreased post operative pain. The disadvantages of the laparoscopic approach include longer operating time and need for advanced laparoscopic surgical skills including suturing. Robot-assisted laparoscopic procedure allows the performance of complex laparoscopic maneuvers with less difficulty, and thereby simplifies the complex procedure. The aim is to describe and demonstrate the use and benefit of robot-assisted laparoscopic sacrocolpopexy in the treatment of posthysterectomy vaginal vault prolapse in obese patients along with mid-urethral sling application.

The use of synthetic mesh and the management of mesh extrusion in vaginal surgery

The authors present a review of the literature regarding the management of mesh extrusion in vaginal surgery. As used in traditional surgical techniques, the use of mesh theoretically allows for a broader base of support and eliminates the need to rely on pre-existing weakened fascia. In this article, the different physical properties and types of synthetic mesh used, and their respective advantages and disadvantages in terms of mesh extrusion, are reviewed.

Magnetic resonance imaging of abdominal versus vaginal prolapse surgery with mesh

INTRODUCTION AND HYPOTHESIS

We compared two surgical approaches in patients with symptomatic prolapse of the vaginal apex with normal controls by analyzing pelvic landmark relationships measured using magnetic resonance imaging (MRI) before and after surgery.

METHODS

In this prospective multicenter pilot study involving 16 participants, nulliparous controls (n = 6) were compared with ten parous (3.0 ± 1.0) women with uterine apical prolapse equal to or greater than stage 2. Group A (n = 5) underwent abdominal sacral colpopexy with monofilament polypropylene mesh and group B (n = 5) with vaginal mesh kit repair (Total ProLift). Subtotal hysterectomy was performed in all group A and no group B women. All patients underwent preoperative and 3-month postoperative Pelvic Organ Prolapse Quantification (POP-Q) and dynamic MRI. Comparison of MRI pelvic angles and distances was performed and analyzed by Mann-Whitney rank sum test and chi-square test.

RESULTS

Vaginal apical support is similar at 3 months for abdominal sacral colpopexy (ASCP) and ProLift by POP-Q examination and MRI analysis. In both treatment groups, the postoperative POP-Q point C and MRI parameters were similar to nulliparous controls at 3 months.

CONCLUSIONS

Anatomic outcomes for ASCP compared with ProLift were similar at 3 months in terms of vaginal apical support by POP-Q and MRI analysis. Continued comparative analysis of postoperative support with objective imaging seems warranted.

Local reaction to the different meshes at the vesicovaginal space in rabbit model

INTRODUCTION AND HYPOTHESIS

This paper aims to study the vesicovaginal space local tissue reaction to type I and II polypropylene mesh in a rabbit model.

METHODS

Different types of meshes were implanted into the rabbit vesicovaginal space. The animals were killed at days 7 and 60, and the initial implant and the neighboring host tissue were removed, including the bladder and vaginal wall. Histopathology and immunohistochemistry (Ki-67 and proliferating cell nuclear antigen) were performed to evaluate the cell proliferation, and the indirect local inflammatory response was described.

RESULTS

One rabbit had erosion at the urinary bladder mucous membrane, which resulted in vesical stone formation in the type I mesh group at day 60. Obvious local tissue reaction was found after the different types of meshes were implanted, and the reaction tapered and disappeared over time. At day 7, the reaction in the type I mesh group was stronger than that in the type II group, while at day 60, the reaction shows no difference.

CONCLUSION

The two types of meshes could induce local tissue reaction, but this was stronger in type I mesh group at day 7 and shows no obvious difference between the two groups at day 60.

Role of laparoscopy in reconstructive surgery

PURPOSE OF REVIEW

Despite increasing laparoscopic expertise in reconstructive surgery, open procedures still represent the gold standard. Robot-assisted techniques increasingly replace laparoscopy. However, laparoscopy is also developing: by improvement of ergonomics, new instruments, and techniques further reducing access trauma. We evaluated the actual role of laparoscopy focusing on main indications of urologic reconstructive surgery.

RECENT FINDINGS

We analysed the current literature (PubMed/Medline) concerning indications, perioperative results, complications, and long-term outcome of laparoscopy for pyeloplasty, ureteral reimplantation, stone surgery, management of vesico-vaginal fistula, sacrocolpopexy (including evidence level). For all indications, laparoscopy provides the advantages of less postoperative pain, blood loss, shorter convalescence, and minimal disfigurement. However, it requires expertise with endoscopic suturing. Most experience (N > 1000) exists with laparoscopic pyeloplasty and sacrocolpopexy which can be considered as valuable options (IIB). Concerning ureteral reimplantation and repair of vesico-vaginal fistula, only a limited number of cases were reported (N < 150) (III). Laparoscopic stone surgery may gain importance particularly in developing countries. Robot-assistance will definitively increase the application of laparoscopic techniques providing optimal ergonomics, whereas the role of single-port surgery will be limited.

SUMMARY

Laparoscopy will increasingly be used for reconstructive urologic surgery. This trend will be supported by the widespread use of the DaVinci device.

Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model

BACKGROUND

Pre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder.

METHODS

We developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting.

FINDINGS

261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility.

INTERPRETATION

The fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia.

FUNDING

Canadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute.

