Mesh sacrocolpopexy compared with native tissue vaginal repair: a systematic review and meta-analysis

COMET (Composite Outcomes of Mesh vs suture Techniques for prolapse repair)- Protocol for a single blind randomized controlled multicenter trial testing surgical innovation in female pelvic surgery

BACKGROUND

Pelvic organ prolapse (POP) increases in incidence and severity with aging. At least 1 in 4 women seek pelvic floor care and many more suffer with concurrent symptoms of bowel, bladder and sexual dysfunction, which can have a large impact on quality of life. It is estimated that 1 in 5 women will undergo surgery for POP. POP is difficult to cure with existing surgeries and therefore treatment failure and reoperations are common. Surgical innovation in this area is urgently needed and we have developed a novel technique of bilateral sacrospinous vaginal vault fixation with synthetic mesh arms (BSSVF-M). Based on preliminary studies it may be more successful, durable and cost-effective than standard sacrospinous ligament suspension with sutures (SSLS). Preliminary development and exploration studies showed safety and efficacy of BSSVF-M. Following an established framework for research in surgical innovations, we now wish to conduct a randomized comparative effectiveness trial for assessment of this novel technique.

METHODS

This is a multi-center randomized controlled trial in Canada comparing the surgical techniques of BSSVF-M vs. SSLS to address apical prolapse. In total, 358 women with symptomatic POP at five centers will be randomized with 80% power to detect a 15% difference in primary composite outcome and accounting for a 15% loss to follow-up over 2 years. The primary objective is to investigate BSSVF-M vs. SSLS using an established composite of 3 objective signs and 1 subjective symptom of POP measured 2 years postoperatively. Secondary objectives: 1) To determine changes in condition-specific pelvic symptoms, quality of life, pain and condition-specific body image post BSSVF-M vs. SSLS using validated questionnaires; 2) To determine changes in sexuality post BSSVF-M vs. SSLS; 3) To determine global impression of improvement, adverse events (validated classification scheme), reoperations and health utility post BSSVF-M vs. SSLS; 4) To determine the cost-effectiveness of BSSVF-M vs SSLS. Study Registration at clinicaltrials.gov (NCT02965313).

DISCUSSION

There is a need for innovation to improve the surgical approach to vaginal apical suspension. Despite controversies with mesh, it has been shown to be safe when used appropriately and to have higher durability when compared with sutures. As well, the importance of restoring anatomy and tension-free surgical approach in pelvic reconstructive surgery has led to better long-term outcomes and fewer side effects. These principles have been applied when developing the novel BSSVF-M technique. Anticipated challenges of this trial include recruitment, compliance problems and loss to follow up However, the robust methodology will provide evidence on the best surgical approach to correct POP, a common condition among aging women.

Outcomes of Laparoscopic versus Robotic-Assisted Sacrocolpopexy for Pelvic Organ Prolapse-A Comprehensive Retrospective Analysis

INTRODUCTION AND HYPOTHESIS

Minimally invasive abdominal sacrocolpopexy (SC) is the gold standard for managing symptomatic pelvic organ prolapse (POP). Robot-assisted laparoscopy (RSC) offers a promising surgical option compared to conventional laparoscopy (LSC). This study compares the clinical and operative outcomes of these techniques to determine if RSC is superior to LSC.

METHODS

We conducted a retrospective, single-center study in the Gynecology Department at the Citadelle Hospital in Liège, Belgium. Data from all patients who underwent SC between January 2019 and December 2023 were collected. We evaluated demographic and clinical data, perioperative complications, operative time (OT), length of stay, risk of recurrence and follow-up duration. Statistical analysis was performed to compare outcomes between the groups.

RESULTS

Data from 208 patients (97 LSC and 111 RSC) were analyzed. No significant differences were found between the groups. A higher body mass index trend was observed in the RSC group (mean BMI: 26.63, range: 20-43) compared to the LSC group (mean BMI: 25.45, range: 15-34; p = 0.0625). The median OT was similar (LSC: 111 min vs RSC 119 min; p = 0.104), with a notable reduction in OT compared to the literature. Additionally, more RSC procedures could be performed per day (3 RSC vs. a maximum of 2 for LSC).

CONCLUSION

Robot-assisted laparoscopy was not demonstrated to be superior to LSC. However, both procedures had comparable OT, significantly shorter than previously reported. RSC's operational efficiency might allow for a higher number of daily procedures, translating into practical benefits in clinical settings.

Associations Between Short-Term Postoperative Outcomes and Immunocompromised Status in Patients Undergoing Sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Few data exist on the impact of immunosuppression on perioperative outcomes in women undergoing sacrocolpopexy. The objective of this study was to compare differences in 30-day perioperative morbidity in immunocompromised versus non-immunocompromised women undergoing sacrocolpopexy (SCP). We hypothesize that compared with the non-immunocompromised group, immunocompromised women undergoing SCP experience worse composite 30-day postoperative outcomes.

METHODS

Retrospective cohort of female patients aged 18 years or older who underwent sacrocolpopexy from 2012 to 2017. Current procedural terminology (CPT) codes 57280 and 57425 identified sacrocolpopexy in the American College of Surgeons-National Surgical Quality Improvement Project database. The primary exposure was a binary indicator of immunocompromised status, and the primary outcome was a composite indicator of readmission, reoperation, or a severe adverse event 30 days after surgery. Marginal standardization, a G-computation method, was used to estimate risk ratios (RR) and 95% confidence intervals (CI) representing the association between exposure and outcome.

RESULTS

A total of 13,505 women underwent SCP between 2012 and 2017. Of those, 2,625 (19.4%) had an indicator of immunocompromised status, with diabetes and smoking being most common. The risk of the composite adverse outcome in immunocompromised women was 7.3% versus 4.6% in non-immunocompromised women. After adjusting for age, race, ethnicity, and body mass index, immunocompromised women experienced 54% increased relative risk of an adverse outcome, compared with non-immunocompromised women (RR = 1.54; 95% CI: 1.31, 1.82).

CONCLUSIONS

Immunocompromised status, most commonly caused by diabetes and smoking, increases the risk of readmission, reoperation, and a severe adverse event within 30 days of sacrocolpopexy.

Short-term outcomes of single port robotic hysterectomy with concomitant sacrocolpopexy

The Da Vinci single port® (SP) robotic platform heralds a new era of minimally invasive surgery (MIS). The primary objective of this study was to assess short-term outcomes in patients undergoing SP robotic hysterectomy with concomitant sacrocolpopexy for pelvic organ prolapse (POP). We performed a retrospective case series at two tertiary care centers between January 2021 and August 2023. Patients with POP electing to undergo SP robotic hysterectomy with concomitant sacrocolpopexy were included. Chart abstraction was used to collect patient demographics and clinical outcomes. Recurrent POP was defined as new bothersome vaginal bulge symptoms and evidence of POP beyond the hymen on postoperative examination. 69 patients were included. Median operative time was 209 min (135-312) and estimated blood loss was 100 mL (20-2000). 1 (1.4%) patient sustained a major vascular injury resulting in laparotomy. Median pain score and morphine equivalents administered in PACU were low at 3 (0-7) and 3.2 (0-27) respectively. At 3 months, 60 (86.9%) patients were seen either in person or via telemedicine for their follow up appointment. 59/60 (98.3%) reported no vaginal bulge symptoms and 50/51 (98.0%) had stage 0 or 1 prolapse on exam. One (1.4%) patient had recurrent prolapse and underwent an additional repair. Postoperative complications included 2 (2.9%) cases of ileus/small bowel obstruction, 1 (1.4%) pelvic hematoma requiring a blood transfusion, and 1 (1.4%) umbilical hernia. The SP robotic platform is a safe and feasible platform for MIS hysterectomy and sacrocolpopexy with good short term anatomic and symptomatic outcomes.

Contrasting Effects of Music Therapy and Aromatherapy on Perioperative Anxiety: A Systematic Review and Meta-Analysis

INTRODUCTION

Music therapy and aromatherapy have been demonstrated effective for perioperative anxiety. However, the available studies have indicated discordant results about which adjunct treatment is better for perioperative anxiety. Therefore, we conducted this meta-analysis to explore the contrasting effects between them.

METHODS

Six electronic databases were searched for clinical trials evaluating the efficacy of music therapy compared with aromatherapy in alleviating perioperative anxiety. The primary outcome was the postintervention anxiety level. Secondary outcomes included differences in blood pressure and heart rate before and after the intervention as well as pain scores at intraoperative and postoperative time points. The study protocol was registered on PROSPERO (CRD42021249737).

RESULTS

Twelve studies (894 patients) were included. The anxiety level showed no statistically significant difference (SMD, 0.28; 95% CI: -0.12, 0.68; p = 0.17). The analysis of blood pressure and heart rate also did not identify statistically significant differences. Notably, the pain scores at the intraoperative time point suggested that aromatherapy was superior to music therapy (WMD, 0.29 cm; 95% CI: 0.05, 0.52; p = 0.02), while those at 4 h after surgery indicated the opposite results (WMD, -0.48 cm; 95% CI: -0.60, -0.36; p < 0.001).

CONCLUSION

Low-to-moderate quality evidence suggests that music therapy and aromatherapy have similar potential to relieve perioperative anxiety. The potential data indicate that the two therapies have different benefits in intervention duration and age distribution. More direct high-quality comparisons are encouraged in the future to verify this point.

Einleitung

Musik- und Aromatherapie haben sich bei perioperativen Angstzuständen als wirksam erwiesen. Die verfügbaren Studien zeigten jedoch widersprüchliche Ergebnisse zur Frage, welche adjuvante Therapie bei perioperativen Angstzuständen besser ist. Daher führten wir die vorliegende Metaanalyse durch, um die unterschiedlichen Effekte der beiden Therapien zu untersuchen.

Methoden

Sechs (6) elektronische Datenbanken wurden nach klinischen Studien zur Wirksamkeit von Musiktherapie im Vergleich zur Aromatherapie bei der Linderung perioperativer Angstzustände durchsucht. Primäres Zielkriterium war das Angstniveau nach der Intervention. Die sekundären Zielkriterien umfassten die Unterschiede bei Blutdruck und Herzfrequenz vor und nach der Intervention sowie die Schmerz-Scores zu intra- und postoperativen Zeitpunkten. Das Studienprotokoll wurde auf PROSPERO (CRD42021249737) registriert.

Ergebnisse

Zwölf (12) Studien (894 Patienten) wurden eingeschlossen. Das Angstniveau zeigte keinen statistisch signifikanten Unterschied (SMD, 0,28; 95%-KI: −0,12, 0,68, p = 0,17) und auch die Analyse von Blutdruck und Herzfrequenz ergab keine statistisch signifikanten Unterschiede. Insbesondere die Schmerz-Scores zum intraoperativen Zeitpunkt sprachen dafür, dass die Aromatherapie gegenüber der Musiktherapie überlegen war (WMD, 0,29 cm; 95%-KI: 0,05, 0,52; p = 0,02), während die Werte 4 Stunden nach der Operation gegenteilige Ergebnisse zeigten (WMD, −0,48 cm; 95%-KI: −0,60, −0,36, p < 0,001).

