Sacrospinous ligament fixation for pelvic organ prolapse in the era of vaginal mesh kits

High Uterosacral Ligaments Suspension for Post-Hysterectomy Vaginal Vault Prolapse Repair

Background and Objectives: Uterosacral ligaments (USLs) suspension is a well-studied, safe, and long-lasting technique for central compartment correction. Preliminary clinical experiences showed encouraging data for this technique, also for post-hysterectomy vaginal vault prolapse surgical treatment. However, up-to-date evidence for post-hysterectomy vaginal vault prolapse repair through high uterosacral ligaments suspension is limited. Consequently, with this study, we aimed to assess the efficiency, complications frequency, and functional results of native-tissue repair through USLs in vaginal vault prolapse. Materials and Methods: This was a retrospective study. Women with symptomatic vaginal vault prolapse (≥stage 2) who underwent surgery with transvaginal native-tissue repair by high uterosacral ligaments were included. Patient characteristics, preoperative assessment, operative data, postoperative follow-up visits, and re-interventions were collected from the hospital's record files. High uterosacral ligament suspension was performed according to the technique previously described by Shull. A transverse apical colpotomy at the level of the post-hysterectomy scar was performed in order to enter the peritoneal cavity. USLs were identified and transfixed from ventral to dorsal with three absorbable sutures. Sutures were then passed through the vaginal apex and tightened to close the transverse colpotomy and suspend the vaginal cuff. At the end of the surgical time, a diagnostic cystoscopy was performed in order to evaluate ureteral bilateral patency. Using the POP-Q classification system, we considered an objective recurrence as the descensus of at least one compartment ≥ II stage, or the need for a subsequent surgery for POP. The complaint of bulging symptoms was considered the item to define a subjective recurrence. We employed PGI-I scores to assess patients' satisfaction. Results: Forty-seven consecutive patients corresponding to the given period were analyzed. No intraoperative complications were observed. We observed one postoperative hematoma that required surgical evacuation. Thirty-three patients completed a minimum of one-year follow-up (mean follow-up 21.7 ± 14.6 months). Objective cure rate was observed in 25 patients (75.8%). No patients required reintervention. The most frequent site of recurrence was the anterior compartment (21.2%), while apical compartment prolapse relapsed only in 6% of patients. An improvement in all POP-Q parameters was recorded except TVL which resulted in a mean 0.5 cm shorter. Subjective recurrence was referred by 4 (12.1%) patients. The mean satisfaction assessed by PGI-I score was 1.6 ± 0.8. Conclusion: This analysis demonstrated that native-tissue repair through high USL suspension is an effective and safe procedure for the treatment of post-hysterectomy vaginal vault prolapse. Objective, subjective, functional, and quality of life outcomes were satisfactory, with minimal complications.

Manometric comparison of anorectal function after posterior vaginal compartment repair with and without mesh

Background:

Although repair augmented with mesh has been proved its priority in anatomical and functional recovery after anterior compartment reconstruction, the data about posterior compartment are scarce. The aim of this study was to compare bowel functional outcome of posterior vaginal compartment repair with and without mesh in patients with pelvic organ prolapse (POP).

Methods:

This was a prospective, double-blind, clinical pilot study of 22 postmenopausal women with symptomatic POP (overall POP-quantification [POP-Q] Stage III-IV) who underwent total pelvic floor reconstruction. Patients were grouped according to the use of mesh for posterior vaginal compartment repair: A mesh group and a nonmesh group. POP-Q stage, the pelvic floor impact questionnaire short form-7 (PFIQ-7) and anorectal manometry were evaluated before and 3 months after surgery. Anatomical success was defined as POP-Q Stage II or less. A t-test was used to compare preoperative with postoperative data in the two groups.

Results:

Totally, 17 (71%) were available for the follow-up. POP-Q measurements improved significantly compared to baseline (P < 0.05) in both groups. No recurrence was observed. Subjects in both groups reported improvement in pelvic floor symptoms, and there was no significant difference in the PFIQ-7 score between groups at follow-up (P > 0.05). Compared with baseline, the nonmesh group exhibited a statistically significant decrease in anal residual pressure, a significant increase in the anorectal pressure difference during bowel movement, and a reduced rate of dyssynergia defecation pattern (P < 0.05).

Conclusions:

Provided there is sufficient support for the anterior wall and apex of vagina with mesh, posterior compartment repair without mesh may be as effective as repair with mesh for anatomical recovery while providing better anorectal motor function.

A new reusable suturing device for vaginal sacrospinous fixation: feasibility and safety study

OBJECTIVE

We sought to evaluate the feasibility and safety of SeraPro(®) (Serag-Wiessner, Germany), an innovative reusable suturing device for vaginal sacrospinous ligament fixation.