Pelvic magnetic resonance imaging for assessment of the efficacy of the Prolift system for pelvic organ prolapse

OBJECTIVE

The purpose of this study was to compare pre- and postoperative pelvic organ prolapse-quantification (POP-Q) and magnetic resonance imaging (MRI) measurements in patients who undergo total Prolift (Ethicon, Inc, Somerville, NJ) colpopexy.

STUDY DESIGN

Pre- and postoperative MRI and POP-Q examinations were performed on patients with stage 2 or greater prolapse who underwent the Prolift procedure. MRI measurements were taken at maximum descent. Correlations between changes in MRI and POP-Q measurements were determined.

RESULTS

Ten subjects were enrolled. On MRI, statistically significant changes were seen with cystocele, enterocele, and apex. Statistically significant changes were seen on POP-Q measurements for Aa, Ba, C, Ap, Bp, and GH. Positive correlations were demonstrated between POP-Q and MRI changes. Minimal tissue reaction was seen on MRI.

CONCLUSION

The Prolift system is effective in the surgical management of pelvic organ prolapse as measured by POP-Q and MRI. Postoperative MRIs support the inert nature of polypropylene mesh.

MRI pelvic landmark angles in the assessment of apical pelvic organ prolapse

PURPOSE

The aim of the study was to evaluate the utility of magnetic resonance imaging (MRI) pelvic landmark angles and lines in the assessment of apical vault prolapse.

METHODS

Seventeen women were evaluated as part of a prospective surgical trial. Baseline data are presented as a pilot study of the utility of MRI in addition to this evaluation of 6 nulliparous volunteers without prolapse and 11 parous women with symptomatic ≥ stage II uterine prolapse. Each patient underwent assessment for pelvic organ prolapse quantification (POPQ) and pelvic MRI. Pelvic landmark angles and lines were measured. Mann-Whitney Rank sum test and Spearman's Rank order correlation test were used to assess agreement.

RESULTS

Women with prolapse had a significantly larger h angle, g angle, and e angle at rest than those without prolapse. Correlation between apical vault descent was measured clinically by POPQ point C with MRI measurements: h angle (r = 0.61, p = 0.01), g angle (r = 0.64, p = 0.005), and e angle (r = 0.62, p = 0.007).

CONCLUSION

MRI measurements of pelvic landmark angles reliably differentiate between women with and without uterine prolapse and correlate best with POPQ point C.

Does the Prolift system cause dyspareunia?

OBJECTIVE

The purpose of this study was to determine the de novo dyspareunia rate with the Prolift procedure.

STUDY DESIGN

All Prolift cases performed between August 2005 and August 2007 were evaluated. The rate of de novo dyspareunia was calculated by chart review. Type and degree of dyspareunia were assessed by self-administered questionnaire. Demographics, use of hormone therapy, failure rate, and willingness to have the surgery again were summarized using descriptive statistics.

RESULTS

The rate of de novo dyspareunia was 16.7%. Over 75% of patients with de novo dyspareunia described the pain as mild or moderate. Most described dyspareunia with insertion. Eighty-three percent of respondents with de novo dyspareunia would have the procedure done again.

CONCLUSION

The Prolift is associated with a 17% de novo dyspareunia rate. Despite this, most would have the surgery done again.

Prolapse surgery: an update

PURPOSE OF REVIEW

The purpose of the review is to highlight the latest developments in the surgical treatment of pelvic organ prolapse.

RECENT FINDINGS

Total vaginal mesh has been developed with the intent to improve the outcome of pelvic floor reconstructive surgery. Two interesting papers were published in 2006. At the short follow up available, the data appear interesting, although the rate of erosions is quite high. Two American teams reported their experience in robotic surgery for the management of sacrocolpopexy and hysterectomy. The published data on the use of the da Vinci system are interesting, although they need to be reproduced and improved in other centers. A randomized controlled trial suggests the efficacy of Burch colposuspension as an antiincontinence procedure in patients undergoing sacrocolpopexy for pelvic organ prolapse.

SUMMARY

Total vaginal mesh and robotic surgery are major innovations in the field of urogynecology. Also, Burch colposuspension has proved to be an effective antiincontinence procedure in patients undergoing sacrocolpopexy for pelvic organ prolapse. Further studies are needed, however, with longer follow-up periods.

Imaging for urinary incontinence: a contemporary perspective

PURPOSE OF REVIEW

To highlight the current role of the imaging techniques in urinary incontinence.

RECENT FINDINGS

The text for the Third International Consultation of Incontinence, published in 2005, provides major insights into all the imaging techniques. In addition, the most important findings regarded imaging technique in the patients surgically treated for stress urinary incontinence. An article from Singapore suggested that about one-third of patients with tension-free vaginal tape had the tape in the proximal or distal one-third of the urethra, without jeopardizing tape's clinical efficacy. This finding would tend to indicate that the support of the midurethra, as suggested by the integral theory of incontinence, might not be mandatory. Another interesting article demonstrated by ultrasonography, a surprisingly high rate of collagen retention in patients who had undergone collagen injection for stress urinary incontinence due to intrinsic sphincter deficiency.

SUMMARY

Most of the articles published underscored the role of ultrasonography and/or magnetic resonance imaging in assessing the patients with urinary incontinence. The purpose of the imaging is to investigate the correlations between morphology and function of both the bladder and the urethra, and detect concomitant defects in the pelvic floor. Definitive studies comparing the different diagnostic options, as well as their impact on patient management and outcome are still lacking.