Schlussfolgerung

Evidenzen von geringer bis mässiger Qualität deuten darauf hin, dass Musik- und Aromatherapie ein vergleichbares Potenzial bei der Linderung perioperativer Ängste besitzen. Die potenziellen Daten zeigen, dass die beiden Therapien unterschiedliche Vorteile hinsichtlich Interventionsdauer und Altersverteilung haben. Künftig sollten mehr direkte und qualitativ hochwertige Vergleiche durchgeführt werden, um diesen Aspekt zu überprüfen.

Risk of thrombosis and bleeding in gynecologic noncancer surgery: systematic review and meta-analysis

OBJECTIVE

This study aimed to provide procedure-specific estimates of the risk for symptomatic venous thromboembolism and major bleeding in noncancer gynecologic surgeries.

DATA SOURCES

We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar. Furthermore, we performed separate searches for randomized trials that addressed the effects of thromboprophylaxis.

STUDY ELIGIBILITY CRITERIA

Eligible studies were observational studies that enrolled ≥50 adult patients who underwent noncancer gynecologic surgery procedures and that reported the absolute incidence of at least 1 of the following: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic venous thromboembolism, bleeding that required reintervention (including re-exploration and angioembolization), bleeding that led to transfusion, or postoperative hemoglobin level <70 g/L.

METHODS

A teams of 2 reviewers independently assessed eligibility, performed data extraction, and evaluated the risk of bias of the eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine the cumulative incidence at 4 weeks postsurgery stratified by patient venous thromboembolism risk factors and used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the evidence certainty.

RESULTS

We included 131 studies (1,741,519 patients) that reported venous thromboembolism risk estimates for 50 gynecologic noncancer procedures and bleeding requiring reintervention estimates for 35 procedures. The evidence certainty was generally moderate or low for venous thromboembolism and low or very low for bleeding requiring reintervention. The risk for symptomatic venous thromboembolism varied from a median of <0.1% for several procedures (eg, transvaginal oocyte retrieval) to 1.5% for others (eg, minimally invasive sacrocolpopexy with hysterectomy, 1.2%-4.6% across patient venous thromboembolism risk groups). Venous thromboembolism risk was <0.5% for 30 (60%) of the procedures; 0.5% to 1.0% for 10 (20%) procedures; and >1.0% for 10 (20%) procedures. The risk for bleeding the require reintervention varied from <0.1% (transvaginal oocyte retrieval) to 4.0% (open myomectomy). The bleeding requiring reintervention risk was <0.5% in 17 (49%) procedures, 0.5% to 1.0% for 12 (34%) procedures, and >1.0% in 6 (17%) procedures.

CONCLUSION

The risk for venous thromboembolism in gynecologic noncancer surgery varied between procedures and patients. Venous thromboembolism risks exceeded the bleeding risks only among selected patients and procedures. Although most of the evidence is of low certainty, the results nevertheless provide a compelling rationale for restricting pharmacologic thromboprophylaxis to a minority of patients who undergo gynecologic noncancer procedures.

Postoperative complications and unanticipated healthcare encounters following mini-laparotomy vs. laparoscopic/robotic-assisted sacrocolpopexy: a comparative retrospective study

BACKGROUND

Pelvic organ prolapse is a debilitating condition impacting lives of millions of women worldwide. Sacrocolpopexy (SCP) is considered an effective and durable surgical technique for treatment of apical prolapse. The aim of this study was to compare short-term outcomes including postoperative complications and unanticipated healthcare encounters between patients who underwent SCP with a mini-laparotomy approach compared to patients treated with laparoscopic and robotic-assisted laparoscopic SCP.

METHODS

This was a retrospective cohort study including patients treated for apical prolapse at a university affiliated urogynecology practice. Patients over the age of 18 who underwent abdominal SCP between 2019 and 2023 were included. The cohort was formed into two groups: (1) Patients who underwent SCP through a mini-laparotomy incision (Mini-lap group); (2) Patients who underwent laparoscopic or robotic-assisted laparoscopic SCP (Lap/Robot group).

RESULTS

A total of 116 patients were included in the final analysis. Ninety patients underwent either laparoscopic or robotic-assisted SCP, whereas 26 patients underwent SCP with a mini-laparotomy approach. Study participants exhibited a mean age of 63.1 ± 10.3 years, mean body mass index (BMI) of 25.8 ± 4.9 Kg/m2, and 77.6% of them identified as Caucasian. Upon comparison of demographic and past medical history between groups there were no statistically significant differences in age, BMI, menopausal status, race, parity or comorbid conditions. Patients in the Mini-lap group were less likely to have undergone previous abdominal surgery (11.5% vs. 50.6%, p < 0.001) and had more severe apical prolapse (stage 4 prolapse, 40% vs. 21.2%, p < 0.001) than their counterparts in the Lap/robot group. Regarding intraoperative parameters, length of surgery was significantly shorter in the Mini-lap group compared to the Lap/robot group (97.3 ± 35.0 min vs. 242.0 ± 52.6 min, p < 0.001). When focusing on the primary outcome, postoperative complications within the first 30 days after surgery, there were no differences noted between groups. Additionally, the number of unanticipated healthcare encounters, such as phone calls, clinic visits, emergency department visits, urgent care visits, readmissions and reoperations were similar between groups.

CONCLUSIONS

Mini-laparotomy approach for SCP is safe with comparable intra- and postoperative complications, and unanticipated healthcare encounters compared to conventional minimally invasive methods.

Longitudinal Reoperation Risk After Apical Prolapse Procedures in Women Aged 65 Years and Older

OBJECTIVE

To describe longitudinal reoperation risk among older women undergoing surgery for apical pelvic organ prolapse (POP) and to compare risk of reoperation for prolapse and complications among different surgical approaches.

METHODS

This nationwide, retrospective cohort study evaluated older adult women (aged 65 years and older) within the Centers for Medicare & Medicaid Services' (CMS) 5% LDS (Limited Data Set) who underwent sacrocolpopexy, uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF), or colpocleisis, or their uterine-preserving equivalents, from January 1, 2011, to December 31, 2018, with follow-up through 2019. The primary outcome was overall reoperation, and secondary outcomes included reoperation for POP and for complications. Rates were compared using χ 2 tests for categorical variables, Wilcoxon rank-sum for continuous variables and Kaplan Meier estimates of cumulative incidence. Death and exit from CMS insurance were considered as censoring events. We used cumulative incidence to calculate reoperation risk as a function of time at 1 year or more, 3 years or more, and 7 years or more.

RESULTS

This cohort included 4,089 women who underwent surgery to treat apical POP from 2011 to 2018: 1,034 underwent sacrocolpopexy, 717 underwent USLS, 1,529 underwent SSLF, and 809 underwent colpocleisis. Demographics varied among patients for each POP surgery. Patients who underwent the different surgeries had differences in age ( P <.01), Charlson Comorbidity Index score ( P <.01), diabetes ( P <.01), chronic obstructive pulmonary disease ( P <.01), hypertension ( P <.01), chronic pain ( P =.01), congestive heart failure ( P <.01), and concomitant hysterectomy ( P <.01). Reoperation rates were low and increased over time. The overall reoperation risk through 7 years was 7.3% for colpocleisis, 10.4% for USLS, 12.5% for sacrocolpopexy, and 15.0% for SSLF ( P <.01). Reoperation for recurrent POP through 7 years was 2.9% for colpocleisis, 7.3% for sacrocolpopexy, 7.7% for USLS, and 9.9% for SSLF ( P <.01). Reoperation for complications through 7 years was 5.3% for colpocleisis, 8.2% for sacrocolpopexy, 6.4% for USLS, and 8.2% for SSLF ( P <.01).

CONCLUSION

The type of surgical repair is significantly associated with long-term risk of reoperation. Colpocleisis offers the least likelihood of reoperation for prolapse, followed by sacrocolpopexy; colpocleisis followed by USLS has the least risk of long-term reoperation for complication.

Effect of age in women undergoing laparoscopic sacrocolpopexy: A retrospective study

OBJECTIVE

To determine whether elderly women (≥65 years) have an increased risk of complications and lower success when undergoing laparoscopic sacrocolpopexy (LSC) compared with younger women (<65 years).

METHODS

This was a retrospective study of all LSC procedures performed from August 2014 to February 2021 by a single urogynecologic surgeon in an academic affiliated hospital system. Charts were identified through procedure codes. Patient demographics, clinical, surgical, and postoperative data were collected. The primary outcome of this study was to compare complications associated with LSC, including intraoperative and postoperative complications. Secondary outcomes included subjective, objective, and composite success.

RESULTS

In total, 312 participants met the criteria. The mean age of the group who were younger than 65 years was 55.7 years (±6.5) and of the group aged 65 years or older was 69.3 years (±3.5). Racial demographics revealed no differences between the two groups. Patients aged 65 years or older had a statistically significant lower body mass index (calculated as weight in kilograms divided by the square of height in meters), a higher rate of hypertension, smaller genital hiatus, and a larger anterior vaginal wall prolapse compared with the younger cohort. They also less often underwent a posterior repair. No statistically significant differences were found with regards to intraoperative and postoperative complications, including 30-day re-admission, between the two age groups. Both groups had high anatomic success rates, with no significant difference (<65 = 96.3%; ≥65 = 98.4%; P = 0.326). Those aged younger than 65 years compared with those aged 65 years or older had lower subjective success that was not significantly different (<65 = 62.8%; ≥65 = 71.0; P = 0.134). Composite success was noted to reach the threshold of a statistically significant difference in the group aged younger than 65 years compared with those aged 65 years or older (60.1% vs 71.0%; P = 0.0499).

CONCLUSION

In this study, elderly patients did not have increased intraoperative and postoperative complications after undergoing LSC. Similar rates of anatomic and subjective success were also found with younger patients having a lower composite success. Proper candidates for LSC should not be excluded based upon age.

A Randomized Clinical Trial Comparing Dubuisson Laparoscopic Lateral Suspension with Laparoscopic Sacropexy for Pelvic Organ Prolapse: Short-Term Results

BACKGROUND

Laparoscopic sacrocolpopexy (LSC) is the gold standard for the treatment of apical prolapse, although dissection of the promontory may be challenging. Laparoscopic lateral suspension (LLS) with mesh is an alternative technique for apical repair with similar anatomical and functional outcomes, according to recent studies. The purpose of this study was to compare these operative techniques.

METHODS

Women with uterine Pelvic Organ Prolapse Quantification (POP-Q) stage 2 were enrolled in this prospective study and were randomly allocated to the LLS or LSC group. At the 12-month follow-up, primary measures included both anatomical and functional outcomes. Perioperative parameters and complications were recorded.

RESULTS

A total of 93 women were randomized, 48 in the LLS group and 45 in the LSC group, with 2 women lost to follow-up in both groups. LSC anatomic success rates were 81.82% for the apical compartment and 95.22% for the anterior compartment. LLS anatomic success rates for the apical and anterior compartments were 90% and 92.30%, respectively. The mean operative time for LLS was 160.3 min, while for LSC it was 168.3 min. The mean blood loss was 100 mL in both procedures. Conversion to laparotomy was necessary in three women. Mesh erosion was not observed in any of the cases. In terms of the complication, Clavien-Dindo grade 1 was observed in two patients in the LLS group and a complication rated grade 3b was observed in one patient in LSC group.

