Risk factors for pelvic organ prolapse recurrence following colpocleisis: A meta-analysis

BACKGROUND

Studies aimed to assess risk factors for pelvic organ prolapse (POP) recurrence following colpocleisis with nonconclusive results.

OBJECTIVE

To investigate risk factors for POP recurrence following colpocleisis.

SEARCH STRATEGY

MEDLINE, PUBMED, Embase, Web of Science, and Cochrane databases were systematically searched.

SELECTION CRITERIA

Experimental and non-experimental studies investigating POP recurrence following colpocleisis.

DATA COLLECTION AND ANALYSIS

We assessed the association between preoperative and postoperative physical examination findings, demographics and medical history, and the risk of recurrence following colpocleisis.

MAIN RESULTS

A total of 954 studies were identified, of which five studies comprising 2978 patients were eligible for analysis. Both preoperative and postoperative genital hiatus length were significantly longer in the recurrence group (mean difference [MD] 0.48, 95% confidence interval [CI] 0.01-0.94, P = 0.04, I2  = 0% and MD 1.15, 95% CI 0.50-1.81, P = 0.005, I2  = 0%; respectively). Preoperative total vaginal length (TVL) did not differ between groups (MD 0.05, 95% CI -0.40 to 0.50, P = 0.83, I2  = 6%), postoperative TVL was found significantly longer in the recurrence group (MD 0.07, 95% CI -0.03 to 1.38, P = 0.04, I2  = 68%). Both preoperative and postoperative perineal body did not differ between groups. Women with a previous POP surgery were more likely to experience recurrence following colpocleisis (relative risk 2.09, 95% CI 1.18-3.69, P = 0.01, I2  = 0%). Patient's age and previous hysterectomy did not affect recurrence rates.

CONCLUSION

Wider preoperative and postoperative genital hiatus as well as longer post-operative TVL and previous POP surgery were associated with a higher risk for recurrence following colpocleisis, highlighting the importance of appropriate patient selection and surgical technique in minimizing this risk.

Does variation of surgical technique affect native tissue anterior pelvic organ prolapse repair outcomes?

INTRODUCTION AND HYPOTHESIS

The Variation in Surgical Technique study (VaST), demonstrated the large variation in surgical techniques used in native tissue (NT) anterior pelvic organ prolapse (POP) repairs. However, there are few comparative studies of different surgical techniques. This study was aimed at exploring whether surgical technique influenced the outcomes of NT anterior POP repairs.

METHODS

The surgical techniques of 22 consultant surgeons performing NT anterior POP repairs were filmed and categorised. These surgeons performed 809 anterior repairs within the PROlapse Surgery: Pragmatic Evaluation and randomised Controlled Trial (PROSPECT). Logistical regression models were used to determine the influence of the different surgical techniques on subjective and objective outcomes, using data collected during PROSPECT.

RESULTS

In adjusted multivariate linear regression models, fascial-flap repair was associated with an improved subjective outcome (POP-SS) compared with midline plication (β = -2.50 [-4.42 to -0.57]; p = 0.01). At 12 months, separate fascial defect repair was associated with a poorer objective outcome than midline plication (OR 6.06 [1.82-3.52], p = 0.006). At 24 months, deep dissection was associated with a poorer POP-SS than superficial dissection (0.32-2.60, p = 0.0). Continuous-locking closure of the skin was also associated with improved POP-SS compared with continuous non-locking closure (12 months: β = -1.94 [-3.42 to -0.45], p = 0.01).

CONCLUSION

Surgical technique may influence the outcome of native tissue anterior POP repairs. Our results should not change practice but inform future research; to develop methods of explicitly recording surgical techniques and allow confirmation of the effect of these aspects of technique on outcome.

Prospective Study on the Use of Endo-Stapler for Enclosed Colpotomy to Prevent Tumor Spillage in Gynecologic Oncology Minimally Invasive Surgeries

Background and Objectives

This is a prospective trial of the endo-stapler application for vaginal closure before colpotomy in cases of carcinoma endometrium and carcinoma cervix, managed by minimally invasive surgery with due consideration of its surgical technique and short-term oncologic follow-up outcomes.

Methods

This was a prospective, single center study completed between March 1, 2020 and December 31, 2022. A total of 62 patients (43 cases of carcinoma endometrium and 19 cases of carcinoma cervix) were recruited for the study. Oncologic survival outcomes at the end of 1 and 2 years were documented.

Results

There were no major intraoperative bowel, urinary, or vascular injuries. None of the cases required conversion to laparotomy peroperatively. Our study had 8 patients with carcinoma endometrium (8/43) and 7 patients of carcinoma cervix (7/19) who have completed 24 months of follow-up without any recurrence to date.

Conclusion

Endo-stapler application for enclosed colpotomy to prevent tumor spillage is a futuristic step in gynecologic oncology cases managed by laparoscopy.

Laparotomic radical hysterectomy versus minimally invasive radical hysterectomy using vaginal colpotomy for the management of stage IB1 to IIA2 cervical cancer: Survival outcomes

This study compared survival outcomes for patients with stage IB1 to IIA2 (International Federation of Gynecology and Obstetrics stage 2009) cervical cancer who underwent open radical hysterectomy (ORH) versus those who underwent minimally invasive radical hysterectomy (MIRH) using vaginal colpotomy (VC).Data for 550 patients who were diagnosed with cervical cancer at our institution during the period August 2005 to September 2018 was retrospectively reviewed. Of these, 116 patients who underwent radical hysterectomy (RH) were selected after applying the exclusion criteria. All MIRH patients underwent VC. Clinicopathological characteristics and survival outcomes between the ORH and MIRH groups were compared using appropriate statistical testing.Ninety one patients were treated with ORH and 25 with MIRH during the study period. Among the MIRH patients, 18 underwent laparoscopy-assisted radical vaginal hysterectomy and 7 underwent laparoscopic RH. Preoperative conization was performed more frequently in MIRH patients than in ORH patients (44% vs 22%, respectively, P = .028). The incidence of lymph node invasion was higher in the ORH group than in MIRH group (37.4% vs 12.0% respectively; P = .016). Following RH, ORH patients underwent adjuvant treatment more frequently than MIRH patients (71.4% vs 56.0%, respectively, P = .002). There were no significant differences between ORH and MIRH patients for either progression-free survival (PFS) (91.3% vs 78.7%, respectively; P = .220) or 5-year overall survival (OS) (96.6% vs 94.7%, respectively, P = .929). In univariate analysis, lympho-vascular space invasion was the only clinicopathological feature associated with decreased PFS. No other clinicopathological factors was significantly associated with PFS or OS in univariate and multivariate analyses.Despite a higher incidence of unfavorable prognostic factors in ORH patients, their survival outcomes were not different to those of MIRH patients with VC.

