A long-term cohort study of surgery for recurrent prolapse comparing mesh augmented anterior repairs to anterior colporrhaphy

The analgesic efficacy of ultrasound-guided transversus abdominis plane block vs. local anesthetic infiltration technique in major gynecologic surgery: A randomized controlled trial

Background and Aim

Transversus abdominis plane (TAP) block and local anesthetic infiltration (LAI) technique are used as part of the multimodal analgesic regimen after abdominal surgery. Postoperative opioid consumption and analgesic efficacy was compared using TAP and LAI techniques in patients undergoing gynecologic surgery in a randomized, controlled clinical trial.

Material and Methods

Total of 135 patients scheduled for major gynecological surgeries were allocated into three groups: group T received bilateral TAP block with bupivacaine 0.25%; group I received LAI with 0.25% bupivacaine with epinephrine 5 μ/mL in the peritoneum and abdominal wall, and group C was control group. Anesthesia and postoperative analgesia were standardized. Outcome measures were cumulative and rescue tramadol consumption, numerical rating score (NRS) for pain and side effects in post-anesthesia care unit (PACU) at 4, 8, 12 hours postoperatively.

Results

Tramadol consumption, need for rescue analgesia, and NRS for pain between three groups at 4, 8, and 12 hours postoperatively had no statistically significant difference (P < 0.05). In PACU, median tramadol consumption used for rescue analgesia between group T (15 (15-30)) and group C (30 (15-45)) (P = 0.035), and between group T (15 (15-30)) and group I (30 (15-52)) was statistically significant (P = 0.034). In PACU, the percentage of patients having NRS >4 on movement in group C (72%) compared to group T (46.5%) and group I (46.5%) was significant (P = 0.034). No statistically significant difference was observed in the incidence of side effects among study groups (P > 0.05).

Conclusion

Except for the immediate postoperative period, neither TAP block nor LAI had added benefit to the multimodal analgesia regimen in patients undergoing gynecological surgeries.

Ultralight type I transvaginal mesh: an alternative for recurrent severe posterior vaginal prolapse

OBJECTIVE

This study aimed to analyze the medium-term outcomes of ultralight type I mesh for postmenopausal women with recurrent severe posterior vaginal prolapse (PVP).

METHODS

All participants underwent transvaginal ultralight type I mesh repair between April 2016 and April 2021 and were followed until May 2022. Pelvic Organ Prolapse Quantification System (POP-Q) staging, mesh-related complications, Patient Global Impression of Improvement (PGI-I) scale and quality of life questionnaire responses were evaluated. The primary outcome was composite surgical success rate at the last follow-up, composite success being defined as no vaginal bulge symptoms, no POP-Q point at or beyond the hymen and no re-treatment for POP. Secondary outcomes included anatomic outcomes (POP-Q score), symptomatic relief and complications.

RESULTS

The median follow-up was 37.3 months. At the last follow-up, the composite success rate was 75%, and POP-Q scores for the vault and posterior wall and quality of life questionnaire scores were significantly improved (p < 0.01). The subjective satisfaction (PGI-I ≤ 2) rate was 83.3%. There were no mesh-related complications.

CONCLUSIONS

Ultralight mesh can achieve good clinical outcomes and substantially improve the quality of life of patients with severe recurrent PVP in the medium term, and may thus be a viable alternative for treating this condition.

Long-term surgical outcome of anterior colporrhaphy and autologous fascial sling (AFS) reinforcement for treatment of high-grade cystocoele

Objective:

To determine the long-term outcomes of anterior colporrhaphy with pubovaginal sling reinforcement in the management of high-grade cystocoele and significant urethral dysfunction.

Materials and Methods:

This is a retrospective case series. From May 2008 to October 2017, all patients who underwent concurrent anterior colporrhaphy and pubovaginal fascial sling performed by a single surgeon were included. Subjective success rates were determined from patient-reported outcomes on follow-up questionnaires using The Patient Global Impression of Improvement (PGI-I) scores. Primary outcome of this study was subjective cystocoele recurrence-free survival. Secondary outcome was complication rate.