CONCLUSIONS

LLS is a good alternative to LSC, with promising anatomical and quality-of-life results.

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

CONTEXT

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

OBJECTIVE

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

Cuff meshoma post-laparoscopic sacrocolpopexy: vaginal-endoscopic mesh excision

INTRODUCTION AND HYPOTHESIS

The objective was to present endoscopic images of a meshoma and describe the complete excision of a complicated mesh after sacrocolpopexy (SCP) using a combined vaginal-endoscopic technique.

METHODS

We present a video documentation of an innovative technique. A 58-year-old woman was referred with painless, foul-smelling vaginal discharge and recurrent vaginal mesh erosions. She had undergone a laparoscopic SCP 12 years ago and her symptoms had begun 5 years ago. A pre-operative MRI scan revealed a cuff meshoma and an inflammatory sinus around the mesh extending from the cuff to the sacral promontory. Under general anesthesia, a 30° hysteroscope was inserted transvaginally into the sinus, where the retained mesh was seen in the form of a shrunken meshoma, and then the mesh arms were recognized extending cephalad into a sinus tract. Under direct endoscopic visualization, the mesh was carefully mobilized at its highest point with the use of laparoscopic grasping forceps. Then, the mesh was dissected with hysteroscopic scissors in close proximity to the bone. No peri-operative complications were recognized.

RESULTS

A combined vaginal-endoscopic approach was successfully used to remove an eroded mesh and cuff meshoma after SCP.

CONCLUSION

This procedure offers a minimally invasive, low-morbidity, and rapid-recovery approach.

Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis

BACKGROUND

There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization.

OBJECTIVE

This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy.

STUDY DESIGN

We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated.

RESULTS

There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001).

CONCLUSION

This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

Supramolecular Fibrous Hydrogel Augmentation of Uterosacral Ligament Suspension for Treatment of Pelvic Organ Prolapse

Uterosacral ligament suspension (USLS) is a common surgical treatment for pelvic organ prolapse (POP). However, the relatively high failure rate of up to 40% underscores a strong clinical need for complementary treatment strategies, such as biomaterial augmentation. Herein, the first hydrogel biomaterial augmentation of USLS in a recently established rat model is described using an injectable fibrous hydrogel composite. Supramolecularly-assembled hyaluronic acid (HA) hydrogel nanofibers encapsulated in a matrix metalloproteinase (MMP)-degradable HA hydrogel create an injectable scaffold showing excellent biocompatibility and hemocompatibility. The hydrogel can be successfully delivered and localized to the suture sites of the USLS procedure, where it gradually degrades over six weeks. In situ mechanical testing 24 weeks post-operative in the multiparous USLS rat model shows the ultimate load (load at failure) to be 1.70 ± 0.36 N for the intact uterosacral ligament (USL), 0.89 ± 0.28 N for the USLS repair, and 1.37 ± 0.31 N for the USLS + hydrogel (USLS+H) repair (n = 8). These results indicate that the hydrogel composite significantly improves load required for tissue failure compared to the standard USLS, even after the hydrogel degrades, and that this hydrogel-based approach can potentially reduce the high failure rate associated with USLS procedures.

Surgery for women with apical vaginal prolapse

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.

Comparison of tube shunt implantation and trabeculectomy for glaucoma: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of tube shunt implantation with trabeculectomy in the treatment of patients with glaucoma.

METHODS

A systematic literature search was performed for studies comparing tube with trabeculectomy in patients with glaucoma (final search date: 27 February 2022). Comparisons between tube and trabeculectomy were grouped by the type of tube (Ahmed, Baerveldt, Ex-PRESS and XEN). The primary endpoints included intraocular pressure (IOP), IOP reduction (IOPR), IOPR percentage (IOPR%), complete success rate (CSR), qualified success rate (QSR) and adverse events (AEs).

RESULTS

Forty-nine studies were included in this meta-analysis and presented data for 3795 eyes (Ahmed: 670, Baerveldt: 561, Ex-PRESS: 473, XEN: 199, trabeculectomy: 1892). Ahmed and Ex-PRESS were similar to trabeculectomy in terms of IOP outcomes and success rate (Ahmed vs trabeculectomy: IOPR%: mean difference (MD)=1.34 (-5.35, 8.02), p=0.69; Ex-PRESS vs trabeculectomy: IOPR%: MD=0.12 (-3.07, 3.31), p=0.94). The IOP outcomes for Baerveldt were worse than those for trabeculectomy (IOPR%: MD=-7.51 (-10.68, -4.35), p<0.00001), but the QSR was higher. No significant difference was shown for the CSR. XEN was worse than trabeculectomy in terms of IOP outcomes (IOPR%: MD=-7.87 (-13.55, -2.18), p=0.007), while the success rate was similar. Ahmed and Ex-PRESS had a lower incidence of AEs than trabeculectomy. Baerveldt had a lower incidence of bleb leakage/wound leakage, hyphaema and hypotonic maculopathy than trabeculectomy but a higher incidence of concurrent cataracts, diplopia/strabismus and tube erosion. The incidence of AEs was similar for the XEN and trabeculectomy procedures.

CONCLUSION

Compared with trabeculectomy, both Ahmed and Ex-PRESS appear to be associated with similar ocular hypotensive effects and lower incidences of AEs. However, Baerveldt and XEN cannot achieve sufficient reductions in IOP outcomes similar to those of trabeculectomy.

PROSPERO REGISTRATION NUMBER

CRD42021257852.

Hysteropexy and Anterior Vaginal Native Tissue Repair in Women with Anterior and Central Compartment Prolapse: A Long Term Follow-Up

Although it is known that hysterectomy (HY) alone cannot resolve apical prolapse, vaginal hysterectomy (VH) remains the most common surgical procedure for this issue. In recent years, various procedures for uterine conservation have been proposed to avoid the surgical risks of HY. Furthermore, most women with symptomatic pelvic organ prolapse (POP) prefer uterine conservation in the absence of considerable benefit in uterine removal. In 2017, we proposed a new technique for hysteropexy and anterior vaginal native tissue repair (NTR) in women with cystocele and apical prolapse. The objective of this study is to assess the efficacy and safety of this new procedure after at least 5 years of follow-up. We included only patients with stage II or greater prolapse of the anterior vaginal wall and a concomitant stage II uterine prolapse in accordance with Pelvic Organ Prolapse Quantification (POP-Q) system. A Patient Global Impression of Improvement (PGI-I) score ≤ 2 in addition with the absence of POP symptoms was defined as subjective success. A descensus with a maximum point of less than −1 in any compartment was considered objective cure. A total of 102 patients who fulfilled the inclusion criteria were enrolled. At 60 months follow-up, 90 out of 102 patients (88%) were subjectively cured, whereas 88 out of the 102 (86%) patients were objectively cured. Subjective and objective cure rates persisted during the entire study period. Uni- and multivariate analysis of possible predictive factors associated with recurrence of prolapse showed that only a preoperative point C > 0 cm and BMI ≥ 25 kg/m2 were risk factors for failure. In conclusion, our study showed that hysteropexy with anterior vaginal native tissue repair may be an effective and safe option for the treatment of anterior vaginal prolapse and concomitant stage II uterine prolapse by at least 5 years of follow-up.

Laparoscopic pectopexy with native tissue repair for pelvic organ prolapse

PURPOSE

The use of mesh for vaginal repair is currently problematic; consequently, there is increased interest in native tissue repair. Combining native tissue repair with sufficient mesh-applied apical repair might provide effective treatment. We describe the study focusing on the combination of pectopexy and native tissue repair.

METHODS

Between April 2020 and November 2021, 49 patients with symptomatic stage III or IV were treated with laparoscopic pectopexy combined with native tissue repair. The mesh was solely used for apical repair. All other clinically relevant defects were treated with native tissue repair. The perioperative parameters including surgical time, blood loss, hospital stay, and complications were recorded. The anatomical cure rate was evaluated according to the Pelvic Organ Prolapse Questionnaire (POP-Q) assessment. Validated questionnaires of the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Floor Impact Questionnaire (PFIQ-7) were recorded to evaluate the symptom severity and quality of life.

RESULTS

The mean duration of follow-up was 15 months. All domains of POP-Q, PFDI-20, and PFIQ-7 scores improved significantly after surgery. No major complications, mesh exposure, or mesh complication occurred during the follow-up period.

CONCLUSION

The overall repair concept of laparoscopic pectopexy as the core, assisted by vaginal natural tissue repair for severe pelvic organ prolapse can achieve satisfactory clinical results and improve patient satisfaction.

Management of female pelvic organ prolapse-Summary of the 2021 HAS guidelines

When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life and rule out other pelvic pathologies. The prolapse should be described compartment by compartment, indicating the extent of the externalization for each. The diagnosis of POP is clinical. Additional exams may be requested to explore the symptoms associated or not explained by the observed prolapse. Pelvic floor muscle training and pessaries are non-surgical conservative treatment options recommended as first-line therapy for pelvic organ prolapse. They can be offered in combination and be associated with the management of modifiable risk factors for prolapse. If the conservative therapeutic options do not meet the patient's expectations, surgery should be proposed if the symptoms are disabling, related to pelvic organ prolapse, detected on clinical examination and significant (stage 2 or more of the POP-Q classification). Surgical routes for POP repair can be abdominal with mesh placement, or vaginal with autologous tissue. Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse. Autologous vaginal surgery (including colpocleisis) is a recommended option for elderly and fragile patients. For cases of isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route. The decision to place a mesh must be made in consultation with a multidisciplinary team. After the surgery, the patient should be reassessed by the surgeon, even in the absence of symptoms or complications, and in the long term by a primary care or specialist doctor.

Strengthen the sacral ligament and paravagina by equilibrium control severe pelvic organ prolapse

Objective

To evaluate and analyze the clinical effect of the combination of laparoscopic sacrocolpopexy (LSC), sacral ligament fusion and vaginal suspension in the treatment of severe pelvic organ prolapse.

Methods

A total of 76 cases of patients with pelvic organ prolapse in our hospital between January 2010 to December 2020 were enrolled for research. They had been evaluated pre- and post-operative through pelvic organ prolapse quantification (POP-Q) system, Pelvic Floor Dysfunction Questionnaire Short Form (PFDI-20), Pelvic Floor Function Impact Questionnaire Short form (PFIQ-7), and the Sexual Function Questionnaire Score (PIQS-31).

Results

All 76 patients went through the procedure successfully without any complications. None of the 76 cases had relapsed. Post-operational results of PFDI-20 and PFIQ-7 were evidently lower than pre-operational results, post-operational results of PIQS-31 were higher than before operation.

Conclusions

For patients with severe pelvic organ prolapse,a balanced control of the pelvic floor centred on the preservation of the stereoscopic ring around the cervix through revascularization is significantly effective, and has no recurrence after surgery, high patient satisfaction, fewer postoperative complications. It is safe and reliable and worthy of clinical application and promotion.

Comparative study of absorbable suture and permanent suture in sacrocolpopexy: a meta-analysis and systematic review

INTRODUCTION AND HYPOTHESIS

The aim of this study was to compare the surgical results and the complications of absorbable suture (AS) versus permanent suture (PS) in sacrocolpopexy (SCP).