Evaluation of the distance from the anterior cervicovaginal junction to the anterior peritoneal reflection for anterior colpotomy during vaginal hysterectomy in Korean women

This study aimed to know the distance of the cervicovaginal junction (CVJ) to the anterior peritoneal reflection (APR) as measured in surgical specimens, and assess the distance between the CVJ and APR to ensure safe anterior colpotomy for vaginal hysterectomy among Korean women.Patients who underwent vaginal hysterectomy were included in the analysis. According to the presence of pelvic organ prolapse or menopausal status, the distance from the CVJ to the APR was assessed preoperatively through transvaginal ultrasonography (TV-US), as well as intraoperatively using surgical specimens. The intraclass correlation coefficient was used to determine the reliability between 2 measurements.In total, 171 patients were included. The median distance from the CVJ to the APR measured on TV-US was 19.8 (3.3-41.3) mm. Meanwhile, the median distance from the CVJ to the APR measured using the surgical specimen was 26.0 (12.0-55.0) mm. The intraclass correlation coefficient for the absolute agreement between 2 measurements was 0.353 (95% confidence interval: 0.002-0.570; P < .001), which is indicative of poor reliability. The median distance from the CVJ to the APR measured using the surgical specimen did not differ significantly between the 2 groups according to pelvic organ prolapse (26.0 [12.0-55.0] vs 27.5 [17.0-55.0] mm, P = .076] and menopausal status (27.0 [15.0-55.0] vs 26.0 [12.0-55.0] mm, P = .237).TV-US does not an accurately measure the dissection plane length from the CVJ to the APR during anterior colpotomy. During vaginal hysterectomy, the median distance from the CVJ to the APR measured using the surgical specimen was 26 (12.0-55.0) mm, which can help decrease surgical complications.

Anterior colporrhaphy: a standard operation? Systematic review of the technical aspects of a common procedure in randomized controlled trials

INTRODUCTION

Anterior colporrhaphy (AC) is considered a standard procedure and is performed all over the world. However, not a single step of the procedure has ever been truly standardized and the rates of failure show a wide range in the literature from 0% up to 92%. The aim of this systematic review was to evaluate the differences in technique and procedure worldwide.

METHODS

We performed a systematic literature search up to March 2016 using the MeSH terms "(anterior AND (colporrhaph* or colporhaph* or repair* or cystocel*)" using Preferred Reporting Items for Sytematic Reviews and Meta-Analyses (PRISMA). Only randomized controlled trials (RCT) were included in the systematic review. A 14-point checklist was used to assess the quality of surgery undertaken in each RCT.

RESULTS

Forty RCTs from all over the world were included in the review. The indication for AC was urinary incontinence and/or pelvic organ prolapse. A detailed description of colporrhaphy was not provided even in the well-conducted RCTs. The review showed differences in each step of the procedure, in perioperative care, in anesthesia and in surgeon' experience.

CONCLUSION

Our results highlight the problems concerning AC with the great range in postoperative outcomes. There is diversity in the anatomical structures used in the repair, in perioperative care and in the procedure itself.

Introduction of a Novel Modification in Laparoscopic Hysterectomy: The Bakay Technique

The last step of laparoscopic hysterectomy when the surgeon attempts to remove the uterus and close the vaginal cuff (colpotomy and cuff closure) is considered the most challenging part of the operation, and the procedure involves a steep learning curve for surgeons. Although various methods have been described and reviewed on vaginal cuff closure in laparoscopic hysterectomy, this study is the first to describe placing a single continuous running purse-string suture using the uterine manipulator to maintain a safe distance between adjacent structures while facilitating the closure before colpotomy.

Comparing two Uterine Manipulators During Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

STUDY OBJECTIVE

To compare 2 different types of uterine manipulators (i.e., tight fitting vs loose fitting) used for total laparoscopic hysterectomy (TLH).

DESIGN

A randomized controlled trial. The primary end points were time for colpotomy, time from skin incision to detachment of the uterus, and histologic assessment of thermal damage to the vagina (Canadian Task Force classification I).

SETTING

A university teaching hospital.

PATIENTS

All consecutive women scheduled for TLH from May 2014 to December 2015. Patients were excluded if pregnancy or malignancy was suspected or uterine size exceeded 20 weeks' gestation.

INTERVENTIONS

Patients were randomized to undergo TLH with 1 of the following uterine manipulators: (1) Colpo-Probe Vaginal Fornix Delineator (Cooper Surgical, Inc, Trumbull, CT) or (2) Hohl manipulator (KARL STORZ AG, Tuttlingen, Germany).

MEASUREMENTS AND MAIN RESULTS

A total of 91 patients, 49 in the Hohl manipulator group and 42 in the Colpo-Probe group, were included in the final analysis. There was no difference in patient characteristics, uterine weight, or estimated blood loss. The median time for insertion of the manipulator (2 minutes [interquartile range (IQR), 2-5 minutes] vs 6 minutes [IQR, 5-7], p < .001), the median time from skin incision to detachment of the uterus (55 minutes [IQR, 41-70] vs 65 minutes [IQR, 58-79], p = .004), and the median time for colpotomy (7 minutes [IQR, 5-10] vs 12 [IQR, 8-17], p < .001) were shorter with the Hohl manipulator. Thermal damage to the vagina varied greatly and ranged from 32 μm to 5232 μm but was not significantly different between groups (median maximum thermal damage = 1043 μm [IQR, 682-1934] vs 1522 μm [IQR, 884-2144], p = .211).

CONCLUSION

Use of the Hohl manipulator results in a shorter operative time from skin incision to detachment of the uterus during TLH. Although the colpotomy time is shorter using the Hohl manipulator, this did not translate to less thermal damage to the vaginal cuff. Further studies comparing uterine manipulators are warranted to find the optimal instrument for ease of surgery and decreased thermal spread.

