Risk Factors for Surgical Failure and Worsening Pelvic Floor Symptoms Within 5 Years After Vaginal Prolapse Repair

Laparoscopic sacrocolpopexy with concurrent hysterectomy or uterine preservation: A metanalysis and systematic review

BACKGROUND

Literature is lacking strong evidence about comparisons of efficacy and quality of life-related outcomes between laparoscopic total and/or supracervical hysterectomy (LTH/LSCH) with laparoscopic sacrocolpopexy (LSC) and minimally invasive sacrohysteropexy (LSH).

OBJECTIVE

To summarize and compare available data on this topic providing a useful clinical tool in the treatment decision process.

SEARCH STRATEGY

We performed a systematic research of PubMed (MEDLINE), Web of Science, and Gooogle Scholar.

SELECTION CRITERIA

We included studies that compared at least one efficacy outcome (objective or subjective outcome) between LTH/LSCH with LSC and LSH. Data on surgery-related morbidities were also extracted where available.

DATA COLLECTION AND ANALYSIS

A random-effect meta-analysis was conducted reporting pooled mean differences and odds ratios (OR) between groups using Review Manager V.7.9.0.

MAIN RESULTS

We included a total of nine observational studies. LTH/LSCH with LSH was associated with a significantly higher objective success (apical compartment OR 7.95; 95% confidence interval [CI] 2.23-28.33; I2 = 0%; P = 0.001; anterior compartment OR 2.23; 95% CI 1.26-4.30; I2 = 12%; P = 0.007) and subjective success (OR 3.19; 95% CI 1.42-7.17; I2 = 39%; P = 0.005). No differences were found regarding intraoperative and postoperative complications, sexual dysfunction, and stress urinary incontinence rate after surgery. Hysteropexy showed shorter operative time and shorter hospital length with a pool mean difference of 27.37 min (95% CI 18.04-32.71; I2 = 0%; P < 0.001) and 0.7 days (95% CI 0.24-1.17; I2 = 75%; P = 0.003), respectively. Concurrent hysterectomy was not associated with a higher rate of mesh-related complications (P = 0.53). No major differences were found regarding recurrence and reoperation rate (P = 0.10 and P = 0.93, respectively).

CONCLUSIONS

LTH/LSCH with LSC has better objective and subjective outcomes in pelvic organ prolapse surgery than LSH alone, especially for apical and anterior compartments, and is not associated with higher postoperative sexual dysfunction and mesh-related complications. Adequate preoperative counseling is highly recommended in patients who desire uterine preservation.

PROSPERO REGISTRATION NUMBER

CRD42024537270.

Impact of preoperative pelvic floor muscle function on the success of surgical treatment of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The objective of this study was to identify the potential characteristics of pelvic floor muscles (PFM) in the preoperative assessment that could be associated with post-surgical prolapse severity. We hypothesized that the same variables, if identified, could be addressed in preoperative rehabilitation to improve surgical results.

METHODS

This was a single-center prospective observational study that included women who underwent surgical pelvic organ prolapse repair between 2020-2022. Genital prolapse was evaluated according to the Pelvic Organ Prolapse Quantification (POP-Q) system. All the participants underwent a PFM assessment, including a vaginal digital assessment and manometry (Peritron™ 9300 V) before surgery and at 1-, 3-, and 6-month follow-ups. Several PFM variables were recorded: vaginal resting pressure, vaginal pressure during maximal voluntary contraction (MVC), area under the curve during a 10-second MVC, ability to correctly contract the PFMs, and reflexive activation during cough and relaxation. The primary endpoint of the analysis was objective surgical success defined as POP-Q 0 or 1 at the 6-month follow-up. Additionally, a change in pelvic floor muscle function was recorded during postoperative visits.

RESULTS

A total of 106 females were included in the study. Fifty-one were lost during the 6-month follow-up, which is a major limitation of the study. None of the examined parameters evaluating PFM were associated with surgical success. No statistically significant difference was found in MVC and PFM endurance before and after surgery. Post-surgery, a significant change was observed in the vaginal resting pressure and the ability to correct PFM activation and relaxation.

CONCLUSIONS

Preoperative PFM function is not associated with surgical success 6 months after surgery.

Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry

OBJECTIVE

The aim of the study was to compare 12-month subjective and objective outcomes between 3 approaches to apical pelvic organ prolapse (POP) surgery in patients presenting with uterovaginal or posthysterectomy vaginal prolapse enrolled in the Pelvic Floor Disorders Registry for Research.

STUDY DESIGN

This was an analysis of a multicenter, prospective registry that collected both patient- and physician-reported data for up to 3 years after conservative (pessary) and surgical treatment for POP. Twelve-month subjective and anatomic outcomes for patients who underwent surgical treatment were extracted from the registry for analysis. Pelvic organ prolapse recurrence was defined as a composite outcome and compared between the 3 apical surgery groups (native tissue repair, sacrocolpopexy, colpocleisis) as well as the 2 reconstructive surgery groups (native tissue repair and sacrocolpopexy).