METHODS

We systematically searched PubMed, Embase, ClinicalTrials.gov, and the Cochrane Library Central Register of Controlled Trials for articles in which researchers compared AS with PS in SCP. The primary outcomes were the surgical success rate and suture-related complications (suture exposure/erosion, mesh erosion, and suture removal). All analyses were performed with Review Manager 5.3.

RESULTS

Four articles involving 689 patients were ultimately included. Our findings demonstrated that AS had similar surgical success rates to those of PS (OR=1.34; 95% CI, 0.60-2.96) and no significant differences in failure rates were noted between the two groups (OR=0.75; 95% CI, 0.34-1.66). Subgroup analyses in patients with anatomical failure revealed no significant differences in recurrent posterior prolapse (OR=0.33; 95% CI, 0.05-2.10) or in recurrent apical (OR=0.64; 95% CI, 0.03-13.66) or anterior prolapse (OR=0.45; 95% CI, 0.13-1.57). However, the AS group were at a lower risk of suture exposure/erosion (OR=0.18; 95% CI, 0.06-0.58) and a lower suture removal rate (OR=0.14; 95% CI, 0.03-0.61) and retreatment (OR=0.36; 95% CI, 0.16-0.82), but the mesh erosion was not significantly different (OR=1.00; 95% CI, 0.49-2.08).

CONCLUSIONS

The data showed that AS had a similar success rate, less exposure/erosion, and were less likely to be removed and require retreatment than PS, which supported the notion that AS is as effective as PS but safer.

Long-term mesh exposure after minimally invasive total hysterectomy and sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

The objective was to evaluate total and incident mesh exposure rates at least 2 years after minimally invasive total hysterectomy and sacrocolpopexy. Secondary aims were to evaluate surgical success and late adverse events.

METHODS

This extension study included women previously enrolled in the multicenter randomized trial of permanent vs delayed-absorbable suture with lightweight mesh for > stage II uterovaginal prolapse. Owing to COVID-19, women were given the option of an in-person (questionnaires and examination) or telephone visit (questionnaires only). The primary outcome was total and incident suture or mesh exposure, or symptoms suggestive of mesh exposure in women without an examination. Secondary outcomes were surgical success, which was defined as no subjective bulge, no prolapse beyond the hymen, and no pelvic organ prolapse retreatment, and adverse events.

RESULTS

A total of 182 out of 200 previously randomized participants were eligible for inclusion, of whom 106 (58%) women (78 in-person and 28 via questionnaire only) agreed to the extension study. At a mean of 3.9 years post-surgery, the rate of mesh or suture exposure was 7.7% (14 out of 182) of whom only 2 were incident cases reported after 1-year follow-up. None reported vaginal bleeding or discharge, dyspareunia, or penile dyspareunia. Surgical success was 93 out of 106 (87.7%): 13 out of 94 (13.8%) failed by bulge symptoms, 2 out of 78 (2.6%) by prolapse beyond the hymen, 1 out of 85 (1.2%) by retreatment with pessary, and 0 by retreatment with surgery. There were no serious adverse events.

CONCLUSIONS

The rate of incident mesh exposure between 1 and 3.9 years post-surgery was low, success rates remained high, and there were no delayed serious adverse events.

Surgical treatment of advanced anterior wall and apical vaginal prolapse using the anchorless self-retaining support implant: long-term follow-up

INTRODUCTION AND HYPOTHESIS

Following health notification by the FDA in 2008 of serious complications with transvaginal mesh for anterior pelvic organ prolapse, there has been a return to native tissue repairs. Earlier work with a self-retaining support (SRS) implant showed a high anatomical success rate with minimal implant-related complications over a medium-term follow-up. It is proposed that post-implant complications are more a consequence of the method of mesh anchoring rather than the implant itself. Our system incorporates an ultralight mesh with a frame that provides level I, II, and III support without the need for fixation. The first long-term outcomes of SRS implantation are presented.

METHODS

A prospective multicenter trial was conducted using two consecutive identical protocols of the use of the SRS implant in women with symptomatic anterior compartment prolapse extending their follow-up to 36 months. Anatomical success (Pelvic Organ Prolapse Quantification stage 0 or 1 or a Ba ≤ -2) was recorded along with subjective success as defined by regular quality-of-life (PFDI-20 and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire) assessments.

RESULTS

Sixty-seven patients completed 36 months of follow-up. Mean Ba measurements improved from 3.1 (-1 to 6) cm to -2.8 (-1 to -3) cm and C point from 0.4 (-8 to 6) cm to -6.9 (-10 cm to 1) cm. accumulating to a significant anatomical success rate of 94.3%. Subjective success based on question #3 of the PFDI-20, analyzed for the index surgical compartment, reached 95.7%. Post-operative complications included 2 cases of urinary retention, 1 minor frame exposure, 1 case of delayed voiding dysfunction, and 2 cases of de novo stress urinary incontinence. Untreated pre-operative second-degree Bp measurements had increased in 27% at follow-up.

CONCLUSION

The long-term outcome of the SRS implant shows an excellent subjective and objective success with minimal risk of complications or need for reintervention.

Comparing Minimally Invasive Sacrocolpopexy With Vaginal Uterosacral Ligament Suspension: A Multicenter Retrospective Cohort Study Through the Fellows' Pelvic Research Network

IMPORTANCE

Comparing one-year surgical outcomes of two widely used surgical procedures for apical suspension.

OBJECTIVES

The objective of this study is to compare anatomic outcomes after minimally invasive sacrocolpopexy (MISC) and vaginal uterosacral ligament suspension (vUSLS).

STUDY DESIGN

This was a multicenter, retrospective cohort study through the Fellows' Pelvic Research Network. Patients with ≥ stage II pelvic organ prolapse (POP) who underwent MISC or vUSLS from January 2013 to January 2016, identified through the Current Procedural Terminology codes, with 1 year or longer postoperative data were included. Patients with prior POP surgery or history of connective tissue disorders were excluded. Anatomic success was defined as Pelvic Organ Prolapse Quantification System measurements: Ba/Bp ≤ 0 or C ≤ -TVL/2. Data were compared using χ 2 or Fisher exact tests. Continuous data were compared using Wilcoxon rank sum test.

RESULTS

Three hundred thirty-seven patients underwent MISC (171 laparoscopic, 166 robotic) and 165 underwent vUSLS. The MISC group had longer operative time (205.9 minutes vs 187.5 minutes, P = 0.006) and lower blood loss (77.8 mL vs 187.4 mL; P < 0.001). Two patients (0.6%) in the MISC group had mesh exposure requiring surgical excision. Permanent suture exposure was higher after vUSLS (6.1%). At 1 year, anatomic success was comparable in the apical (322 [97%] MISC vs 160 [97%] vUSLS, P = 0.99) and posterior compartments (326 [97.6%] MISC vs 164 [99.4%] vUSLS; P = 0.28). Anterior compartment success was higher in the MISC group (328 [97.9%] vs 156 [94.9%], P = 0.04) along with longer total vaginal length (9.2 ± 1.8 vs 8.4 ± 1.5, P < 0.001).

CONCLUSION

At 1 year, patients who underwent MISC or vUSLS had similar apical support. Low rates of mesh and suture exposures, less anterior recurrence, and longer TVL were noted after MISC.

Rate of Mesh Erosion After Sacrocolpopexy With Concurrent Supracervical Compared With Total Hysterectomy: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate the effect of concomitant supracervical hysterectomy compared with total hysterectomy during abdominal sacrocolpopexy on the rate of mesh erosion by performing a systematic review and meta-analysis of the existing literature.

DATA SOURCES

From database inception through January 2022, we explored MEDLINE, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov , and Cochrane Central Register of Controlled Trials. Studies comparing the rate of mesh erosion in women undergoing abdominal sacrocolpopexy who had concomitant supracervical hysterectomy compared with total hysterectomy were included.

DATA EXTRACTION AND SYNTHESIS

Two reviewers separately ascertained studies, obtained data, and gauged study quality. The rate of mesh erosion was compared, and odds ratios (ORs) with 95% CIs were estimated.

TABULATION, INTEGRATION, AND RESULTS

Nineteen studies with 10,572 women who underwent abdominal sacrocolpopexy were identified, including 4,285 women in the supracervical group and 6,287 women in the total hysterectomy group. The overall mean postprocedure follow-up time was 30.7±15.1 months (median 12.4, range 1.5-44.2). The median (95% CI) point prevalence of mesh erosion was 0.36% (0-1.9%) in women who had supracervical hysterectomy compared with 3.8% (1.8-8.7%) in women who had total hysterectomy. The overall rate of mesh erosion in women who had supracervical hysterectomy was lower compared with women who had total hysterectomy (pooled OR 0.26, 95% CI 0.18-0.38, I 2 0%).

CONCLUSION

In women with symptomatic apical pelvic organ prolapse who undergo abdominal sacrocolpopexy with concomitant hysterectomy, supracervical hysterectomy is associated with a lower risk of mesh erosion compared with total hysterectomy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022301862.

Complications After Vaginal Vault Suspension Versus Minimally Invasive Sacrocolpopexy in Women With Elevated Body Mass Index: A Retrospective Cohort Study Using Data From the National Surgical Quality Improvement Program Database

IMPORTANCE

Overweight and obese women represent a growing share of pelvic floor reconstruction surgeons' practices. Determining perioperative risk specific to this population is essential to inform decision making regarding operative approach in this population.

OBJECTIVE

The aim of the study was to compare surgical complications among overweight and obese women undergoing apical compartment prolapse surgery by either minimally invasive abdominal or vaginal approach.

STUDY DESIGN

The American College of Surgeons National Surgical Quality Improvement Database was used to identify overweight and obese patients (body mass index ≥ 25) undergoing either minimally invasive sacrocolpopexy (MISC) or vaginal vault suspension (VVS) in the form of a sacrospinous vault fixation or uterosacral ligament fixation for pelvic organ prolapse from 2012 to 2019. Odds ratios for surgical complications, readmission, and reoperation were estimated using multivariable logistic regression.

RESULTS

Of 8,990 eligible patients, 5,851 underwent a VVS and 3,139 patients underwent MISC. There was a greater odds of any complication in the first 30 days following VVS (n = 608 [10.4%]) compared with MISC (n = 247 [7.9%]; odds ratio, 1.27; 95% confidence interval, 1.08-1.48) on multivariable analysis. Urinary tract infections (UTIs) were the most common complication and were more likely following VVS (112 (3.6%) versus 350 (6.0%), P < 0.001). When UTIs were excluded, there was no difference in complications between approaches (1.00; 95% CI, 0.82-1.22). There were no statistically significant odds of readmission, reoperation, or serious complications between approaches.

CONCLUSIONS

Vaginal vault suspension may be associated with a higher odds of any complication compared with MISC in overweight and obese women, but the rate of serious complications, readmission, and reoperation are low, and approaches were comparable when considering complications other than UTI.

Postoperative complications and pelvic organ prolapse recurrence following combined pelvic organ prolapse and rectal prolapse surgery compared with pelvic organ prolapse only surgery

BACKGROUND

There is a growing interest in combined pelvic organ prolapse and rectal prolapse surgery for concomitant pelvic floor prolapse despite a paucity of data regarding complications and clinical outcomes of combined repair.