Vaginal cuff dehiscence after hysterectomy

OBJECTIVE

To determine the incidence of vaginal cuff dehiscence (VCD) among women undergoing hysterectomy according to clinico-surgical factors including surgical route, and to describe patient characteristics associated with VCD.

METHODS

In a retrospective study, the medical records of all women who underwent hysterectomy between January 2005 and March 2011 at a university teaching hospital in Seoul, Republic of Korea, were reviewed. The incidence of VCD was determined in relation to the following factors: patient age, hysterectomy route, indication for hysterectomy, and extent of resection (either simple or radical hysterectomy).

RESULTS

Among 9973 hysterectomies, 37 (0.37%) cases of VCD were identified. The incidence of VCD was significantly higher after abdominal hysterectomy (0.6%) than after laparoscopic (0.2%) or vaginal (0.4%) hysterectomy (P=0.016). Compared with laparoscopic approaches, abdominal hysterectomy was associated with a higher risk of VCD (odds ratio, 2.735; 95% confidence interval, 1.380-5.420). However, there was no significant difference in the incidence of VCD according to surgical indication or extent of resection.

CONCLUSION

Laparoscopic hysterectomy was found to be associated with a lower risk of VCD compared with abdominal hysterectomy. The lower risk is probably related to the different techniques used for colpotomy and cuff closure.

Optimization strategies for colpotomizer technology during total laparoscopic hysterectomy

As technology has evolved, so has the ability to perform a hysterectomy in a minimallly invasive fashion. Currently, total laparoscopic hysterectomy has been further advanced with the advent of uterine manipulation devices that incorporate the use of a cupped colpotomizer. Unfortunately, many gynecologic surgeons lack the understanding of how to fully utilize such a surgical guide to facilitate development of the vesico-uterine reflection, skeletonize uterine vasculature, gain entry into the vagina, and subsequently close the vaginal cuff. Safe completion of these steps has the potential to minimize complications such as ureteral and bladder injury in addition to vaginal cuff dehiscence. The following technical review will address methods for the safe and effective use of various cupped colpotomizer devices during total laparoscopic hysterectomy.

McKusick-Kaufman syndrome: the difficulty of establishing a prenatal diagnosis of an uncommon disorder

Prenatal evaluation of abdominal cystic masses can be complex and challenging. We report the case of a fetus with a large cystic abdominal mass and discuss how the differential diagnosis was narrowed to include McKusick-Kaufman syndrome (MKS). MKS is characterized by the triad of postaxial polydactyly, congenital heart disease, hydrometrocolpos, and genital malformations in males. Rare conditions such as MKS are difficult to diagnose prenatally and require postnatal phenotyping and molecular studies before a definitive diagnosis can be established.

[Improvement of operative conditions during a laparoscopic prosthetic sacral colpopexy for pelvic organ prolapse repair]

Actually, the choice of surgical approach for pelvic organ prolapse repair depends more on surgeon experience rather than patients characteristics. Laparoscopic sacral colpopexy seems to offer complete repair, low morbidity and satisfactory anatomic and functional results. This technique requires specially trained and experienced surgeons and optimal operative conditions. To improve feasibility of laparoscopic sacral colpopexy, we propose a simplified operative strategy to optimise this complex procedure.

[Analysis of 81 cases of congenital anomalies of the vagina]

OBJECTIVE

To investigate the types, clinical features and therapeutic approaches of congenital anomalies of the vagina.

METHODS

The clinical data of 81 patients with congenital anomalies of the vagina were analyzed retrospectively.

RESULTS

There were 5 types in these 81 patients, and 16 (19.7%) patients showed absence of the vagina, 15(18.5%) had vaginal obstruction, 10 (12.3%) had transverse vaginal septum,14(17.2%) had longitudinal vaginal septae,18(22.2%) had septum obliquus, and 8 (9.8%) had imperforate hymen. Forty-eight (59.2%) patients presented with primary amenorrhea, and 22(27.1%) complained of irregular pelvic pain. Fifteen of the patients with absent vagina underwent amnion artificial vaginoplasty, and the others were treated with incising and removing the septum, all having good clinical outcomes.

CONCLUSION

Amnion artificial vaginoplasty is a good option for treatment of absent vagina.

Reconstruction of defect after radical vulvectomy by the use of four-flap local transfer--a case report

Malignant vulvar tumors must be treated by radical removal of the tumor as well as a sufficient amount of surrounding healthy tissue. The resulting defects can be resolved by skin transplants, local transfers, skin flaps, muscle flaps or free tissue transfers. We describe the case history of a patient who underwent radical vulvectomy for a malignant tumor with immediate reconstruction by local flaps from the area of inner thighs and mons pubis. The advantages and disadvantages of this method are compared to other reconstructive surgery methods.

[Vaginal or laparoscopic assisted vaginal myomectomy: interest in the double way]

OBJECTIVES

To evaluate vaginal and laparoscopic-assisted vaginal myomectomy in order to find interest and indications of this two-way approach of myomectomy.

PATIENTS AND METHODS

Retrospective study of 60 patients operated of a myomectomy by vaginal or laparoscopic-assisted vaginal way between December 1999 and January 2007.

RESULTS

Thirty-three patients (55%) profited from an exclusive vaginal myomectomy (group 1) and 27 (45%) from a laparoscopic-assisted vaginal myomectomy (group 2). The vaginal gesture in group 2 was carried out mainly because of difficult dissections of deep interstitial myomes (60%) or for the closing of hysterotomies not accessible by coelioscopic way (40%). Mean operating time, blood loss and length of hospital stay were 120 minutes, 431 ml, 3.2 days in group 1 and 180 minutes, 437 ml, 5.1 days in group 2, respectively. Laparoconversions and notable complications rates were 9% in group 1 and 15% in group 2.

DISCUSSION AND CONCLUSION

Laparoscopic-assisted vaginal myomectomy is interesting to widen indications of laparoscopic way for myomectomy. However, considering complications and rate of laparoconversion, it is necessary to define situations against indicating this gesture. The methods of prevention of the infection also remain to be found.