Results:

Eighty patients were included with a median age of 63 years. All women had urethral dysfunction (type II urethral hypermobility or intrinsic sphincter deficiency) on fluoroscopic urodynamics in association with a high-grade cystocoele. The median follow-up time for recurrence of cystocoele was 36 months. The 1- and 5-year estimated cystocoele recurrence-free survival was 97.2% and 84.8%, respectively.

Conclusion:

Anterior colporrhaphy with concurrent pubovaginal sling reinforcement for treatment of high-grade cystocoele is a safe procedure with a high rate of success durable up to 5 years. The risk of complications is low with no patient developing chronic pain or rejection of the fascial graft.

Level of evidence:

Not applicable.

Early experience of transabdominal and novel transvaginal robot-assisted laparoscopic removal of transvaginal mesh

Background Mesh removal following transvaginal mesh placement has typically involved transvaginal, open pelvic, laparoscopic or a combination of approaches. Robotic pelvic mesh removal has been described in a small number of cases only. This study aims to determine the feasibility and safety of using robot-assisted laparoscopic surgery in removal of pelvic mesh via trans-abdominal and novel trans-vaginal approach. Materials and methods This is a prospective case series study on women who underwent transabdominal or transvaginal robot-assisted removal of pelvic mesh. Women were offered participation in this study if they were over the age of 18 with pelvic mesh and a clinical indication for mesh removal. Alternative surgical options including conventional open removal of mesh were discussed and offered to patients. The primary outcome of this study is the rate of successful removal of mesh and the 30-day complication rates. Ethics approval was obtained for this study. Results Thirty patients were included in this study. Median age was 62. Median operative and console time was 240 and 148 minutes, respectively. Concomitant reconstructive procedures were performed in 40% of patients. Complete or near-complete mesh removal was achieved in 83.3% of patients. For the remaining patients, partial removal of mesh was performed as planned pre-operatively. Three Clavien-Dindo grade 3b complications resulted from mesh removal: concomitant ureteric and bladder injury, omental bleed and groin wound infection. Conclusion This study presents the early experience of robotic-assisted removal of transvaginal mesh with a transvaginal or transabdominal approach and demonstrated feasibility of removal of both retropubic and transobturator MUSS as well as trans-vaginal prolapse meshes with transobturator and sacrospinous mesh arms. Further studies are required to expand understanding on the learning curve, operating times, complication rates and functional outcome of this operation.

Long-term outcome (5-10 years) after non absorbable mesh insertion compared to partially absorbable mesh insertion for anterior vaginal wall prolapse repair

Objective:

To evaluate long-term (5-10 years) outcomes of Minimally Invasive Surgical (MIS) kit insertion with Prolift^® (non-absorbable) mesh compared to the use of Prolift M^® (partially absorbable), for anterior vaginal wall prolapse repair.

Study design:

In this retrospective study we compared women undergoing MIS kit Prolift^® insertion (n=90) vs. Prolift M^® insertion (n=79) for anterior vaginal wall prolapse repair between 2006 and 2012 at our Institution. A number of 169 women fulfilled the inclusion criteria and were included in the study.

Results:

During the study period 128 women (76%) completed full follow-up; of them 58 (73%) following MIS kit Prolift^® insertion, and 70 (88%) following MIS kit ProliftM^® insertion. There was no significant difference between the Prolift® and Prolift M^® regarding parity (3.04 vs. 2.88, p=0.506), presence of hypertension (24.1% vs. 39.1%, p=0.088), diabetes mellitus (3.4% vs. 11.6%, p=0.109), or urinary stress incontinence (39.7% vs. 47.1%, p=0.475). All participants had been diagnosed with POP grade 3 or 4 before the procedure. No significant complications during the procedure or postoperative period were identified in the study groups. The follow-up period was at least five years in duration for both groups. Both groups were comparable according to questionnaires focused on function and satisfaction.

Conclusion:

Patients undergoing MIS kit Prolift^® and Prolift M^® insertion for anterior vaginal wall prolapse repair had comparable early and late postoperative outcomes. No differences in patient's function and satisfaction between the two groups were identified. According to our findings, there is no superiority to either of the two studied mesh devices.