OBJECTIVE

The primary objective of this study was to compare the <30-day postoperative complication rate in women undergoing combined POP + RP surgery with that of women undergoing pelvic organ prolapse-only surgery. The secondary objectives were to describe the <30-day postoperative complications, compare the pelvic organ prolapse recurrence between the 2 groups, and determine the preoperative predictors of <30-day postoperative complications and predictors of pelvic organ prolapse recurrence.

STUDY DESIGN

This was a multicenter, retrospective cohort study at 5 academic hospitals. Patients undergoing combined pelvic organ prolapse and rectal prolapse surgery were matched by age, pelvic organ prolapse stage by leading compartment, and pelvic organ prolapse procedure compared with those undergoing pelvic organ prolapse-only surgery from March 2003 to March 2020. The primary outcome measure was <30-day complications separated into Clavien-Dindo classes. The secondary outcome measures were (1) subsequent pelvic organ prolapse surgeries and (2) pelvic organ prolapse recurrence, defined as patients who complained of vaginal bulge symptoms postoperatively.

RESULTS

Overall, 204 women underwent combined surgery for pelvic organ prolapse and rectal prolapse, and 204 women underwent surgery for pelvic organ prolapse only. The average age (59.3±1.0 vs 59.0±1.0) and mean parity (2.3±1.5 vs 2.6±1.8) were similar in each group. Of note, 109 (26.7%) patients had at least one <30-day postoperative complication. The proportion of patients who had a complication in the combined surgery group and pelvic organ prolapse-only surgery group was similar (27.5% vs 26.0%; P=.82). The Clavien-Dindo scores were similar between the groups (grade I, 10.3% vs 9.3%; grade II, 11.8% vs 12.3%; grade III, 3.9% vs 4.4%; grade IV, 1.0% vs 0%; grade V, 0.5% vs 0%). Patients undergoing combined surgery were less likely to develop postoperative urinary tract infections and urinary retention but were more likely to be treated for wound infections and pelvic abscesses than patients undergoing pelvic organ prolapse-only surgery. After adjusting for combined surgery vs pelvic organ prolapse-only surgery and parity, patients who had anti-incontinence procedures (adjusted odds ratio, 1.85; 95% confidence interval, 1.16-2.94; P=.02) and perineorrhaphies (adjusted odds ratio, 1.68; 95% confidence interval, 1.05-2.70; P=.02) were more likely to have <30-day postoperative complications. Of note, 12 patients in the combined surgery group and 15 patients in the pelvic organ prolapse-only surgery group had subsequent pelvic organ prolapse repairs (5.9% vs 7.4%; P=.26). In the combined surgery group, 10 patients (4.9%) underwent 1 repair, and 2 patients (1.0%) underwent 2 repairs. All patients who had recurrent pelvic organ prolapse surgery in the pelvic organ prolapse-only surgery group had 1 subsequent pelvic organ prolapse repair. Of note, 21 patients in the combined surgery group and 28 patients in the pelvic organ prolapse-only surgery group reported recurrent pelvic organ prolapse (10.3% vs 13.7%; P=.26). On multivariable analysis adjusted for number of previous pelvic organ prolapse repairs, combined surgery vs pelvic organ prolapse-only surgery, and perineorrhaphy at the time of surgery, patients were more likely to have a subsequent pelvic organ prolapse surgery if they had had ≥2 previous pelvic organ prolapse repairs (adjusted odds ratio, 6.06; 95% confidence interval, 2.10-17.5; P=.01). The average follow-up times were 307.2±31.5 days for the combined surgery cohort and 487.7±49.9 days for the pelvic organ prolapse-only surgery cohort. Survival curves indicated that the median time to recurrence was not statistically significant (log-rank, P=.265) between the combined surgery group (4.2±0.4 years) and the pelvic organ prolapse-only surgery group (5.6±0.4 years).

CONCLUSION

In this retrospective cohort study, patients undergoing combined pelvic organ prolapse and rectal prolapse surgery had a similar risk of <30-day postoperative complications compared with patients undergoing pelvic organ prolapse-only surgery. Furthermore, patients who underwent combined surgery had a similar risk of recurrent pelvic organ prolapse and subsequent pelvic organ prolapse surgery compared with patients who underwent pelvic organ prolapse-only surgery.

Long-term reoperation risk after apical prolapse repair in female pelvic reconstructive surgery

BACKGROUND

Although several different apical suspension procedures are available to women with pelvic organ prolapse, data on long-term efficacy and safety profiles are limited.

OBJECTIVE

The primary aim of this study was to analyze longitudinal reoperation risk for recurrent prolapse among the 4 apical suspension procedures over 2 to 15 years. Secondary aims included evaluation of all-cause reoperation, defined as a repeated surgery for the indications of recurrent prolapse and adverse events, and total retreatment rate, which included a repeated treatment with another surgery or a pessary.

STUDY DESIGN

This was a multicenter, retrospective cohort study within Kaiser Permanente Southern California that included women who underwent sacrocolpopexy, uterosacral ligament suspension, sacrospinous ligament fixation, or colpocleisis from January 2006 through December 2018. Women who underwent concomitant rectal prolapse repair or vaginal prolapse repair with mesh augmentation were excluded. Data were abstracted using procedural and diagnostic codes through July 2021, with manual review of 10% of each variable. Patient demographics and pessary use were compared using analysis of variance or chi square tests for continuous and categorical variables, respectively. Time-to-event analysis was used to contrast reoperation rates. A Cox regression model was used to perform an adjusted multivariate analysis of the following predictors of reoperation for recurrence: index surgery, concomitant procedures, patient demographics, baseline comorbidities, and year of index surgery. Censoring events included exit from the health maintenance organization and death.

RESULTS

The cohort included 9681 women with maximum follow-up of 14.8 years. The overall incidence of reoperation for recurrent prolapse was 7.4 reoperations per 1000 patient-years, which differed significantly by type of apical suspension (P<.0001). The incidence of reoperation was lower after colpocleisis (1.4 events per 1000 patient-years) and sacrocolpopexy (4.8 events per 1000 patient-years) when compared with uterosacral ligament suspension (9 events per 1000 patient-years) and sacrospinous ligament fixation (13.9 events per 1000 patient-years). All pairwise comparisons between procedures were significant (P=.0003-.0018) after correction for multiplicity, except for uterosacral ligament suspension or uterosacral ligament hysteropexy vs sacrospinous ligament fixation or sacrospinous ligament hysteropexy (P=.05). The index procedure was the only significant predictor of reoperation for recurrence (P=.0003-.0024) on multivariate regression analysis. Reoperations for complications or sequelae (overall 2.9 events per 1000 patient-years) also differed by index procedure (P<.0001) and were highest after sacrocolpopexy (4.4 events per 1000 patient-years). The incidence of all-cause reoperation for recurrence and adverse events after sacrocolpopexy, however, was comparable to that of the other reconstructive procedures (P=.1-.4) in pairwise comparisons with Bonferroni correction. Similarly, frequency of pessary use differed by index procedure (P<.0001) and was highest after sacrospinous ligament fixation at 9.3% (43/464).

CONCLUSION

Among nearly 10,000 patients undergoing prolapse surgery within a large managed care organization, colpocleisis and sacrocolpopexy offered the most durable obliterative and reconstructive prolapse repairs, respectively. All-cause reoperation rates were lowest after colpocleisis by a large margin, but similar among reconstructive apical suspension procedures.

Contemporary Use and Techniques of Laparoscopic Sacrocolpopexy With or Without Robotic Assistance for Pelvic Organ Prolapse

Laparoscopic sacrocolpopexy with or without robotic assistance is an effective approach for the treatment of any pelvic organ prolapse when apical involvement is present.

The past 4 years have been consequential in the world of surgery to correct pelvic organ prolapse. In 2018, results of a large, multicenter randomized trial demonstrated very disappointing cure rates of traditional native tissue repairs at 5 years or more. In 2019, a vaginal mesh hysteropexy kit was removed from the market by the U.S. Food and Drug Administration only to subsequently demonstrate it provided better cure rates and similar risk profile to vaginal hysterectomy plus native tissue repair in its own 5-year study published in 2021. Meanwhile, the use and techniques of laparoscopic sacrocolpopexy with or without robotic assistance have evolved such that it is commonly adapted to treat all support defects for patients with uterovaginal or posthysterectomy prolapse. This article is intended to provide an overview of the contemporary use and techniques of laparoscopic sacrocolpopexy based on the evidence and our clinical experience.

Robot-assisted sacro(hystero)colpopexy with anterior and posterior mesh placement: impact on lower bowel tract function and clinical outcomes at mid-term follow-up

Background:

Robotic sacrocolpopexy (RSCP) is an established option for the treatment of apical, anterior, and proximal posterior compartment pelvic organ prolapses (POP). However, there is lack of evidence investigating how lower bowel tract symptoms (LBTS) may change after RSCP.

Methods:

Data from consecutive patients treated with RSCP for stage 3 or higher POP from 2012 to 2019 at a single tertiary referral center with at least 1 year of follow-up were prospectively collected and retrospectively analyzed. RSCP was performed following a standardized technique which always employed both anterior and posterior hand-shaped meshes. Outcomes were collected at follow-up and analyzed. LBTS were evaluated through the Wexner questionnaire.

Results:

Overall, 114 women underwent RSCP. Eleven were excluded for missing data, whereas 12 had insufficient follow-up. Thus, 91 (79.8%) patients were included in this cohort. Median follow-up was 42 [interquartile range (IQR), 19–62] months. Mean age was 65 ± 10 years. In our series, RSCP was mainly performed for anterior and apical/medium stage 3 POP (in 95.6% of patients). Anatomic success rate of RSCP was 97.8%, with 89 patients with POP stage 0–1 at 12-month follow-up. Two patients (2.2%) experienced POP recurrence and were treated with redo-SCP. No patient experienced clinically significant posterior vaginal wall prolapse after RSCP. When analyzing LBTS, there was no significant change in postoperative total Wexner’s score as compared to the preoperative value ( p > 0.05). However, the manual assistance subscore was statistically significantly lower within the first-year follow-up ( p = 0.04), but it spontaneously improved during the follow-up ( p = 0.12).

Conclusion:

RSCP with simultaneous placement of both anterior and posterior mesh is safe and successful to treat high-stage POP in carefully selected patients. Of note, LBTS appear unaffected by posterior mesh placement, supporting its routine use to prevent posterior POP recurrence. Larger prospective studies are needed to confirm our results.

Health Care Disparities in Surgical Management of Pelvic Organ Prolapse: A Contemporary Nationwide Analysis

OBJECTIVES

Our objective was to compare the rate of native tissue repair (NTR) versus sacrocolpopexy (SCP) and reconstructive (RECON) versus obliterative repair (OBR) for the treatment of pelvic organ prolapse (POP), evaluating for health care disparities based on race, socioeconomic, and geographic factors.

METHODS

The National Inpatient Sample database was queried for patients older than 18 years undergoing POP surgery from 2008 to 2018. Baseline demographics, comorbidity index, socioeconomic, and hospital variables were extracted. The weighted t test, Wilcoxon test, and χ2 test were used to compare the rate of (1) NTR versus SCP and (2) RECON vs OBR. Multivariate weighted logistic regression was used to compare while controlling for confounders. Reference groups were White race, Medicare patients, northeast region, small hospital size, and rural location.