Abdominal sacral colpopexy: surgical pearls and outcomes

Vaginal vault prolapse is a challenging form of pelvic organ prolapse that occurs in combination with cystocele, rectocele, or enterocele in nearly 75% of affected patients. Clinical presentation will vary depending on the associated defects. Any successful therapy for vaginal vault prolapse will depend on a thorough evaluation of the vaginal compartments and concomitant lower urinary tract function. Surgical correction of vaginal vault prolapse can be achieved through a variety of vaginal or abdominal approaches. This review focuses on the abdominal approach for vaginal vault prolapse surgery. We review outcomes of abdominal sacral colpopexy (ASC) and available comparisons to vaginal vault suspension. We address the role of laparoscopy and robotics in ASC and examine the outcomes of such procedures. We also discuss available literature on the management of the lower urinary tract in combination with ASC.

Site-specific rectocele repair with dermal graft augmentation: comparison of porcine dermal xenograft (Pelvicol) and human dermal allograft

This study is a retrospective chart review comparing 195 women who underwent rectocele repair with either a porcine dermal xenograft or human allogenic cadaveric dermal graft augmentation over a two year period. A site-specific defect repair was completed prior to augmentation with the graft. Examinations were performed preoperatively and postoperatively using the pelvic organ prolapse quantification system. Questionnaires were used to assess constipation and dyspareunia. De novo dyspareunia and cure rates for constipation and dyspareunia were not statistically different between the two groups. Site-specific fascial rectocele repairs with xenograft or allograft augmentation were found to have similar complication rates as well as objective and subjective cure rates.

Retroperitoneal hemorrhage after a vaginal mesh prolapse procedure

BACKGROUND

The present study describes a complication of a transvaginal pelvic floor repair system for the treatment of anterior vaginal prolapse.

CASE

A postmenopausal woman with anterior vaginal wall prolapse was treated with a transvaginal nonabsorbable polypropylene mesh system. The procedure was complicated by a large perioperative retroperitoneal hematoma.

CONCLUSION

The insertion of synthetic meshes in gynecologic surgery is gaining popularity, but all pelvic surgeons should be aware of the potential complications associated with these new techniques.

Low-Weight Polypropylene Mesh for Anterior Vaginal Wall Prolapse

OBJECTIVE

To compare anterior colporrhaphy with and without a tailored mesh.

METHODS

Postmenopausal women with anterior vaginal prolapse to the hymen or beyond were randomly assigned to undergo traditional anterior colporrhaphy alone or reinforced with mesh. The low-weight monofilament polypropylene mesh was self-tailored, having four arms and being placed over the plicated fascia. Before and 2 and 12 months after surgery, participants were evaluated by physical examination, postvoidal residual urine measurement and standard questions covering prolapse-related symptoms. The primary outcome was recurrence of anterior vaginal prolapse at 12 months. Secondary outcomes included operative complications, symptom resolution, and postvoidal urine residual volume.

RESULTS

Of the 202 women randomly assigned, 201 were operated on (97 without, 104 with mesh). Thirty-seven women (38.5%) in the no-mesh and seven (6.7%) in the mesh group experienced a recurrence of anterior wall prolapse (P<.001) at 12 months; as a result, the number needed to treat for benefit was four. The mean (standard deviation) postvoidal residual urine volume was lower in patients with mesh than in those undergoing the traditional operation: 25 (26) mL and 41 (57) mL (P=.01). Twenty-three women (23%) with mesh and 9 (10%) with no mesh reported stress urinary incontinence (P=.02). In 18 (17.3%), exposure of the mesh was noted, mainly asymptomatic.

CONCLUSION

Anterior colporrhaphy, reinforced with, tailored mesh significantly reduced the rate of recurrence of anterior vaginal wall prolapse compared with the traditional operation, but was associated more often with stress urinary incontinence.

[Anterior approach sacrospinous colpopexy in a patient with vaginal vault prolapse, stress urinary incontinence and cystocoele with lateral defect]

We present a case of vaginal vault prolapse after hysterectomy associated with cystocoele with central and lateral defect and stress urinary incontinence, that was treated surgically with employment of sacrospinous colpopexy through anterior approach (from paravesical space), combined with anterior colporrhaphy by double TOT approach method (that is a butterfly-shaped polipropylen mesh, which arms were carried through upper and lower parts of obturator foramens by tension-free method). There were no postoperative complications. A control examination at 1 and 3 months after the operation showed maintenance of normal anatomic relations, which were obtained as a result of repair, total control of urinary continence and full patient's satisfaction from the operation.

Laparoscopic uterine nerve ablation versus vaginal uterosacral ligament resection in postmenopausal women with intractable midline chronic pelvic pain: a randomized study

OBJECTIVE

To assess and compare the laparoscopic uterine nerve ablation (LUNA) and the vaginal uterosacral ligament resection (VUSR) in postmenopausal women with chronic pelvic pain (CPP).

STUDY DESIGN

Eighty postmenopausal women with intractable and severe midline CPP were randomized to undergo LUNA or VUSR. Costs of two surgical procedures were assesses. Cure rate, severity of CPP, and deep dyspareunia were also evaluated after 6 and 12 months from surgery.

RESULTS

The mean cost of LUNA resulted significantly higher in comparison with VURS (2078+/-637 versus 1497+/-297, P<0.001). The cure rate was not significantly different between the two groups at 6 (33/40, 82.5% versus 35/40, 87.5% for groups A and B, respectively; P=0.530; RR 0.94, 95% CI 0.78-1.13), and 12 months (27/36, 75.0% versus 28/38, 73.7%, for groups A and B, respectively; P=0.901; RR 0.90, 95% CI 0.78-1.33) of follow-up. At same times, a significant (P<0.01) decrease in severity of CPP and deep dyspareunia was observed in both groups with no difference between them.

CONCLUSIONS

Both LUNA and VUSR are equally effective surgical treatments in postmenopausal women with central CPP but VUNR is significantly cheaper than LUNA.

Transvaginal myomectomy with screw traction by colpotomy

INTRODUCTION

The aim of this study is to evaluate the clinical effectiveness and safety of the enucleation of uterine leiomyomas by traction method via colpotomy.

METHODS

Ten women with menorrhagia, pelvic pain, or secondary infertility associated with single uterine myomas underwent transvaginal myomectomy with screw traction by colpotomy. The feasibility of the procedure, operative complications, postoperative recovery, pregnancies, and relief of symptoms were the main outcome measures.