RESULTS

A total of 1,153 women were enrolled in the registry and 777 (67%) opted for surgical treatment, of whom 641 underwent apical repair and were included in this analysis (404 native tissue repair, 187 sacrocolpopexy, and 50 colpocleisis). The overall incidence of recurrence was as follows: subjective 6.5%, anatomic 4.7%, retreatment 7.2%, and composite 13.6%. The incidence of recurrence was not different between the 3 surgical groups. When baseline patient characteristics were controlled for, composite POP recurrence between the native tissue and sacrocolpopexy groups remained statistically nonsignificant. Concurrent perineorrhaphy with any type of apical POP surgery was associated with a lower risk of recurrence (adjusted odds ratio, 0.43; 95% confidence interval, 0.25-0.74; P = 0.002) and prior hysterectomy was associated with a higher risk (adjusted odds ratio, 1.77, 95% confidence interval, 1.04-3.03; P = 0.036).

CONCLUSION

Pelvic Floor Disorders Registry for Research participants undergoing native tissue apical POP repair, sacrocolpopexy, and colpocleisis surgery had similar rates of POP recurrence 12 months after surgery.

Association between oxidative balance score and urinary incontinence in females: results from the national health and nutrition examination survey in 2005-2018

PURPOSE

Oxidative stress plays a crucial role in the pathogenesis of urinary incontinence (UI). This study aimed to assess the association between the oxidative balance score (OBS) and UI in adult females in the United States.

METHODS

The study utilized data from the National Health and Nutrition Examination Survey database, spanning from 2005 to 2018. Weighted multivariate logistic regression, subgroup analyses, and restricted cubic spline regression were conducted to determine the odds ratio (OR) and 95% confidence intervals (95% CI) regarding the association between OBS and UI. Sensitivity analyses were performed to assess the robustness of the findings.

RESULTS

A total of 7304 participants were enrolled in this study. After adjusting for potential confounders, participants with lower OBS were found to have a higher likelihood of experiencing stress, urge, and mixed incontinence (OR, 0.986; 95% CI 0.975-0.998; p = 0.022; OR, 0.978; 95% CI 0.963-0.993; p = 0.004; and OR, 0.975; 95% CI 0.961-0.990; p = 0.001). Lifestyle factors were strongly associated with the prevalence and frequency of UI. The results remained consistent, and no significant interaction effects were observed in the subgroup analyses. The prevalence of three types of UI exhibited a nonlinear inverted U-shaped trend with increasing in OBS and dietary OBS (p for nonlinear < 0.05).

CONCLUSION

Among females, the higher the OBS, the lower the prevalence of UI. Therefore, dietary and lifestyle-related antioxidant therapy for females with UI should receive attention and be subject to further investigation.

Association Between Enlarged Genital Hiatus and Composite Surgical Failure After Vaginal Hysterectomy With Uterosacral Ligament Suspension

IMPORTANCE

The impact of a persistently enlarged genital hiatus (GH) after vaginal hysterectomy with uterosacral ligament suspension on prolapse outcomes is currently unclear.

OBJECTIVES

This secondary analysis of the Study of Uterine Prolapse Procedures Randomized trial was conducted among participants who underwent vaginal hysterectomy with uterosacral ligament suspension. We hypothesized that women with a persistently enlarged GH size would have a higher proportion of prolapse recurrence.

STUDY DESIGN

Women who underwent vaginal hysterectomy with uterosacral ligament suspension as part of the Study of Uterine Prolapse Procedures Randomized trial (NCT01802281) were divided into 3 groups based on change in their preoperative to 4- to 6-week postoperative GH measurements: (1) persistently enlarged GH, 2) improved GH, or (3) stably normal GH. Baseline characteristics and 2-year surgical outcomes were compared across groups. A logistic regression model for composite surgical failure controlling for advanced anterior wall prolapse and GH group was fitted.

RESULTS

This secondary analysis included 81 women. The proportion with composite surgical failure was significantly higher among those with a persistently enlarged GH (50%) compared with a stably normal GH (12%) with an unadjusted risk difference of 38% (95% confidence interval, 4%-68%). When adjusted for advanced prolapse in the anterior compartment at baseline, the odds of composite surgical failure was 6 times higher in the persistently enlarged GH group compared with the stably normal group (95% confidence interval, 1.0-37.5; P = 0.06).

CONCLUSION

A persistently enlarged GH after vaginal hysterectomy with uterosacral ligament suspension for pelvic organ prolapse may be a risk factor for recurrent prolapse.

