Abdominal Sacrocolpopexy Research Articles

Clinical outcome of abdominal sacrocolpopexy.

Introduction:Vaginal vault prolapse is one of the distressing conditions which occur after hysterectomy. This is due to the weakness or detachment of sacrouterine cardinal ligament complex from the vaginal cuff. Till now, the most accepted procedure for this condition is sacrocolpopexy.Materials and Methods:We present a cohort of patients who underwent abdominal sacrocolpopexy (ASC) from April 2009 to August 2013. These patients were followed till April 2014 and were evaluated for subjective and objective outcomes following ASC.Results:One patient had intraoperative hemorrhage and postoperative hematoma formation. One patient had vault abscess which was managed conservatively. Hundred percent success rate was noted at 1 year. Long-term patient satisfaction score was 85 (70-90).

What Happens to the Posterior Compartment and Bowel Symptoms After Sacrocolpopexy?

Posterior pelvic organ prolapse (pPOP) commonly occurs with apical prolapse, other vaginal compartment defects, and symptoms of defecatory dysfunction including obstructed defecation (OD). The indication for concomitant posterior repair (PR) during apical prolapse repair may be based on the presence or absence of symptoms. Some surgeons do not perform PR during repair of apical prolapse in the absence of symptoms. The Extended Colpopexy and Urinary Reduction Efforts (E-CARE) trial assessed the progression of posterior compartment prolapse and symptoms of OD after open abdominal sacrocolpopexy (ASC). Data from that study have been published in the primary article (Nygaard, JAMA 2013;309:2016). This secondary analysis of E-CARE data assessed the occurrence of pPOP and symptoms of OD in patients 5 years after open ASC. The study was designed to determine whether PR is necessary at the time of ASC. Participants with baseline and 5-year outcome data were divided into 3 groups using baseline posterior Pelvic Organ Prolapse Quantification points and concomitant PR: (1) no PR, Ap < 0; (2) no PR, Ap ≥ 0; and (3) +PR. Decision for concomitant PR was performed at the surgeon’s discretion and included posterior colporrhaphy, perineorrhaphy, or sacrocolpoperineopexy. Five-year outcomes were dichotomized into presence/absence of pPOP (Ap > 0) and OD symptoms of moderate or greater bother (≥2) on 1 or more Pelvic Floor Distress Inventory questions about digital assistance, excessive straining, or incomplete evacuation. Composite failure during the 5-year interval was defined by both pPOP and OD symptoms or pPOP reoperation. Completed baseline and 5-year outcomes were available for 90 participants (60%); mean (SD) follow-up was 7.1 (1.0) years. At 5 years, only 2 women (6%) with no PR (AP < 0) developed de novo pPOP with OD symptoms; 1 of these underwent subsequent PR. Without PR repair, nearly all participants (23/24; 96%) demonstrated sustained resolution of pPOP, and none underwent PR within 5 years. Obstructed defecation symptoms improved in all groups after ASC with or without PR, although OD symptoms were still present at 5 years, with rates ranging from 17% to 19%. Regardless of concomitant PR, symptomatic pPOP is common 5 years after ASC. Obstructed defecation symptoms may improve after ASC with or without PR. Additional studies are needed to define criteria for performing PR at the time of planned ASC.

Effect of reproductive characteristics, body mass index, and anterior/posterior vaginal compartment defects on the short-term success of abdominal sacrocolpopexy

Objective Vaginal vault prolapse is caused by the loss of apical support in the cardinal-uterosacral ligament complex. Abdominal sacrocolpopexy (ASCP) is one means of repairing vaginal vault prolapse. In the present study, we investigated the effects of reproductive factors, body mass index (BMI), and anterior or posterior vaginal compartment defects on short-term outcomes of ASCP. Method We retrospectively studied 70 women who had undergone ASCP between February 2012 and November 2012 in our clinic. Result There were no significant differences in the complication rate among menopausal, nonmenopausal women, and grand multiparous patients. Operational success was not significantly affected by menopausal status. The long-term rate of grade ≥ 2 prolapse in the apical, anterior, or posterior vaginal wall after ASCP did not differ significantly by menopausal status. Correlation analysis showed that BMI was not associated with operational success in the early postoperative period in patients with vaginal prolapse and was not associated with the detection of grade ≥ 2 prolapse in apical, anterior, and posterior compartments after 1 year. Conclusion ASCP should be the first-line treatment for obese/overweight, menopausal, or grand multiparous patients with additional anterior or posterior vaginal vault prolapse.