RESULTS

Traction myomectomy was completed vaginally in all patients. The mean operating time was 71 min and average blood loss 385 ml. The mean size of a single myoma was 6.7 cm (range 5.6-8.0 cm) and weight 153 g. One patient developed a transient hematoma. All women reported relief of their symptoms after a mean follow-up of 24 months. Three patients had a term delivery postoperatively.

CONCLUSIONS

Traction myomectomy by colpotomy is a feasible approach for selected patients wishing to preserve their ability to conceive. A single well-lined myoma of 5-8 cm diameter and possible to reach via colpotomy is a suitable subject for the procedure, which proved a viable surgical approach.

Laparoscopic sacrocolpopexy for severe vaginal vault prolapse: five-year outcome

STUDY OBJECTIVE

To assess the efficacy of the laparoscopic sacrocolpopexy in the treatment of severe vaginal prolapse.

DESIGN

(Canadian Task Force classification II-1).

SETTING

Private clinic.

PATIENTS

Fifty-one consecutive posthysterectomy patients with severe vaginal prolapse (Baden-Walker Grade 3 or 4).

INTERVENTIONS

The patients were treated by laparoscopic sacrocolpopexy in conjunction with other laparoscopic and/or vaginal procedures, as indicated.

MEASUREMENTS AND MAIN RESULTS

Of the 43 patients seen at 5-year follow-up, 3 had recurrent vaginal prolapse (objective cure rate 93%). In the patients with recurrence, the polypropylene mesh had torn partially or completely from the vaginal apex. When the posterior strip of mesh was extended to the perineal body, there were fewer recurrences of posterior compartment defects. Postoperatively, two patients had a partial small bowel obstruction secondary to bowel adherence to the mesh. Four patients had mesh erosion at the vaginal apex: two responded to local treatment, and two required vaginal flaps to cover the defect.

CONCLUSION

Laparoscopic sacrocolpopexy can be used safely with cure rates similar to abdominal sacrocolpopexy. Extending the mesh to the perineum appears to decrease posterior vault defects. There is a protracted learning curve. Patient recovery is greatly enhanced, in most cases requiring only an overnight hospitalization.

Benefits of intracervical injection of sterile saline solution in laparoscopically assisted vaginal hysterectomy with vaginal colpotomy and bladder mobilization

OBJECTIVE

To evaluate the influence of intracervical saline injection on inexperienced operators and on laparoscopically assisted vaginal hysterectomy (LAVH).

STUDY DESIGN

This retrospective study included 273 women undergoing LAVH. From July 1997 to June 2002, 138 LAVHs were performed with laparoscopically approached colpotomies and bladder mobilization. Among 135 LAVHs with a vaginal approach, colpotomies/bladder mobilization was done directly in 62 and in the other 73 after a circumferential intracervical saline injection. All operations were performed by inexperienced operators under the supervision of senior surgeons. Blood loss, operative time and complications were analyzed.

RESULTS

The average follow-up period was 41.2 +/- 17.4 months (range, 12-72). No statistically significant differences were observed in age, hemoglobin levels or length of postoperative hospital stay. The incidence of postoperative infection, hematoma and bowel injury was not significantly different. LAVH with vaginal colpotomies/bladder mobilization and intracervical saline injection was associated with the smallest estimated blood loss (p = 0.002) and operative time (p < 0.001). LAVH with laparoscopic colpotomies and bladder mobilization had the longest operative time (p<0.001) and the highest bladder injury rate (p= 0.004).

CONCLUSION

A circumferential injection of normal saline at the cervicovaginal junction is a good option for inexperienced operators.

Laparoscopic vaginal vault suspension using uterosacral ligaments: A review of 133 cases

The objective of our study was to describe the surgical technique of laparoscopic vaginal vault suspension using the uterosacral ligaments. In addition, we performed a retrospective analysis of this laparoscopic technique on 133 patients with advanced symptomatic vaginal vault prolapse to evaluate the efficacy and durability of this laparoscopic technique. Efficacy and anatomic outcome were assessed by the Baden-Walker halfway scoring system before and after the surgical procedure. Preoperatively, all patients showed evidence of grade 2 or greater prolapse (descent to the level of the hymen). Fifty-one patients (38.4%) had uterovaginal prolapse, and 82 patients (61.6%) had vaginal vault prolapse. The patients were reevaluated at 1, 6, and 12 months postoperatively and yearly thereafter. The postoperative follow-up ranged from 2.0 to 7.3 years. Postoperatively, 116 patients (87.2%) had no recurrence of prolapse, and 17 patients (12.8%) had recurrence of prolapse. The major complication rate was 2.25%. We conclude that laparoscopic vaginal vault suspension is a safe, efficacious, and durable alternative for the management of vaginal vault prolapse.

A 2-year anatomical and functional assessment of transvaginal rectocele repair using a polypropylene mesh

This study reports the 2-year results of an original technique for rectocele repair by the vaginal route, using a combined sacrospinous suspension and a polypropylene mesh. Twenty-six women were successively operated between October 2000 and February 2003. Mean age was 63.7 years [range 35-92]. 19 women had had previous pelvic surgery for prolapse and/or urinary incontinence (73.1%), but none had had a previous rectocele repair. Patients underwent physical examination staging of prolapse in the international pelvic organ prolapse staging system. Eleven women had stage 2 posterior vaginal wall prolapse (42.3%), seven had stage 3 (26.9%) and eight had stage 4 (30.8%). The procedure included a bilateral sacrospinous suspension and a polypropylene mesh (GyneMesh, Gynecare, Ethicon France) attached from the sacrospinous ligaments to the perineal body. We did not perform any associated posterior fascial repair, nor myorraphy. Patients were followed up for 10-44 months, with a median follow-up (+/- SD) of 22.7 +/- 9.2 months. Functional results and sexual function were evaluated using the PFDI, the PFIQ and the PISQ-12 self-questionnaires. Twenty-five women returned for follow-up (96.2%). At follow-up, 24 women were cured (92.3%) and one had asymptomatic stage 2 rectocele. All the patients but one had symptoms and impact on quality of life improved. No postoperative infection of the mesh or rectovaginal fistula was found, but there were three vaginal erosions (12%) and one out of 13 had de novo dyspareunia (7.7%).