RESULTS

Of 71,262 patients, 67,382 (94.6%) underwent RECON. Patients undergoing OBR were older and had a higher comorbidity score. Multivariate analysis showed the following: (1) Black, Hispanic, and other races; (2) Medicaid patients; (3) patients at urban teaching hospitals are less likely to receive RECON. Patients in the midwest were more likely to receive RECON. Among 68,401 patients, 23,808 (34.8%), and 44,593 (65.19%) underwent SCP and NTR, respectively. Hysterectomy was more common in the NTR group. Multivariate analysis showed the following:(1) Black, Hispanic, and "other" races; (2) uninsured and Medicaid patients; (3) patients in the midwest, south, and west were at higher odds of receiving NTR. Patients in large and urban hospitals were less likely to undergo NTR.

CONCLUSIONS

Racial, socioeconomic, and geographic disparities exist in surgical management for POP warranting further study to seek to eliminate these disparities.

A novel bilateral anterior sacrospinous hysteropexy technique for apical pelvic organ prolapse repair via the vaginal route: a cohort study

Background

Uterine-preserving techniques are becoming increasingly popular in the last decade. This investigation evaluates a novel hysteropexy technique using a mesh in sling-alike configuration [Splentis (Promedon, Argentina)] which is attached anteriorly to the cervix and suspended to the sacrospinous ligaments bilaterally via the vaginal route in women undergoing surgery for uterine prolapse.

Methods

This was a single-center cohort study, evaluating women who underwent transvaginal hysteropexy with Splentis for primary uterine descent. Data have been collected prospectively as part of the quality assurance system. Primary endpoint was treatment success, defined as a combined endpoint including the absence of a vaginal bulge symptom and no retreatment of apical prolapse. A validated questionnaire to evaluate quality-of-life and prolapse symptoms was utilized. Descriptive analysis was applied. Wilcoxon signed-rank test was performed to compare paired samples. The significance level was set at 5%.

Results

A total of 103 women with a median age of 68.0 [IQR 11.5] years with a median apical POP-Q stage of 3 were included. The median surgery time was 22 [IQR 12] minutes and no intraoperative complication occurred. After a median follow-up time of 17 months, treatment success was achieved in 91 (89.2%) patients and quality of life and patient report outcomes improved significantly (p < 0.001). Mesh exposure occurred in 3 (2.9%) patients. Of these, two patients required surgical revision, and one patient was treated conservatively. One patient required partial mesh removal due to dyspareunia.

Conclusion

Bilateral sacrospinous hysteropexy with Splentis offers an efficacious and safe alternative for apical compartment repair, incorporating the advantages of pelvic floor reconstruction via the vaginal route.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-022-06486-4.

Transvaginal single-port versus multi-port laparoscopic sacrocolpopexy: a retrospective cohort study

Background

Sacrocolpopexy is the gold standard treatment for apical prolapse. With the development of minimally invasive surgical techniques, the new approach of transvaginal single-port laparoscopic sacrocolpopexy (TS-LSC) has become available. However, its therapeutic effects remain unclear. The aim of this study is to compare the middle-term clinical outcomes of transvaginal single-port laparoscopic sacrocolpopexy with multi-port laparoscopic sacrocolpopexy (LSC) for apical prolapse.

Methods

We conducted a retrospective cohort study. Patients with advanced apical prolapse who underwent either TS-LSC or LSC between May 2017 to June 2019 were enrolled. Baseline demographics, perioperative results, perioperative and postoperative complications, pelvic organ prolapse quantification (POPQ) scores, pelvic floor distress inventory (PFDI-20) score and pelvic organ prolapse/urinary incontinence sexual function questionnaire (PISQ-12) score were collected at 2 years.

Results

89 subjects were analyzed: 46 in TS-LSC and 43 in LSC group. Follow-up time was 38.67 ± 7.46 vs 41.81 ± 7.13 months, respectively. Baseline characteristics and perioperative outcomes were similar except that pain score was lower (2.37 ± 0.90 vs 3.74 ± 1.05) and cosmetic score was higher (9.02 ± 0.75 vs 7.21 ± 0.89) in TS-LSC group (P < 0.05). Complication rates did not differ between groups. 3 mesh exposure in each group were noted. Recurrence rate was 2.17% in TS-LSC and 6.98% in LSC, no apical recurrence occurred. Constipation was the most common postoperative symptom. Besides, patients in TS-LSC group had better POP-Q C point (− 6.83 ± 0.54 vs − 6.39 ± 0.62, P < 0.05), and similar Aa, Ap and TVL values. Bladder and pelvic symptoms were improved in both groups, but colorectal symptoms were not relieved. There were no differences of PISQ-12 scores between groups.

Conclusion

TS-LSC was not inferior to LSC at 2 years. Patients may benefit from its mild pain, better cosmetic effect and better apical support as well as good safety and efficacy. TS-LSC is a promising considerable choice for advanced vaginal apical prolapse.

Trial registration ChiCTR2000032334, 2020-4-26 (retrospectively registered)

Sacrocolpopexy using autologous rectus fascia: Cohort study of long-term outcomes and complications

OBJECTIVE

To evaluate objective and subjective outcomes of patients who underwent sacrocolpopexy using autologous rectus fascia to provide more data regarding non-mesh alternatives in pelvic organ prolapse surgery.

DESIGN

Ambispective cohort study with retrospective and prospective data.

SETTING

A single academic medical centre.

POPULATION

Women who underwent abdominal sacrocolpopexy using autologous rectus fascia between January 2010 and December 2019.

METHODS

Patients were recruited for a follow-up visit, including completing the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse Quantification (POP-Q) examination. Demographic and clinical characteristics were collected.

MAIN OUTCOME MEASURES

Composite failure, anatomic failure, symptomatic failure and retreatment.

RESULTS

During the study period, 132 women underwent sacrocolpopexy using autologous rectus fascia. The median follow-up time was 2.2 years. Survival analysis showed that composite failure was 0.8% (95% CI 0.1%-5.9%) at 12 months, 3.5% (95% CI 1.1%-10.7%) at 2 years, 13.2% (95% CI 7.0%-24.3%) at 3 years and 28.3% (95% CI 17.0%-44.8%) at 5 years. The anatomic failure rate was 0% at 12 months, 1.4% (95% CI 0.2%-9.2%) at 2 years, 3.1% (95% CI 0.8%-12.0%) at 3 years and 6.8% (95% CI 2.0%-22.0%) at 5 years. The symptomatic failure rate was 0% at 12 months, 1.3% (95% CI 0.2%-9.0%) at 2 years, 2.9% (95% CI 0.7%-11.3%) at 3 years and 13.1% (95% CI 5.3%-30.3%) at 5 years. The retreatment rate was 0.8% (95% CI 0.1%-5.9%) at 12 months and 2 years, 9.4% (95% CI 4.2%-20.3%) at 3 years and 13.0% (95% CI 6.0%-27.2%) at 5 years.

CONCLUSION

Autologous rectus fascia sacrocolpopexy may be considered a safe and effective alternative for patients who wish to avoid synthetic mesh.

A biomechanical analysis of different meshes for reconstructions of the pelvic floor in the porcine model

Purpose

Many different surgical approaches have been established for the repair of a pelvic organ prolapse. Especially in laparoscopic surgery, it is important to generate easy surgical techniques with similar stability. This study shall simplify the choice of mesh by evaluating three polypropylene meshes regarding their biomechanical properties.

Methods

Biomechanical testing was performed in the porcine model. The meshes are fixated on porcine fresh cadaver cervices after subtotal hysterectomy. The apical part of the mesh is fixated with parallel screw clamps at the testing frame. Forty-one trials were performed overall, subdivided into four subgroups. The groups differ in mesh type and fixation method. Maximum load, displacement at failure and stiffness parameters were evaluated with an Instron 5565^® test frame.

Results

SERATEX^® E11 PA (E11) showed the highest values for maximum load (199 ± 29N), failure displacement (71 ± 12 mm) and stiffness (3.93 ± 0.59 N/mm). There was no significant difference in all three evaluated parameters between SERATEX^® B3 PA (B3) and SERATEX^® SlimSling^® with bilateral fixation (SSB). SERATEX^® SlimSling^® with unilateral fixation (SSU) had the lowest stiffness (0.91 ± 0.19 N/mm) and maximum load (30 ± 2 N) but no significant difference in displacement at failure.

Conclusion

All meshes achieved a good tensile strength, but the results of maximum load show that the E11 is superior to the other meshes. Through a bilateral fixation of SERATEX^® SlimSling^®, a simple operating method is generated without a loss of stability.

Readmission and emergency department visits after minimally invasive sacrocolpopexy and vaginal apical pelvic organ prolapse surgery

BACKGROUND

Minimally invasive pelvic reconstructive surgery is becoming increasingly common; however, data on readmission and emergency department visits within 30 days of surgery are limited.

OBJECTIVE

Our objective was to report the risk factors for 30-day readmission and emergency department visits after minimally invasive pelvic organ prolapse surgery.

STUDY DESIGN

This retrospective cohort study included all minimally invasive urogynecologic prolapse procedures with and without concomitant hysterectomy performed within a large managed healthcare organization of 4.5 million members from 2008 to 2018. We queried the system-wide medical record for current procedural terminology and International Classification of Diseases, Ninth or Tenth Revision codes for all included procedures and patient demographic and perioperative data. Our primary outcome was 30-day hospital readmission, and our secondary outcome was 30-day emergency department visits. Risk factors including demographics, surgical approach, and characteristics for 30-day outcomes were examined using odds ratios and chi-square tests for categorical variables and Wilcoxon rank sum tests for continuous variables.

RESULTS

Of the 13,445 patients undergoing prolapse surgery, 6171 patients underwent concomitant hysterectomy whereas 7274 did not. Readmission within 30 days was 2.1% for those with and 1.5% for those without a concomitant hysterectomy. Emergency department visit within 30 days was 9.5% in those with and 9.2% in those without a concomitant hysterectomy. Concomitant hysterectomy (adjusted odds ratio, 1.41; 95% confidence interval, 1.07-1.81) was associated with an increased risk of 30-day readmission. There was no difference in risk of 30-day readmission when comparing the various approaches to hysterectomy. When compared with patients who underwent sacrocolpopexy, undergoing a sacrospinous ligament suspension increased the risk (adjusted odds ratio, 2.43; 95% confidence interval, 1.22-4.70) of 30-day readmission, while undergoing uterosacral ligament suspension (adjusted odds ratio, 0.99; 95% confidence interval, 0.57-1.63) or colpocleisis (adjusted odds ratio, 1.79; 95% confidence interval, 0.50-5.24) did not in the concomitant hysterectomy subgroup, when compared with patients who underwent sacrocolpopexy, there was no difference in the risk of 30-day readmission for sacrospinous ligament suspension (adjusted odds ratio, 1.09; 95% confidence interval, 0.61-3.34), uterosacral ligament suspension (adjusted odds ratio, 1.39; 95% confidence interval, 0.61-3.34) or colpocleisis (adjusted odds ratio, 1.88; 95% confidence interval, 0.71-4.02). Similarly, sacrocolpopexy was not associated with an increased risk of emergency department visits in either subgroup. For those who had a concomitant hysterectomy, the patient factors that were associated with an increased 30-day readmission risk were hypertension (odds ratio, 1.54; 95% confidence interval, 1.03-2.31; P=.03) and chronic obstructive pulmonary disease (odds ratio, 2.52; 95% confidence interval, 1.32-4.81; P<.01). For those whose prolapse procedure did not include concomitant hysterectomy, the patient factors that were associated with an increased 30-day readmission risk were age (odds ratio, 1.05; 95% confidence interval, 1.02-1.07; P<.01) and heart failure (odds ratio, 3.26; 95% confidence interval, 1.68-6.33; P<.01).

