Uterine prolapse: from antiquity to today

Sacrospinous fixation: Review of relevant anatomy and surgical technique

Apical support is an important component of pelvic floor reconstruction for pelvic organ prolapse. Sacrospinous ligament fixation is a recognized procedure for apical support. Complications from sacrospinous ligament fixation include pain (buttock and leg) and bleeding. There is some debate as to the optimal location for placement of the sacrospinous fixation sutures. This review summarizes the neuroanatomy of the coccygeus sacrospinous ligament as it pertains to the sacrospinous ligament fixation procedure. An appreciation of the neuroanatomy will lead to a better understanding of methods to reduce operative complications and improve suture placement. This paper also describes a technique for the sacrospinous fixation procedure to better assist clinicians in dissecting the connective tissue off the ligament. Removing or clearing the connective tissue off the ligament will allow critical landmarks to be easily palpated and hence a more accurate placement of sutures. This in turn may reduce the risk of perioperative complications.

Vaginal mesh hysteropexy: a review

PURPOSE OF REVIEW

Pelvic organ prolapse surgery is performed via native tissue or graft augmented repair. Graft augmentation with synthetic mesh was introduced to improve long-term surgical outcomes compared with vaginal native tissue repairs. Vaginal hysteropexy has recently become increasingly popular due to patient preference and an improved morbidity profile over hysterectomy, while maintaining comparable efficacy. As long-term outcomes remain unanswered, mesh augmentation to vaginal hysteropexy has sought to improve efficacy while minimizing complications.

RECENT FINDINGS

Recent studies have demonstrated superiority of vaginal mesh hysteropexy to vaginal hysterectomy with native tissue vault suspension. Short-term follow-up of vaginal mesh hysteropexy has also demonstrated lower blood loss and operative time with improved vaginal length compared with hysterectomy. Mesh exposure rates across studies were low and comparable to those of abdominally placed prolapse mesh.

SUMMARY

Vaginal mesh hysteropexy is a comparably well tolerated and effective surgical treatment option for women with uterovaginal prolapse. Although vaginal mesh kits are not commercially available, this procedure may be a viable treatment option in select patients.

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.

Comparison of treatment outcomes for native tissue repair and sacrocolpopexy as apical suspension procedures at the time of hysterectomy for uterine prolapse

Concomitant apical suspension should be performed at the time of hysterectomy for uterine prolapse to reduce the risk of recurrent prolapse. Native tissue repair (NTR) and sacrocolpopexy (SCP) are commonly used apical suspension procedures; however, it remains unclear which one is preferred. This study aimed to compare the treatment outcomes of NTR and SCP in terms of surgical failure, complication and reoperation rates. Surgical failure was defined as the presence of vaginal bulge symptoms, any prolapse beyond the hymen, or retreatment for prolapse. This retrospective cohort study included 523 patients who had undergone NTR (n = 272) or SCP (n = 251) along with hysterectomy for uterine prolapse and who had at least 4-month follow-up visits. During the median 3-year follow-up period, the surgical failure rate was higher in the NTR group (21.3% vs 6.4%, P < 0.01), with a low rate of retreatment in both groups. Overall complication rates were similar, but complications requiring surgical correction under anesthesia were more common in the SCP group (7.2% vs 0.4%, P < 0.01). As a result, the total reoperation rate was significantly higher in the SCP group (8.0% vs 2.6%, P = 0.02). Taken together, NTR may be a preferred option for apical suspension when hysterectomy is performed for uterine prolapse.

The international discussion and the new regulations concerning transvaginal mesh implants in pelvic organ prolapse surgery

The use of transvaginal mesh implants for POP and urinary incontinence is currently being extensively debated among experts as well as the general public. Regulations surrounding the use of these implants differ depending on the country. Although in the USA, the UK, in Canada, Australia, New Zealand, and France, transvaginal mesh implants have been removed from the market, in most mainland European countries, Asia, and South America, they are still available as a surgical option for POP correction. The aim of this review is to provide an overview of the historical timeline and the current situation worldwide, as well as to critically discuss the implications of the latest developments in urogynecological patient care and the training of doctors.

Historic transvaginal meshes and procedures: what did my patient have done?

PURPOSE OF REVIEW

Transvaginal mesh kits were widely used to treat pelvic organ prolapse for over a 10-year period in the early 2000s. Due to safety concerns and FDA regulations, these mesh kits are no longer available for use. Thus, current Obstetricians and Gynecologists are likely to encounter these meshes, but may have no previous experience or exposure to the devices making it difficult to adequately monitor, counsel, and care for patients that underwent these types of procedures. This review highlights the most commonly used transvaginal mesh kit types, provides insight into signs and symptoms related to transvaginal mesh complications, and provides guidance for management of mesh complications.

RECENT FINDINGS

Not all transvaginal mesh will give rise to a complication. If complications do occur, treatment options range from conservative observation to total mesh excision. Management must be customized to an individual patient's needs and goals.

SUMMARY

Transvaginal mesh kits promised increased durability of surgical repair for pelvic organ prolapse. Safety concerns over time caused these kits to no longer be available for use. Practicing Obstetricians and Gynecologists should be aware of the history of transvaginal mesh and the signs and symptoms of mesh complications.

The effect of diagnosis-related group payment system on the quality of medical care for pelvic organ prolapse in Korean tertiary hospitals

PURPOSE

To assess changes in clinical practice patterns after implementing diagnosis-related group (DRG) payment system in July 2013 and its effect on the quality of care for pelvic organ prolapse (POP).