Concomitant pericervical reconstruction with sacrospinous hysteropexy: Anatomical and functional results

OBJECTIVE

Pericervical ring reconstruction through restoration of pubocervical and rectovaginal fascia is performed concomitantly with sacrospinous hysteropexy as a transvaginal native tissue procedure for vaginal apical prolapse. The main goal of this study was to assess subjective and objective outcomes of sacrospinous hysteropexy and additional pericervical ring reconstruction.

MATERIALS AND METHODS

We conducted a prospective and observational study. All participants underwent sacrospinous hysteropexy and pericervical ring reconstruction and perineorrhaphy. Surgical complications, anatomical and functional efficacy were assessed.

RESULTS

108 cases were included in this study. The mean follow-up timeframe was 18.62 ± 1.22 months (minimum 12 and maximum 26 months). All parameters of subjective outcomes were improved significantly. The overall anatomic success rate was 92.59%. Mean operation time was 50.64 ± 20.8 min. No major intraoperative or postoperative complications were found. There was no statistically significant difference in demographic characteristics including age, BMI, gravidity, medical comorbidities, menopausal status, sexual activity, pretreatment prolapse severity scores between subjects with failure, and good anatomical outcome. Recurrence was mostly observed in patients with higher prolapse stages of anterior and apical compartments. Baseline POP-Q parameters Ba, C, D were significantly higher in cases with failure.

CONCLUSION

Our study disclosed sustainable anatomic and subjective outcomes of modified sacrospinous hysteropexy by means of additional pericervical ring reconstruction.

Characteristics associated with composite surgical failure over 5 years of women in a randomized trial of sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral ligament suspension

BACKGROUND

Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery in the Vaginal hysterectomy with Native Tissue Vault Suspension vs Sacrospinous Hysteropexy with Graft Suspension (Study for Uterine Prolapse Procedures Randomized Trial) trial, sacrospinous hysteropexy with graft (hysteropexy) resulted in a lower composite surgical failure rate than vaginal hysterectomy with uterosacral suspension over 5 years.

OBJECTIVE

This study aimed to identify factors associated with the rate of surgical failure over 5 years among women undergoing sacrospinous hysteropexy with graft vs vaginal hysterectomy with uterosacral suspension for uterovaginal prolapse.

STUDY DESIGN

This planned secondary analysis of a comparative effectiveness trial of 2 transvaginal apical suspensions (NCT01802281) defined surgical failure as either retreatment of prolapse, recurrence of prolapse beyond the hymen, or bothersome prolapse symptoms. Baseline clinical and sociodemographic factors for eligible participants receiving the randomized surgery (N=173) were compared across categories of failure (≤1 year, >1 year, and no failure) with rank-based tests. Factors with adequate prevalence and clinical relevance were assessed for minimally adjusted bivariate associations using piecewise exponential survival models adjusting for randomized apical repair and clinical site. The multivariable model included factors with bivariate P<.2, additional clinically important variables, apical repair, and clinical site. Backward selection determined final retained risk factors (P<.1) with statistical significance evaluated by Bonferroni correction (P<.005). Final factors were assessed for interaction with type of apical repair at P<.1. Association is presented by adjusted hazard ratios and further illustrated by categorization of risk factors.

RESULTS

In the final multivariable model, body mass index (increase of 5 kg/m2: adjusted hazard ratio, 1.7; 95% confidence interval, 1.3-2.2; P<.001) and duration of prolapse symptoms (increase of 1 year: adjusted hazard ratio, 1.1; 95% confidence interval, 1.0-1.1; P<.005) were associated with composite surgical failure, where rates of failure were 2.9 and 1.8 times higher in women with obesity and women who are overweight than women who have normal weight and women who are underweight (95% confidence intervals, 1.5-5.8 and 0.9-3.5) and 3.0 times higher in women experiencing >5 years prolapse symptoms than women experiencing ≤5 years prolapse symptoms (95% confidence interval, 1.8-5.0). Sacrospinous hysteropexy with graft had a lower rate of failure than hysterectomy with uterosacral suspension (adjusted hazard ratio, 0.6; 95% confidence interval, 0.4-1.0; P=.05). The interaction between symptom duration and apical repair (P=.07) indicated that failure was less likely after hysteropexy than hysterectomy for those with ≤5 years symptom duration (adjusted hazard ratio, 0.5; 95% confidence interval, 0.2-0.9), but not for those with >5 years symptom duration (adjusted hazard ratio, 1.0; 95% confidence interval 0.5-2.1).

CONCLUSION

Obesity and duration of prolapse symptoms have been determined as risk factors associated with surgical failure over 5 years from transvaginal prolapse repair, regardless of approach. Providers and patients should consider these modifiable risk factors when discussing treatment plans for bothersome prolapse.