CONCLUSION

In women undergoing minimally invasive pelvic organ prolapse surgery, sacrocolpopexy was not associated with an increased risk of 30-day readmission and emergency department visits. Clinicians may consider surgical approach and other factors when counseling patients about their risks after minimally invasive pelvic organ prolapse surgery.

Racial and ethnic differences in reconstructive surgery for apical vaginal prolapse

BACKGROUND

There is limited literature identifying racial and ethnic health disparities among surgical modalities and outcomes in the field of urogynecology and specifically pelvic organ prolapse surgery.

OBJECTIVE

This study aimed to evaluate the differences in surgical approach for apical vaginal prolapse and postoperative complications by race and ethnicity.

STUDY DESIGN

This is a retrospective cohort study of women undergoing surgical repair for apical vaginal prolapse between 2014 and 2017 using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients were eligible for inclusion if they underwent either vaginal colpopexy or abdominal sacrocolpopexy. Abdominal sacrocolpopexy cases were further divided into those performed by laparotomy and those performed by laparoscopy. Multivariable logistic regression models that controlled for age, comorbidities, American Society of Anesthesiologists physical status classification, and concurrent surgery were used to determine whether race and ethnicity are associated with the type of colpopexy (vaginal vs abdominal) or the surgical route of abdominal sacrocolpopexy. Similar models that also controlled for surgical approach were used to assess 30-day complications by race and ethnicity.

RESULTS

A total of 22,861 eligible surgical cases were identified, of which 12,337 (54%) were vaginal colpopexy and 10,524 (46%) were abdominal sacrocolpopexy. Among patients who had an abdominal sacrocolpopexy, 2262 (21%) were performed via laparotomy and 8262 (79%) via laparoscopy. The study population was 70% White, 9% Latina, 6% African American, 3% Asian, 0.6% Native Hawaiian or Pacific Islander, 0.4% American Indian or Alaska Native, and 11% unknown. In multivariable analysis, Asian and Native Hawaiian or Pacific Islander women were less likely to undergo abdominal sacrocolpopexy compared with White women (odds ratio, 0.82; 95% confidence interval, 0.68-0.99, and odds ratio, 0.56; 95% confidence interval, 0.39-0.82, respectively). Among women who underwent an abdominal sacrocolpopexy, Latina women and Native Hawaiian or Pacific Islander women were less likely to undergo a laparoscopic approach compared with White women (odds ratio, 0.68; 95% confidence interval, 0.58-0.79, and odds ratio, 0.31; 95% confidence interval, 0.1-0.56, respectively). Complication rates also differed by race and ethnicity. After a colpopexy, African American women were more likely to need a blood transfusion (odds ratio, 3.04; 95% confidence interval, 1.95-4.73; P≤.001) and have a deep vein thrombosis or pulmonary embolus (odds ratio, 2.46; 95% confidence interval, 1.10-5.48; P=.028), but less likely to present with postoperative urinary tract infections (odds ratio, 0.68; 95% confidence interval, 0.49-0.96; P=.028) than White women in multivariable regression models. Using the Clavien-Dindo classification system, Latina women had higher odds of developing grade II complications than White women in multivariable models (odds ratio, 1.25; 95% confidence interval, 1.04-1.51; P=.02).

CONCLUSION

There are racial and ethnic differences in the type and route of surgical repair for apical vaginal prolapse. In particular, Latina and Pacific Islander women were less likely to undergo a laparoscopic approach to abdominal sacrocolpopexy compared with White women. Although complications were uncommon, there were several complications including blood transfusions that were higher among African American and Latina women. Additional studies are needed to better understand and describe associated factors for these differences in care and surgical outcomes.

Serious complications and recurrences after pelvic organ prolapse surgery for 2309 women in the VIGI-MESH registry

OBJECTIVE

To assess the incidence of serious complications and reoperations for recurrence after surgery for pelvic organ prolapse (POP) and compare the three most common types of repair.

DESIGN

Prospective cohort study using a registry.

SETTING

Nineteen French surgical centres.

POPULATION

A total of 2309 women participated between 2017 and 2019.

METHODS

A multivariate analysis including an inverse probability of treatment weighting approach was used to obtain three comparable groups.

MAIN OUTCOME MEASURES

Serious complications and subsequent reoperations for POP recurrence.

RESULTS

The median follow-up time was 17.6 months. Surgeries were native tissue vaginal repairs (n = 504), transvaginal mesh placements (n = 692) and laparoscopic sacropexies with mesh (n = 1113). Serious complications occurred among 52 women (2.3%), and reoperation for POP recurrence was required for 32 women (1.4%). At 1 year the cumulative weighted incidence of serious complications was 1.8% for native tissue vaginal repair, 3.9% for transvaginal mesh and 2.2% for sacropexy, and the rates for reoperation for recurrence of POP were 1.5, 0.7 and 1.1%, respectively. Compared with native tissue vaginal repair, the risk of serious complications was higher in the transvaginal mesh group (weighted hazard ratio, wHR 3.84, 95% CI 2.43-6.08) and the sacropexy group (wHR 2.48, 95% CI 1.45-4.23), whereas the risk of reoperation for prolapse recurrence was lower in both the transvaginal mesh (wHR 0.22, 95% CI 0.13-0.39) and sacropexy (wHR 0.29, 95% CI 0.18-0.47) groups.

CONCLUSIONS

Our results suggest that native tissue vaginal repairs have the lowest risk of serious complications but the highest risk of reoperation for recurrence. These results are useful for informing women and for shared decision making.

TWEETABLE ABSTRACT

Laparoscopic sacropexy had fewer serious complications than transvaginal mesh and fewer reoperations for recurrence than vaginal repair.

Total Vaginal Hysterectomy With Uterosacral Ligament Suspension Compared With Supracervical Hysterectomy With Sacrocervicopexy for Uterovaginal Prolapse

OBJECTIVE

To compare prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension to recurrence after supracervical hysterectomy with mesh sacrocervicopexy for the primary management of uterovaginal prolapse.

METHODS

We conducted a retrospective cohort study of women undergoing uterovaginal prolapse repair at an academic center from 2009 to 2019. Women who underwent vaginal hysterectomy with uterosacral ligament suspension or laparoscopic supracervical hysterectomy with mesh sacrocervicopexy were included. The primary outcome was composite prolapse recurrence (prolapse beyond the hymen or retreatment with pessary or surgery). Secondary outcomes included mesh complications, time to recurrence, and overall reoperation for either prolapse recurrence or mesh complication. We used propensity scoring with a 2:1 ratio of sacrocervicopexy to uterosacral suspension.

RESULTS

The cohort consisted of 654 patients, of whom 228 (34.9%) underwent uterosacral suspension and 426 (65.1%) underwent sacrocervicopexy. The median follow-up was longer for the sacrocervicopexy group (230 vs 126 days, P<.001) and less than 1 year for both groups. The uterosacral group had a greater proportion of composite prolapse recurrence (14.9% [34/228] vs 8.7% [37/426], P=.02) and retreatment for recurrent prolapse (7.5% [17/228] vs 2.8% [12/426], P=.02). The uterosacral group demonstrated a shorter time to prolapse recurrence on multivariable Cox regression (hazard ratio 3.14, 95% CI 1.90-5.16). There were 14 (3.3%) mesh complications in the sacrocervicopexy group. Overall reoperation was similar between groups (4.8% [11/228] vs 3.8% [16/426], P=.51).

CONCLUSION

Total vaginal hysterectomy with uterosacral ligament suspension was associated with higher rate of, and shorter time-to-prolapse recurrence compared with supracervical hysterectomy with mesh sacrocervicopexy.

Enhanced Recovery and Same-Day Discharge After Minimally Invasive Sacrocolpopexy

OBJECTIVE

The objective of this study was to evaluate whether an enhanced recovery after surgery (ERAS) protocol was associated with a higher rate of same-day discharge after robot-assisted or laparoscopic sacrocolpopexy and to describe the safety and feasibility of same-day discharge after these procedures.

METHODS

A historical control, retrospective cohort study of women undergoing minimally invasive sacrocolpopexy comparing rates of same-day discharge before and after implementation of an ERAS protocol was conducted. Secondary outcomes were obtained by comparing women discharged the same day with those discharged postoperative day ≥1, including postoperative complications and unplanned postoperative patient encounters within 30 days of surgery. Logistic regression was performed to control for potential confounders.

RESULTS

Of the 166 women identified (83 before ERAS implementation; 83 after ERAS implementation), 43 underwent same-day discharge versus 123 admitted overnight. The rate of same-day discharge increased 28 percentage points after ERAS implementation (12% vs 40%, P < 0.01). Compared with women admitted overnight, same-day discharge women had shorter procedures (154 vs 173 minutes, P = 0.01), spent longer time in the postanesthesia care unit (130 vs 106 minutes, P = 0.01), and were more likely to be discharged with a Foley catheter (58% vs 28%, P < 0.01). After multivariable logistic regression analysis, ERAS was associated with increased odds of same-day discharge (odds ratio, 4.91; 95% confidence interval, 2.17-11.09). There were no differences in unplanned postoperative patient contacts or postoperative complications within 30 days between same-day discharge and overnight admission groups.

CONCLUSIONS

Implementation of an ERAS protocol for minimally invasive sacrocolpopexy was associated with a 3-fold increase in same-day discharge.

Current situation of complications related to reconstructive surgery for pelvic organ prolapse: a multicenter study

Introduction and hypothesis

This study aimed to investigate the evaluation and management of complications after pelvic floor reconstructive surgery for pelvic organ prolapse in China.

Methods

Complications of pelvic floor reconstructive surgery for pelvic organ prolapses from 27 institutions were reported from November 2017 to October 2019. All complications were coded according to the category-time-site system proposed by the International Urogynecological Association (IUGA) and the International Continence Society (ICS). The severity of the complications was graded by the Clavien-Dindo grading system. Four scales were used to evaluate patient satisfaction and quality of life after management of the complications: the Patient Global Impression of Improvement (PGI-I), the Pelvic Floor Impact Questionnaire Short Form (PFIQ-7), the Pelvic Organ Prolapse Symptom Score (POP-SS), and a 5-point Likert-type scale that evaluated the patient’s choice of surgery.

Results

Totally, 256 cases were reported. The occurrence of complications related to transvaginal mesh (TVM) and laparoscopic sacrocolpopexy (LSC) had a significantly longer post-surgery delay than those of native tissue repair surgery (p < 0.001 and p = 0.010, respectively). Both PFIQ-7 and POP-SS score were lower after management of complications (p < 0.001). Most respondents (81.67%) selected very much better, much better, or a little better on the PGI-I scale. Only 13.3% respondents selected unlikely or highly unlikely on the 5-point Likert-type scale.