Management of Pelvic Organ Prolapse in the Elderly

Pelvic organ prolapse is a common condition for which age is a significant risk factor, making pelvic organ prolapse particularly prevalent in the elderly population. While not a life-threatening condition, pelvic organ prolapse can affect quality of life and impact daily activity with bothersome vaginal, urinary, bowel, and sexual symptoms. This review article addresses the management of symptomatic pelvic organ prolapse in the elderly population including evaluation, conservative and surgical approaches. Conservative management encompasses pelvic floor muscle training therapy and use of vaginal pessaries in addition to lifestyle modifications. Patients who have failed conservative management or desire definitive repair may be amenable to surgical intervention, comprising traditional and minimally invasive abdominal sacrocolpopexy, transvaginal repairs and obliterative procedures. Important pre-operative, intra-operative, and post-operative considerations unique to the elderly population are addressed as well.

Laparoscopic Versus Robotic Sacrocolpopexy: Outcomes and Costs

Abdominal sacrocolpopexy (SCP) has been considered one of the gold standard surgical procedures for correction of apical pelvic organ prolapse, with high success rates and few complications (Maher et al. Database Syst Rev, 2013). Minimally invasive SCP has been shown to have the additional benefit of reduced blood loss and decreased hospital length of stay, without compromising anatomic or subjective outcomes (Freeman et al. Int Urogynecol J 24:377–84, 2013). This report summarizes the latest literature on minimally invasive SCP, with a focus on outcomes and efficiency. Recent randomized controlled trials (RCT) have shown equivalent subjective and anatomic outcomes for robotic SCP (RSCP) and laparoscopic SCP (LSCP), with increased operative time and cost associated with RSCP.

What happens to the posterior compartment and bowel symptoms after sacrocolpopexy? evaluation of 5-year outcomes from E-CARE.

The objective of this study was to describe posterior prolapse (pPOP) and obstructed defecation (OD) symptoms 5 years after open abdominal sacrocolpopexy (ASC). We grouped the extended colpopexy and urinary reduction efforts trial participants with baseline and 5-year outcomes into 3 groups using baseline posterior Pelvic Organ Prolapse Quantification (POP-Q) points and concomitant posterior repair (PR) (no PR, Ap <0; no PR, Ap ≥0; and +PR). Posterior colporrhaphy, perineorrhaphy, or sacrocolpoperineopexy were included as PR, which was performed at surgeon's discretion. Outcomes were dichotomized into presence/absence of pPOP (Ap ≥0) and OD symptoms (≥2 on 1 or more questions about digital assistance, excessive straining, or incomplete evacuation). Composite failure was defined by both pPOP and OD symptoms or pPOP reoperation. Ninety participants completed baseline and 5-year outcomes or were retreated with mean follow-up of 7.1 ± 1.0 years. Of those with no PR (Ap <0), 2 women (2/36; 9%) developed new pPOP with OD symptoms; 1 underwent subsequent PR. Nearly all (23/24; 96%) with no PR (Ap ≥0) demonstrated sustained resolution of pPOP, and none underwent PR. Fourteen percent (4/29) of +PR underwent repeat PR within 5 years, and 12% had recurrent pPOP. Regardless of PR, OD symptoms improved in all groups after ASC, although OD symptoms were still present in 17% to 19% at 5 years. Symptomatic pPOP is common 5 years after ASC regardless of concomitant PR. Obstructed defecation symptoms may improve after ASC regardless of PR. Recurrent pPOP and/or reoperation was highest among those who received concomitant PR at ASC. Further studies identifying criteria for concomitant PR at the time of ASC are warranted.

A review on the role of laparoscopic sacrocervicopexy.