STUDY DESIGN

We reviewed the electronic files of all women who underwent vaginal sacrospinous ligament fixation with SeraPro(®) for apical pelvic floor prolapse, with or without mesh implant, performed between April 2013 and September 2013. Preoperative demographic, clinical, operative and postoperative data were analyzed. The women were interviewed and examined before the procedure, at one month postoperatively and tele-interviewed again after three months.

RESULTS

Overall, 88 women were included in the study. Fifty-three patients (60.2%) had additional anterior mesh placement, 42 (47.7%) had posterior mesh, and 16 (18.2%) had both anterior and posterior mesh insertion. Five patients (5.7%) had no mesh implant. Sixteen patients (18.2%) had an additional mid-urethral sling for the treatment of stress urinary incontinence. No significant technical difficulty was recorded at the procedures. None of the patients had significant long-term morbidity. The mean 3-month follow-up demonstrated significant anatomical and functional improvement.

CONCLUSIONS

The SeraPro(®) reusable suturing device is a feasible and safe tool for sacrospinous ligament fixation during vaginal pelvic floor reconstruction.

Modern role of sacrospinous ligament fixation for pelvic organ prolapse surgery--a systemic review

Pelvic organ prolapse (POP) is a common condition in women. Women with POP often experience pelvic discomfort, urinary and fecal problems, sexual dysfunction, and an overall decrease in their quality of life. Surgical treatment is a feasible option if conservative management fails. Various surgical techniques have been proposed to correct POP with or without the use of graft material. Owing to recent U.S. Food and Drug Administration warnings about mesh-related complications, sacrospinous ligament fixation (SSF), as a traditional vaginal procedure, may play an important role again. To answer this question and evaluate quantitatively the efficacy of SSF in POP, we conducted a systemic review of the available data about SSF and POP. Interventions had to include SSF as a point of attachment. To eliminate confounding bias and effect modification, at least one arm must include SSF without mesh or graft. All follow-up periods were allowed. Information on the following parameters was extracted and entered into a database: study design, type of intervention, number of patients, follow-up in months, cure rate, recurrence rate, intra/postoperative complications, and/or uni/bilateral, preventive/therapeutic, or concomitant procedures. Published papers from the years 1995 to 2011 were selected for analysis.

Transforming growth factor β 1 gene expression during vaginal vs cutaneous surgical woundexpression during vaginal vs cutaneous surgical wound healing in the rabbit

INTRODUCTION AND HYPOTHESIS

Reconstructive pelvic surgery outcome is closely related to the vaginal and pelvic wound healing processes. Transforming growth factor beta 1 (TGF-β1) is a principal mediator of wound repair in dermal tissue. We sought to assess this factor's expression in vaginal and dermal surgical wound repair in the rabbit.

METHODS

We excised bilateral 6-mm full-thickness circular segments from the abdominal skin and vagina in 36 New Zealand White (NZW) nulliparous female rabbits. Animals were sacrificed before, on the day of, and 4, 7, 10, 14, 21, 28, and 35 days after tissue wounding, and their wounds were assessed for surface area and TGF-β1 gene transcription by real-time polymerase chain reaction (PCR).

RESULTS

In both the abdominal skin and vagina, TGF-β1 gene transcription increased immediately after tissue injury, reaching maximal levels on days 4-7, and decreased shortly thereafter, attaining minimal values on day 35. A significant correlation between TGF-β1 expression and the wound's closure rate was found in both tissues.

CONCLUSIONS

TGF-β1 gene transcription significantly correlates with the surgical vaginal and dermal wound closure rate, implying that this factor is involved in the process of wound repair in both tissues.

Expression of platelet-derived growth factor-B mRNA during vaginal vs. dermal incisional wound healing in the rabbit

OBJECTIVE

The outcome of pelvic reconstructive surgery is largely dependent on the vaginal wound healing process, but this process has not yet been fully elucidated. Platelet-derived growth factor (PDGF) is an important mediator of the wound healing process in cutaneous tissue. We sought to compare PDGF-B mRNA expression in vaginal versus cutaneous incisional wound healing in a rabbit model.

STUDY DESIGN

Bilateral 6 mm full-thickness circular segments were excised from the vagina and abdominal skin in 36 New Zealand-White female rabbits. Animals were euthanized sequentially before, on the day of and 4, 7, 10, 14, 21, 28 and 35 days after wounding. Their wounds were evaluated for surface area and PDGF-B mRNA expression using real time PCR.

RESULTS

In both tissues PDGF-B mRNA expression increased constantly after wounding, reaching peak levels on day 10, and declined immediately thereafter, reaching minimal values on day 21. In both tissues, the expression of PDGF-B mRNA significantly correlated with the wound closure rate.

CONCLUSION

PDGF-B mRNA expression significantly correlates with incisional vaginal and cutaneous wound closure, suggesting that this factor plays an important role in the wound healing process of both tissues.