Abdominal sacrocolpopexy for vault prolapse without burial of mesh: a case series

OBJECTIVES

To audit the clinical outcome of abdominal vault suspension (sacrocolpopexy, hysteropexy or cervicopexy) using non-absorbable mesh, without burial by closure of the peritoneum.

DESIGN

A case series.

SETTING

Urogynaecology units of four hospitals.

POPULATION

One hundred and twenty-eight women having open or laparoscopic sacrocolpopexy (121), hysteropexy (6) or cervicopexy (1) using non-absorbable mesh for vault prolapse.

METHODS

Patients had suspension of the vault, uterus or cervix from the sacral promontory using a monofilament polypropylene mesh. The pelvic peritoneum was not closed over the mesh. Patients were followed up every six months.

MAIN OUTCOME MEASURES

Incidence of bowel complications as a consequence of the mesh; cure rate of prolapse and incidence of other post-operative complications; rate of re-operation for prolapse or incontinence.

RESULT

After a median follow up of 19 months (1.5-62), there were no bowel complications as a result of non-burial of mesh. Three patients had asymptomatic vaginal mesh erosion, which required minor surgical intervention. Ninety percent of patients had good resolution of their prolapse symptoms while 10% of patients required further surgery.

CONCLUSION

Leaving the mesh uncovered by the pelvic peritoneum was not associated with complications. It appears safe to perform vault suspension without closing the peritoneum.

[Surgical and conservative methods for removing mummified fetuses in cattle]

The purpose of this study was to describe the findings and therapy in 4 cows and 1 heifer with mummified fetus. All animals were admitted at the clinic after several unsuccessful therapies with prostaglandin F2alpha and local uterine infusions. All animals were in good condition. In case 1, diagnosis of mummified fetus could not be confirmed after manual rectal palpation and ultrasonography whereas cases 2, 4, 5 all had mummified fetus. In case 3, the fetus was in maceration. Initial therapy consisted of administration of prostaglandin F2alpha and prostaglandin E2 followed by repeated administration of prostaglandin E2. Mummies (length from apex to rump 13-32 cm) could be taken out within 3 to 6 days per vias naturales in cases 2, 4, 5 and in case 3, bones (maximal length 4 cm) could be unhinged. The structure in the uterus of case 1 could not be mobilised and was consequently removed under sight control using colpotomy followed by hysterotomy. Animals 2, 3, 4 and 5 were pregnant on the occasion of telephone inquiry. On the basis of our results, we recommend the conservative medical therapy with PGE2 for cases of mummified fetus. Colpotomy and hysterotomy are reserved as therapy feasible if the use of prostaglandin E2 is not successful.

Vaginal myomectomy using posterior colpotomy: feasibility in normal practice

BACKGROUND

Myomectomy is classically performed via laparotomy. Endoscopic surgery is limited for some indications. Vaginal myomectomy is a surgical procedure that has recently been evaluated. The aim of this study was to evaluate the feasibility, reproducibility and complication rate of vaginal myomectomy via posterior colpotomy.

METHODS

A retrospective study was performed from November 1998 to February 2001 in three departments of gynaecology.

RESULTS

Forty-five patients were involved, 17 (37.8%) of whom underwent laparoscopy before vaginal myomectomy for evaluation or treatment of a second pelvic disorder. Myomectomy was performed vaginally in 40 (89%) of the 45 patients. Peroperative laparotomy was required in five patients (11%), either because vaginal myomectomy proved impossible (four cases) or because of rectal injury (one case). One patient needed supplementary laparotomy on day 8 for the treatment of a pelvic abscess.

CONCLUSION

Posterior vaginal myomectomy seems to be a feasible and reproducible surgical procedure. The success rate of vaginal myomectomy in this study was over 80%. Further randomised studies are needed to compare this procedure with laparotomy and laparoscopy.

A randomised trial comparing open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence

OBJECTIVE

To compare open Burch colposuspension using sutures with laparoscopic colposuspension using mesh and staples in women with stress urinary incontinence.

DESIGN

Multicentre, prospective randomised trial.

SETTING

Departments of Obstetrics and Gynaecology, Sahlgrenska University Hospital, Göteborg, Borås County Hospital and Orebro University Hospital, Sweden.

POPULATION

Women with genuine stress urinary incontinence or mixed incontinence with a predominantly stress component were included, and were randomised to either open colposuspension (n= 120) or laparoscopic colposuspension (n= 120).

METHODS

Women were randomised to open colposuspension with sutures or laparoscopic colposuspension with polypropylene mesh and staples. Anaesthesia/operation time, blood loss, complications and other related surgical parameters were compared.

MAIN OUTCOME MEASURES

Objective and subjective cure rates from 48-hour frequency-volume chart, a 48-hour pad test and a subjective assessment of the woman's incontinence and quality of life performed one year after surgery.

RESULTS

Objective and subjective cure rates were higher after open compared with laparoscopic colposuspension (P < 0.001). Quality of life was improved following surgery in both groups (P < 0.0001) and the improvement was significantly greater in the open colposuspension group (P < 0.05) with regard to physical activity. Performing an open colposuspension was less time consuming (P < 0.0001), resulted in more blood loss (P < 0.0001), longer catheterisation time (P < 0.01), greater risk of urinary retention (P < 0.01) and a longer hospital stay (P < 0.0001) compared with performing a laparoscopic colposuspension. The rate of serious complications was low in both groups.

CONCLUSION

Open colposuspension had a higher objective and subjective cure rate one year after surgery but with a greater blood loss, greater risk of urinary retention and a longer hospital stay than laparoscopic colposuspension.