To provide an update on the outcomes and complications of laparoscopic (or robot-assisted) sacrocervicopexy with and without supracervical hysterectomy, and highlight the differences with sacrocolpopexy technique based on the most recent evidence. Laparoscopic and robot-assisted sacrocervicopexy with supracervical hysterectomy and sacrohysteropexy have good success rates, with a mean objective success rate of 96% (range 90-100%), subjective success rates of 80-95% and mean reoperation rate of 3%. Also, pelvic symptoms and quality of life improved after laparoscopic sacrocervicopexy. These results are similar to laparoscopic and abdominal sacrocolpopexy, and are confirmed by the results of two comparative studies. Mesh erosion risk is very low in patients treated with laparoscopic sacrocervicopexy. Studies that compare laparoscopic sacrocolpopexy with concomitant total hysterectomy and sacrocervicopexy with subtotal hysterectomy show that total hysterectomy is associated with a greater prevalence of vaginal mesh exposure when compared with a subtotal hysterectomy. In case of sacralpexy, if it is decided to proceed with a hysterectomy, it is recommended to limit this to a subtotal. The benefits of laparoscopic sacrocervicopexy with or without supracervical hysterectomy in terms of outcomes and reduced risk of mesh erosion in comparison with sacrocolpopexy and concomitant total hysterectomy have to be confirmed by randomized controlled trials. Moreover, standardization of surgical technique is mandatory.

Perioperative adverse events after minimally invasive abdominal sacrocolpopexy

Our first objective was to compare peri- and postoperative adverse events between robotic-assisted laparoscopic sacrocolpopexy (RSC) and conventional laparoscopic sacrocolpopexy (LSC) in a cohort of women who underwent these procedures at a tertiary care center. Our second objective was to explore whether hysterectomy and rectopexy at the time of sacrocolpopexy were associated with these adverse events. This was a retrospective cohort study of women who underwent either RSC or LSC with or without concomitant hysterectomy and/or rectopexy from 2006-2012. Once patients were identified as either having undergone RSC or LSC, the electronic medical record was queried for demographic, peri-, and postoperative data. Four hundred six women met study inclusion criteria. Mean age and body mass index of all the women were 58 ± 10 years and 27.9 ± 4.9 kg/m(2). The women who underwent RSC were older (60 ± 9 vs 57 ± 10 years, respectively; P = .009) and more likely to be postmenopausal (90.9% vs 79.1%, respectively; P = .05). RSC cases were associated with a higher intraoperative bladder injury rate (3.3% vs 0.4%, respectively; P = .04), a higher rate of estimated blood loss of ≥500 mL (2.5% vs 0, respectively; P = .01), and reoperation rate for pelvic organ prolapse (4.9% vs 1.1%, respectively; P = .02) compared with LSC. Concomitant rectopexy was associated with a higher risk of transfusion (2.8% vs 0.3%, respectively; P = .04), pelvic/abdominal abscess formation (11.1% vs 0.8%, respectively; P < .001), and osteomyelitis (5.6% vs 0, respectively; P < .001). The mesh erosion rate for all the women was 2.7% and was not statistically different between LSC and RSC and for patients who underwent concomitant hysterectomy and those who did not. Peri- and postoperative outcomes after RSC and LSC are favorable, with few adverse outcomes. RSC is associated with a higher rate of bladder injury, estimated blood loss ≥500 mL, and reoperation for recurrent pelvic organ prolapse; otherwise, the rate of adverse events is similar between the 2 modalities. Concomitant rectopexy is associated with a higher rate of postoperative abscess and osteomyelitis complications.

Comparison of location of mesh placed transvaginally vs mesh placed abdominally at the time of sacrocolpopexy

The location of mesh placed at the time of abdominal sacrocolpopexy (ASC) is hypothesized to be in the same location histologically as mesh placed via full-thickness vaginal dissection in a cadaver model. Ten fresh frozen cadavers underwent mesh placement via traditional ASC. In the same specimen, a transvaginal mesh (TVM) procedure was performed, attempting a full-thickness dissection. A block section was excised from each area including full thickness of the vagina and bladder with the intervening mesh. This was analyzed by a blinded pathologist. All cadavers underwent successful placement of both transabdominal mesh and TVM. Of the abdominally placed meshes, 6 were located between the vagina and bladder, whereas 3 were situated within the vaginal wall, with an average depth of 0.30 mm. Five of the vaginal mesh pieces were placed between the bladder and vagina, and 4 within the vaginal wall at a depth of 0.25 mm. One specimen placed vaginally was 0.05 mm within the serosa of the bladder. One specimen could not be interpreted, despite multiple cuts. ASC and full-thickness vaginal dissection result in histologically similar locations. Dissection for ASC may only result in the correct plane between the bladder and vagina in approximately 60 % of cases. We achieved full-thickness dissection for the transvaginal approach in 50 % of the cases, with one small penetration into the bladder serosa. Using a full-thickness dissection technique for TVM may be one way of reducing mesh exposure rates in those seen with ASC.