MATERIALS AND METHODS

Using the 2011-2016 administrative database from National Health Insurance claim data, we reviewed medical information of 7362 patients who underwent hysterectomies for POP in Korean tertiary hospitals. We compared changes in several variables including length of stay, concomitant procedures, outpatient visits and readmission within 30 days after discharge, and retreatment for POP or stress urinary incontinence within postoperative 1 year before and after DRG system.

RESULTS

After the introduction of DRG system, the average length of stay decreased (7.74 ± 2.88 to 6.63 ± 2.18 days, p<0.001) without increasing readmission rates. However, the number of outpatient visits increased (2.78±2.33 to 2.98±2.47, p<0.001). Regarding concomitant procedures, the rates of colpopexy and midurethral slings significantly decreased (7.87% and 9.84% to 4.93% and 2.93%, respectively, all p<0.001). Even though there was no difference in the reoperation rates, pessary insertion for recurrent POP significantly increased after the introduction of DRG system (0.10% to 0.38%, p = 0.015).

CONCLUSION

The implementation of DRG in Korean tertiary hospitals has led to increase of outpatient visits and reduced surgical management for POP, which indicates that the uniform application of DRG influences the quality of care for POP patients.

Management of Occult Urinary Incontinence with Prolapse Surgery

PURPOSE OF REVIEW

The purpose of this paper is to review (1) the epidemiology and pathophysiology of pelvic organ prolapse (POP) and occult stress urinary incontinence (SUI), (2) examine the data on combined operative management of POP and occult SUI, (3) discuss the approaches to clinical decision making, and (4) present future therapies.

RECENT FINDINGS

Prospective data on many approaches to concomitant treatment of prolapse and occult stress urinary incontinence, such as minimally invasive sacrocolpopexy and midurethral sling, or older approaches that have regained favor among patients and clinicians wishing to avoid synthetic mesh, such as native tissue prolapse repair and pubovaginal sling, are limited. Safe durable treatments with absorbable graft materials that promote a beneficial host response are intriguing but may be far from clinical implementation. Stem cell therapy for the treatment of stress urinary incontinence has demonstrated benefit in phase I/II trials but has not been studied in the setting of concomitant treatment of occult SUI with POP surgery and remains in the preclinical phase for the treatment of POP. A personalized approach to concomitant SUI surgery that incorporates individual risk assessment as well as informed patient preferences likely optimizes the risk/benefit ratio and patient satisfaction. Novel therapies, including graft materials and cellular therapies that stimulate a regenerative response, may improve or maintain continence outcomes while mitigating risk and alter the approach to both POP and SUI surgery.

Current trends and future perspectives in pelvic reconstructive surgery

Pelvic organ prolapse is a prevalent disorder with a high lifetime incidence of surgical repair. Pelvic organ prolapse surgery has greatly evolved over the past years, and pelvic floor reconstructive surgeons are faced with a vast array of treatment options for their patients. Our review article illustrates the current trends and future perspectives for the surgical treatment of pelvic organ prolapse.

Minimally invasive surgery in pelvic floor repair

PURPOSE OF REVIEW

To review the use and efficacy of minimally invasive surgery in pelvic organ prolapse (POP) repair. This review summarizes surgical options for management of POP with special emphasis on minimally invasive surgical approach and discusses the recent experience and feasibility of integrating robot-assisted technology.

RECENT FINDINGS

Minimally invasive approaches have equal efficacy and less morbidity than laparotomy for POP repair, particularly apical prolapse. Robotics may facilitate the rate of minimally invasive surgery for POP repair with greater cost and as yet no proven superiority for conventional laparoscopy.

SUMMARY

Minimally invasive surgery is the preferred approach to POP repair. Conventional laparoscopic or robotic sacral colpopexy is recommended for apical defect and procidentia.

Sacrospinous hysteropexy: review and meta-analysis of outcomes

INTRODUCTION

Sacrospinous hysteropexy is a uterine-preserving procedure for treatment of apical prolapse. We present a literature review evaluating the sacrospinous hysteropexy procedure and its current place in the surgical management of pelvic organ prolapse. Additionally, to assess the efficacy of the procedure, we performed a meta-analysis of studies comparing sacrospinous hysteropexy to vaginal hysterectomy and repair in terms of anatomical outcomes, complications, and repeat surgery.

METHODS

Major literature databases including MEDLINE (1946 to 2 April 2016), Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), and Embase (1947 to 2 April 2016) were searched for relevant studies. We used Cochrane Collaboration's Review Manager software to perform meta-analysis of randomized controlled studies and observational studies.

RESULTS

Vaginal sacrospinous hysteropexy was first performed in 1989 and is similar in technique to sacrospinous colpopexy. Two randomized controlled trials and four cohort studies (n = 651) were included in the meta-analysis. Apical failure rates after sacrospinous hysteropexy versus vaginal hysterectomy were not significantly different, although the trend favored vaginal hysterectomy [odds ratio (OR) 2.08; 95% confidence interval (CI) 0.76-5.68]. Rates of repeat surgery for prolapse were not significantly different between the two groups (OR 0.99; 95% CI 0.41-2.37). The most significant disadvantage of uterine-preservation prolapse surgery when compared with hysterectomy is the lack of prevention and diagnosis of uterine malignancy.

CONCLUSION

Sacrospinous hysteropexy is a safe and effective procedure for pelvic organ prolapse and has comparable outcomes to vaginal hysterectomy with repair.