Comparison of outcomes between Burch colposuspension with and without concomitant abdominal hysterectomy

A total abdominal hysterectomy may cause a postoperative vesicourethral dysfunction due to an injury to the pelvic nerves. However, many incontinent women with benign diseases of the uterus and its adnexae have undergone a Burch colposuspension with a concomitant abdominal hysterectomy. This study was undertaken to compare the outcomes of a Burch colposuspension performed alone with that of a Burch with a concomitant abdominal hysterectomy. This study included 132 women, who, were treated for primary urinary incontinence from February 1999 to February 2002 and were diagnosed with stress urinary incontinence by means of the urodynamic test at the Department of Obstetrics and Gynecology at Yonsei University Hospital. Forty-two women underwent a Burch colposuspension alone (Burch group) and 90 women underwent a Burch colposuspension with a concomitant abdominal hysterectomy (hysterectomy group). Between the Burch and hysterectomy groups, the mean age, parity, menopausal rate, Hormone Replacement Therapy (HRT) rate, 1 year follow-up outcomes and postoperative complications were compared using the subjective and objective stress tests according to the retrospective chart review. The mean age (54.6 +/- 0.5 vs 58.6 +/- 9.2 years, p=0.382), parity (3.3 +/- 1.2 vs 3.6 +/- 1.7), menopausal rate (71.4 vs 77.7%), or HRT rate (23.3 vs 11.2%) of the two groups were similar. Complications related to surgery were encountered in 5 patients (11.9%) in the Burch group and in 7 patients (7.8%) in the hysterectomy group (p=0.842). One year follow-up subjective symptoms were encountered in 2 patients in the Burch group and in 4 patients in the hysterectomy group (p=1.00). The stress test was positive in only one patient in the hysterectomy (p=1.00). No significant difference was observed in the 1 year follow-up outcomes, which were 91.4% (32/35 patients) in the Burch and 91.2% (73/80) in the hysterectomy groups. The results showed that there were no adverse effects on the 1 year follow-up outcomes or complications in patients who underwent a Burch colposuspension with an abdominal hysterectomy.

Recurrent pelvic organ prolapse in a woman with bladder exstrophy: a case report of surgical management and review of the literature

Management of gynecologic issues in women with bladder exstrophy is challenging. Congenital pelvic organ prolapse and prolapse-associated pregnancy and delivery are common. The management of prolapse is complicated by the anatomic changes involving the bony pelvis, connective tissue support, pelvic floor, and the length and axis of the vagina. A case of recurrent pelvic organ prolapse successfully managed with a sacral colpopexy and a review of the literature are presented.

How long should urinary bladder catheterisation be continued after vaginal prolapse surgery? A randomised controlled trial comparing short term versus long term catheterisation after vaginal prolapse surgery

OBJECTIVE

To determine whether prolonged urinary bladder catheterisation after vaginal prolapse surgery is advantageous.

DESIGN

Randomised controlled trial.

SETTING

A large training hospital in the Netherlands.

POPULATION

Patients undergoing anterior colporrhaphy.

METHODS

One hundred patients were included. Patients were randomised into two groups. In one group (n= 50), a transurethral catheter was in place for four days post-operatively and removed on the fifth post-operative day. In the other group (n= 50), catheterisation was not prolonged and the catheter was removed the morning after surgery. Residual volumes after removal of the catheter were measured by ultrasound scanning. Where residual volumes of >200 mL were found the patient was recatheterised for three more days. Urinary cultures were taken before removal of the catheter. Six patients were excluded: four in the standard prolonged catheterisation group and two in the not prolonged catheterisation group.

MAIN OUTCOME MEASURES

Need for recatheterisation, urinary tract infection, mean duration of catheterisation and hospital stay.

RESULTS

Residual volumes exceeding 200 mL and need for recatheterisation occurred in 9% in the standard prolonged catheterisation group versus 40% of patients in the not prolonged catheterisation group (OR 0.15, 95% CI 0.045-0.47). Positive urine cultures were found in 40% of cases in the standard prolonged catheterisation group compared with 4% in the not prolonged catheterisation group (OR 15, 95% CI 3.2-68.6). Mean duration of catheterisation was 5.3 days in the standard prolonged catheterisation group and 2.3 days in the not prolonged catheterisation group (P < 0.001). Mean duration of hospitalisation was 7 days in the standard prolonged catheterisation group and 5.7 days in the not prolonged group (P < 0.001).

CONCLUSION

The disadvantages of prolonged catheterisation outweigh the advantages, therefore, removal of the catheter on the morning after surgery may be preferable and longer term catheterisation should only be undertaken where there are specific indications.

Tension-free vaginal tape procedure and laparoscopic colposuspension in the treatment of stress urinary incontinence

PURPOSE OF REVIEW

Within the last decade we have seen substantial development in the surgical techniques used to treat female stress urinary incontinence. The laparoscopic approach became available and even less invasive methods like the tension-free vaginal tape procedure were introduced.

RECENT FINDINGS

These procedures offer quicker recovery and faster return to normal activities after surgery compared with the older procedures. The tension-free vaginal tape technique has been extensively studied and clinical data from a significant number of prospective observational cohort studies have been published. The number of reports on laparoscopic incontinence surgery is more limited. Long-term follow-up results with reassuring cure rates at 5 and 7 years are available for the tension-free vaginal tape procedure. Three-year follow-up results for the laparoscopic colposuspension procedure show reasonable cure rates, though not as good as those reported for the open colposuspension, the 'gold standard'. Both of these techniques are now widely used in everyday clinical practice. Perioperative and immediate postoperative complication rates are low and acceptable. However, data are limited in terms of randomized clinical trials comparing these fairly new techniques.

SUMMARY

This review attempts to highlight the recent clinical experience of these two surgical techniques, including cure rates, complications and cost-effectiveness.

Bladder injury after LAVH: a prospective, randomized comparison of vaginal and laparoscopic approaches to colpotomy during LAVH

STUDY OBJECTIVE

To compare results of a vaginal approach to colpotomy (type IA) and laparoscopic-assisted abdominal colpotomy (type ID) in performing a laparoscopic-assisted vaginal hysterectomy (LAVH).

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

Tertiary teaching hospital.

PATIENTS

Five hundred forty-one women, 274 in group 1 (type 1D) and 267 in group 2 (type 1A).

INTERVENTION

LAVH with follow-up for 3 months to 5 years.

MEASUREMENTS AND MAIN RESULTS

There were no statistically significant differences in age, preoperative and postoperative hemoglobin values, or postoperative hospital stay between groups. Operating time and estimated blood loss were significantly reduced in group 2 (p <0.001 and <0.001, respectively). Women in group 1 had nine urinary tract injuries (3.28%), including eight cases of intraoperative bladder injury (2.91%) and one vesicovaginal fistula (0.36%), but no ureteral injury. The bladder injury rate in group 2 was 0.37%, which was significantly lower (p = 0.038). There were no significant differences in ureteral or bowel injuries, pelvic hematomas, or pelvic abscesses.