Perioperative complications in abdominal sacrocolpopexy, sacrospinous ligament fixation and prolift procedures.

Pelvic organ prolapse is an important problem for women. To overcome this issue, different operational technics are in use, such as abdominal sacrocolpopexy, sacrospinous fixation, and the total Prolift procedure. This study assessed perioperative complications in abdominal sacrocolpopexy, sacrospinous fixation, and the total Prolift procedure. Retrospective comparative study. Perioperative complications were defined as any complication occurring during surgery or the first 6 weeks postoperatively. Forty-five patients underwent abdominal procedures, 60 patients underwent sacrospinous fixation, and 43 patients underwent the total Prolift procedure. In the abdominal group, one bladder injury, four hemorrhages, and three wound dehiscences occurred. In the sacrospinous group, one rectal injury and one postoperative vault infection occurred. In the Prolift group, one bladder injury and one hemorrhage occurred. Minor complications were more frequent in the abdominal group than the others. The operating time and hospital stay of the abdominal group were significantly longer than the others. The Pro-lift procedure had less operating time and hospital stay than other procedures. The total Prolift may be a novel alternative for apical prolapse with low perioperative morbidities and complications.

The challenge of implementing laparoscopic sacrocolpopexy.

Vaginal-vault prolapse is effectively treated using sacrocolpopexy (SCP). A randomized trial demonstrated that it can be performed as effectively via laparoscopy (LSCP) as via laparotomy and with less morbidity. This evidence begs the question of how units offering abdominal sacrocolpopexy will implement LSCP. Several limitations need to be overcome. LSCP initially requires longer operating time; however, that decreases with surgeon experience. To decrease operation time, suture training can be implemented ahead. Following a 15-h suturing lab, trainees achieved comparable operation times after 30 cases. Dissection is another critical time-consuming step and is difficult to model. Proficiency is more dependent on patient characteristics, though this component is poorly studied. One experience showed it takes 60 procedures to effectively limit complications. The large number of patients required for surgeon training for this relative infrequent operation creates a problem, thus limiting the number of centers available for training surgeons within a reasonable period.

Additional surgical risk factors and patient characteristics for mesh erosion after abdominal sacrocolpopexy.

The aim of this study is to determine the risk factors of mesh exposures following abdominal sacral colpopexy (ASC) in which polypropylene mesh is used. This is a retrospective cohort study of patients who underwent ASC and were subsequently followed for development of mesh exposure for vaginal/vault prolapse between 2002 and 2012. Demographics and risk factors of the patients who did develop mesh exposure after ASC and the ones who did not were compared. In 42 months of survey, 19 of the 292 patients who underwent ASC developed mesh exposure. It was found that rates of patients with stage 3-4 prolapse were significantly greater in the mesh exposure group than in the control group (P = 0.04). Rates of mesh exposure were lower in patients with previous hysterectomy (P = 0.03). Also, it was found that concomitant hysterectomy or three or more additional procedures increased the risk of mesh exposure (P = 0.03 and P = 0.02). In abdominal sacrocolpopexy operations in which polypropylene meshes are used, stage 3 or 4 prolapse, concomitant hysterectomy and three or more additional procedures increase the risk of mesh exposure development.

Utilization and perioperative outcomes of robotic vaginal vault suspension compared to abdominal or vaginal approaches for pelvic organ prolapse.