Conclusions

The occurrence of complications related to TVM surgery and LSC had a longer post-surgery delay than native tissue repair surgery. Long-term regular follow-up was vital in complication management. Patient satisfaction with the management of TVM complications was acceptable.

Absorbable versus non-absorbable sutures for vaginal mesh attachment during sacrocolpopexy: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

The purpose of the study was to analyze anatomical and functional outcomes after sacrocolpopexy (SCP) for vaginal vault prolapse pelvic organ prolapse quantification (POPQ) II-III by random use of absorbable (Vicryl) and non-absorbable sutures (Ethibond) for vaginal mesh fixation.

METHODS

This study was designed as a two-center randomized controlled study (RCT). The primary objective was to evaluate the anatomical outcome. Success was defined when the vaginal apex (point C; POPQ) did not descend more than 50% of the total vaginal length (tvl) during Valsalva. Patients completed a pelvic examination incorporating the POPQ and questionnaires (the German pelvic floor questionnaire and the PISQ-12 questionnaire) at baseline and 6 months postsurgery. Perioperative adverse events (AE) were recorded. Sample size calculations, based on a 10% non-inferiority limit required 100 participants per group, with power = 90%.

RESULTS

In 190 out of 195 women (ETH group n = 96; VIC group n = 94) anatomical success was achieved. The relative risk of anatomical success failure in the VIC group versus the ETH group was 0.69, with a 95% confidence interval 0.12-4.02. The change in the symptom scores did not differ significantly between the ETH and the VIC group. In the ETH group, three suture penetrations into the vagina were observed, and none in the VIC group 6 months postoperatively.

CONCLUSIONS

Anatomical success after SCP for vaginal vault prolapse POPQ II-III is not affected by suture type for vaginal monofilament mesh attachment. Moreover, we did not see any differences in functional outcomes between the two groups. Three suture penetrations into the vagina were observed in the ETH group, and none in the VIC group 6 months postoperatively.

The Impact of Age on Perioperative Complications After Minimally Invasive Sacrocolpopexy

OBJECTIVE

Our aim was to compare perioperative complications between older (≥65 years), middle-age (55-64 years), and younger (<55 years) women after minimally invasive sacrocolpopexy (SCP).

METHODS

This retrospective cohort study included women undergoing SCP from 2006 to 2016 at a single academic center. Our primary outcome was the rate of perioperative complications (intraoperative and postoperative within 6 weeks of surgery), between groups. Secondary outcomes included readmission and reoperation rates.

RESULTS

There were 440 consecutive participants: 159 (36.1%) older, 160 (36.4%) middle-age, and 121 (27.5%) younger women. The overall intraoperative complication rate from SCP was 9.1%, with the most common being cystotomy (5.0%) and vaginotomy (1.8%). There were no differences in intraoperative complications between groups. Urinary tract infection (10.9%) and port-site cellulitis (3.4%) were the most common postoperative complications. For our primary outcome, younger women had a higher rate of postoperative complications compared with middle-age and older women (P < 0.001). There was no difference in postoperative complications between older and middle-aged women. In a multivariate regression controlling for comorbidity, body mass index, diabetes, smoking status, concomitant hysterectomy, and/or sling, younger women retained a higher rate of postoperative complications (odds ratio, 1.7 [1.2,2.2]). Rates of readmission (3.2%) and reoperation (0.7%) were also similar between groups.

CONCLUSIONS

The rate of perioperative complications was low with no difference in intraoperative complications. Women under 55 had a higher rate of postoperative complications compared to women age 55 to 65 years and those older than 65 years. Our results suggest that it is reasonable to offer SCP to women older than 65 years.

Suturing methods in prolapse surgery: a biomechanical analysis

INTRODUCTION

Pelvic organ prolapse is a common problem in urogynecological surgery. Abdominal and laparoscopic sacrocolpopexy is currently considered to be the gold standard of treatment. The main problem remains the anatomical point of fixation as well as how sutures are placed. We evaluated the biomechanical difference between an in-line ligament suture versus an orthogonal ligament suture and a single suture versus a continuous suture at the anterior longitudinal ligament in an in-vitro, sacrocolpopexy model.

METHODS

Biomechanical in-vitro testing was performed on human, non-embalmed, female cadaver pelvises. An Instron test frame (tensinometer) was used for load/ displacement analysis. The average patient age was 75 years. Ligament preparation yielded 15 ligaments available for testing. Recorded parameters were the ultimate load, failure displacement, and stiffness.

RESULTS

This in-vitro analysis of different suturing methods showed the difference between an orthogonal and an in-line approach to be the ultimate load. Orthogonal sutures displayed an ultimate load of 80 N while in-line suturing yielded only 57 N (p < 0.05). For the anterior longitudinal ligament, this study demonstrated that continuous suture is significantly superior to a single suture regarding failure displacement (p < 0.05).

CONCLUSION

We established baseline biomechanical parameters for the sacrospinous ligament and anterior longitudinal ligament. An orthogonal suture is superior to an in-line suture in an in-vitro model. A continuous suture is superior to a single suture at the anterior longitudinal ligament. Clinical trials might be able to evaluate whether any clinical significance can be established from these findings.

Surgical Outcomes in Urogynecology-Assessment of Perioperative and Postoperative Complications Relative to Preoperative Hemoglobin A1c-A Fellow's Pelvic Research Network Study

OBJECTIVES

Poor control of diabetes mellitus is a known predictor of perioperative and postoperative complications. No literature to date has established a hemoglobin A1c (HbA1c) cutoff for risk stratification in the urogynecology population. We sought to identify an HbA1c threshold predictive of increased risk for perioperative and postoperative complications after pelvic reconstructive surgery.

METHODS

This multicenter retrospective cohort study involving 10 geographically diverse U.S. female pelvic medicine and reconstructive surgery programs identified women with diabetes who underwent prolapse and/or stress urinary incontinence surgery from September 1, 2013, to August 31, 2018. We collected information on demographics, preoperative HbA1c levels, surgery type, complications, and outcomes. Sensitivity analyses identified thresholds of complications stratified by HbA1c. Multivariate logistic regression further evaluated the association between HbA1c and complications after adjustments.

RESULTS

Eight hundred seven charts were identified. In this diabetic cohort, the rate of overall complications was 44.1%, and severe complications were 14.9%. Patients with an AM HbA1c value of 8% or greater (reference HbA1c, <8%) had an increased rate of both severe (27.1% vs 12.8%, P < 0.001) and overall complications (57.6% vs 41.8%, P = 0.002) that persisted after multivariate logistic regression (odds ratio, 2.618; 95% confidence interval, 1.560-4.393 and odds ratio, 1.931; 95% confidence interval, 1.264-2.949, respectively). Mesh complications occurred in 4.6% of sacrocolpopexies and 1.7% of slings. The average HbA1c in those with mesh exposures was 7.5%.

CONCLUSIONS

Preoperative HbA1c of 8% or higher was associated with a 2- to 3-fold increased risk of overall and severe complications in diabetic patients undergoing pelvic reconstructive surgery that persisted after adjustments.

Comparison of Trendelenburg Angles in Vaginal, Laparoscopic, and Robotic Uterovaginal Apical Prolapse Repairs

STUDY OBJECTIVE

To compare the Trendelenburg angle used in laparoscopic uterovaginal apical prolapse repairs with the angles used in vaginal and robotic uterovaginal apical prolapse repairs.

DESIGN

Prospective, multicenter cohort study from May 2015 to December 2016.

SETTING

Two academic teaching hospitals.

PATIENTS

Sixty patients who underwent vaginal high uterosacral ligament suspension, laparoscopic sacrocolpopexy, or robotic sacrocolpopexy performed by 6 surgeons board-certified in female pelvic medicine and reconstructive surgery.

INTERVENTIONS

Measurement of Trendelenburg angle and time spent in Trendelenburg during surgery.

MEASUREMENTS AND MAIN RESULTS

Twenty patients were enrolled in each procedure group. The median maximum angle of Trendelenburg was significantly greater in the laparoscopic group (22° [20-25]) than in the vaginal group (15° [6-19]; p <.001) and the robotic group (19° [16-21]; p = .02). The participants in the laparoscopic group spent significantly more time overall in Trendelenburg (176 minutes [143-221]) than those in the robotic group (150 minutes [127-161]; p = .01) and those in the vaginal group (120 minutes [86-128]; p <.001). The participants in the laparoscopic and robotic groups spent similar amounts of time in maximum Trendelenburg (116 minutes [52-164] and 117 minutes [61-134], respectively; p = .56), whereas the participants in the vaginal group spent significantly less time in maximum Trendelenburg (10 minutes [7-38]) than those in the laparoscopic group (p <.001). The total median operative time was highest for the laparoscopic approach (211 minutes [173-270]), followed by the robotic approach (181 minutes [165-201]) and the vaginal approach (162 minutes [128-186]; p = .008).

CONCLUSION

The median maximum angle of Trendelenburg was highest in laparoscopic sacrocolpopexy-followed by robotic sacrocolpopexy-and lowest in vaginal high uterosacral ligament suspension. Patients who underwent robotic sacrocolpopexy spent less time in Trendelenburg than those who underwent the laparoscopic approach. Prolonged, steep Trendelenburg is often not required for any of the 3 surgical procedures, but a vaginal approach should be considered for those at high risk of complications from Trendelenburg position.

Postoperative complications and recurrence rates after rectal prolapse surgery versus combined rectal prolapse and pelvic organ prolapse surgery

INTRODUCTION AND HYPOTHESIS

Our primary objectives were to compare < 30-day postoperative complications and RP recurrence rates after RP-only surgery and combined surgery. Our secondary objectives were to determine preoperative predictors of < 30-day complications and RP recurrence.

METHODS

A prospective IRB-approved cohort study was performed at a single tertiary care center from 2017 to 2020. Female patients with symptomatic RP underwent either RP-only surgery or combined surgery based on the discretion of the colorectal and FPMRS surgeons. Primary outcome measures were < 30-day complications separated into Clavien-Dindo (CD) classes and rectal prolapse on physical examination.

RESULTS

Seventy women had RP-only surgery and 45 had combined surgery with a mean follow-up time of 208 days. Sixty-eight percent underwent abdominal RP repair, and 32% underwent perineal RP repair. Twenty percent had one or more complications, 14% in the RP-only group and 29% in the combined surgery group (p = 0.06). On multivariate analysis, combined surgery patients had a 30% increased risk of complications compared to RP-only surgery patients (RR = 1.3). Most of these complications were minor (14/17, 82.4%) and categorized as CD I or II, including urinary retention and UTI. Twelve percent of this cohort had RP recurrence, 11% in the RP-only group and 13% in the combined surgery group (p = 0.76). Preoperative risk factors for RP recurrence included a primary complaint of rectal bleeding (RR 5.5) and reporting stools consistent with Bristol Stool Scale of 1 (RR 2.1).

CONCLUSION

Patients undergoing combined RP + POP surgery had a higher risk of complications and equivalent RP recurrence rates compared to patients undergoing RP-only surgery.