CONCLUSION

LAVH type IA achieved better results than type ID in preventing bladder injury.

A randomised controlled trial comparing abdominal and vaginal prolapse surgery: effects on urogenital function

OBJECTIVE

To compare the effects of vaginal hysterectomy (combined with anterior and/or posterior colporraphy) and abdominal sacro-colpopexy (with preservation of the uterus) on urogenital function.

DESIGN

Randomised trial.

SETTING

Three teaching hospitals in The Netherlands.

POPULATION

Eighty-two patients undergoing surgical correction of uterine prolapse stages II-IV.

METHODS

Participating patients completed the urogenital distress inventory (UDI), before and at six weeks, six months and one year after surgery, to measure discomfort of prolapse and micturition symptoms. Domain scores of the UDI (ranging from 0 to 100, higher scores indicating more discomfort) were compared between groups at all time points. Findings at pelvic examination, number of doctor visits within the first year after surgery because of pelvic floor symptoms and performed or planned surgery of recurrent genital prolapse were also compared.

MAIN OUTCOME MEASURE

Domain scores of the UDI at one year after surgery.

RESULTS

At one year after surgery, scores on the discomfort/pain domain (mean difference 7.1, 95% confidence interval [CI] 1.1-13.2), overactive bladder domain (mean difference 8.7, 95% CI 0.5-16.9) and obstructive micturition domain (mean difference 10.3, 95% CI 0.6-20.1) of the UDI were significantly higher in the abdominal group than in the vaginal group. Findings at pelvic examination were similar in both groups. Doctor visits because of pelvic floor symptoms were more frequent in the abdominal group than in the vaginal group. Re-operation was performed or planned in 9 of the 41 patients who underwent abdominal surgery and in 1 of the 41 patients who underwent vaginal surgery (odds ratio [OR] = 11.2, 95% CI 1.4-90.0).

CONCLUSIONS

Our findings suggest that vaginal hysterectomy with anterior and/or posterior colporraphy is preferable to abdominal sacro-colpopexy with preservation of the uterus as surgical correction in patients with uterine prolapse stages II-IV.

The Manchester Procedure

This article describes the historical development for the Manchester Surgical Procedure for the correction of genital prolapse.

Rectus abdominis vaginoplasty after anterior exenteration for urologic malignancy

INTRODUCTION

Vaginal resection is occasionally required in female patients who undergo anterior exenteration for invasive lower urinary tract malignancy. We have used a rectus abdominis myocutaneous flap to reconstruct the vagina and perineum after extensive local resection of bladder and urethral carcinoma.

TECHNICAL CONSIDERATIONS

Either a left or right rectus flap is used. Once anterior exenteration, partial vaginectomy, and urinary diversion are completed, the median infraumbilical incision is extended superiorly to form an elliptical skin paddle centered over the superior half of the muscle. The superior epigastric vessels are ligated, the cephalad end of the muscle is divided at the level of the costal margin, and the flap is progressively elevated out of the rectus sheath by sequentially dividing the lateral perforating nerves and vessels. As the muscle is elevated, the inferior epigastric pedicle is carefully preserved and followed inferiorly to its origin from the external iliac artery. Once a length of muscle sufficient for it to reach the perineum is mobilized, the flap is carried transpelvically. For complete vaginal reconstruction, the flap may be inverted into a tube, with the cephalic portion anchored to the perineum. Alternatively, the skin paddle may be used to fill tissue defects in the vagina and pelvic floor. The anterior abdominal wall fascia and skin edges at the donor site are closed primarily. We have successfully applied this technique in 4 patients who underwent anterior exenteration for invasive bladder and urethral carcinoma.

CONCLUSIONS

Rectus abdominis vaginoplasty is a viable surgical option for reconstruction after anterior exenteration with vaginal resection for invasive cancer of the bladder and urethra.

Vaginal extraction of pelvic masses following operative laparoscopy

OBJECTIVE

To investigate the clinical outcome of patients undergoing operative laparoscopy for a benign pelvic mass followed by vaginal extraction of the surgical specimen.

METHODS

Patients presenting with a suspected benign mass greater than 5 cm or an extrauterine pregnancy undergoing operative laparoscopy were considered eligible. Patients with endometriosis, pelvic inflammatory disease, and previous hysterectomy were excluded. In all cases the surgical specimen was removed through a colpotomy performed in laparoscopy at the level of the posterior vaginal fornix. Additionally, a review of the literature has been conducted to specifically address the incidence of colpotomy-related complications.

RESULTS

Sixty-three patients were included in the study. The median (range) time required to extract the freed mass to the complete suture of the colpotomy was 15 min (5-31). This time was significantly longer in patients with myomas than for others [median 21 min (range: 10-31) vs median 10 min (5-13), p<0.05]. No intra- and postoperative colpotomy related complications occurred. No patients complained dyspareunia at follow-up visits. A total of 23 studies were reviewed for a total of 501 patients and only one (0.2%) complication (severe vaginal bleeding) was directly attributable to the colpotomy.

CONCLUSION

Removal of a pelvic mass through a laparoscopic colpotomy is feasible, safe, and offers better cosmetic results than transabdominal extraction of the surgical specimen.

[Cystocele repair by the vaginal route with a tension-free sub-bladder prosthesis]

OBJECTIVE

To describe a new vaginal approach for the repair of cystoceles, reinforced with a tension-free polypropylene mesh.

METHODS

The vaginal procedure consisted of a complete dissection of the cystocele and a thorough entry from the vesicovaginal space under the inferior pubic ramus into the retropubic space. The polypropylene mesh (GyneMesh(TM), Gynecare, Ethicon France) was placed from the retropubic space to the inferior part of the bladder in a tension-free fashion.

RESULTS

Forty-eight consecutive women with grade 3-4 cystoceles underwent this procedure between October 1999 and September 2001. Mean age was 63.9 years (41-85). Mean follow-up is 18 months (8-32). The success rate was 97.9%. There were a total of four vaginal erosions of the mesh (8.3%). There were no postoperative infections of the mesh.

CONCLUSION

The vaginal repair of severe cystocele reinforced with a tension-free polypropylene mesh is a simple and reproducible technique, with high success rate and low morbidity.