Robot-assisted vaginal vault suspension (RAVVS) for pelvic organ prolapse (POP) represents a minimally-invasive alternative to abdominal sacrocolpopexy. We measured perioperative outcomes and utilization rates of RAVVS. RAVVS (n = 2381) and open VVS (OVVS, n = 11080) data were extracted from the 2009-2010 Nationwide Inpatient Sample. Propensity score-matched analysis compared patients undergoing RAVVS or OVVS for complications, mortality, prolonged length-of-stay, and elevated hospital charges. Use of RAVVS for POP increased from 2009 to 2010 (16.3% to 19.2%). Patients undergoing RAVVS were more likely to be white (77.2% vs. 69.6%), to carry private insurance (52.8% vs. 46.0%) and to have fewer comorbidities (Charlson Comorbidity Index [CCI] ≥1 = 17.5% vs. 26.6%). They were more likely to undergo surgery at urban (98.2% vs. 93.7%) and academic centres (75.7% vs. 56.7%). Patients undergoing RAVVS were less likely to receive a blood-transfusion (0.7% vs. 1.8%, p < 0.001) or experience prolonged length-of-stay (9.3% vs. 25.1%, p < 0.001). They had more intraoperative complications (6.0% vs. 4.2%, p < 0.001), and higher median hospital charges ($32 402 vs. $24 136, p < 0.001). Overall postoperative complications were equivalent (17.9%, p = 1.0), though there were differences in wound (0.4% vs. 1.3%, p < 0.001), genitourinary (4.9% vs. 6.5%, p = 0.009), and surgical (6.6% vs. 4.9%, p = 0.007) complications. The increasing use of RAVVS from 2009 to 2010 suggests a growth in the adoption of robotics to manage POP. We show that RAVVS is associated with decreased length of stay, fewer blood transfusions, as well as lower postoperative wound, genitourinary and vascular complications. The benefits of RAVVS are mitigated by higher hospital charges and higher rates of intra-operative complications.

Perioperative complications of robotic sacrocolpopexy for post-hysterectomy vaginal vault prolapse

Open abdominal sacrocolpopexy has been the preferred treatment for post-hysterectomy vaginal vault prolapse. In light of the rise in popularity of less invasive robotic sacrocolpopexy, our objective was to compare perioperative complications of robotic vs open sacrocolpopexy. This was a single-institution, retrospective cohort study of robotic and open sacrocolpopexies. Robotic sacrocolpopexies performed between 1 January 2007 and 31 December 2009 were compared with open cases performed between 1 January 2002 and 31 December 2006. Baseline and intraoperative variables of the groups were compared. Complications were compared univariately and in a multivariable logistic regression model to adjust for prior transabdominal surgery. A total of 50 robotic and 87 open sacrocolpopexies were analyzed. Baseline characteristics were similar, but patients in the open group had more prior transabdominal surgeries. The robotically assisted group had decreased estimated blood loss (median, 100mL vs 150mL; P = 0.002) and hospital stay (median, 2days vs 3days; P < 0.001), but increased operative time (median, 4.6 vs 2.9h; P < 0.001), cystotomy (10.0% [5 out of 50] vs 1.1% [1 out of 87]; P = 0.02), and vaginotomy (24.0% [12 out of 50] vs 5.7% [5 out of 87]; P = 0.003). Two patients in the robotically assisted group had postoperative hernia. There were no differences in rates of ureteral or bowel injury, urinary tract infection, ileus, bowel obstruction, or overall complications. Overall complication rates of robotic and open sacrocolpopexy were not significantly different. The robotically assisted group experienced shorter hospital stay but increased operative times and increased incidence of cystotomy and vaginotomy, possibly reflecting the learning curve of robotic sacrocolpopexy.

Three‐dimensional transperineal ultrasound for imaging mesh implants following sacrocolpopexy

To characterize, using three-dimensional (3D) transperineal ultrasound, the appearance, position and dimensions of mesh implants following minimally invasive abdominal sacrocolpopexy. In women who underwent sacrocolpopexy, mesh was evaluated at rest and on maximal Valsalva, on all 3D orthogonal planes and rendered views. Mesh dimensions were obtained by 3D processing in the midsagittal and coronal planes (anterior, posterior and sacral arm) and were analyzed offline, the operator blinded to clinical data. Overall, 62 women, mean age 58.4 (range, 42-79) years were evaluated at a median of 9 (range, 1-26) months following surgery. The anterior arm of the mesh was caudal to the lowermost point of descent of the anterior compartment in 56 (90.3%) women, was equally positioned in five (8.1%) and was cranial in one. The posterior arm was caudal in 44 (71%) women, was equally positioned in 16 (25.8%) and was cranial in two (3.2%). The Y connection and the sacral arm of the mesh could not be adequately seen because of physical limitations of ultrasound (lower resolution at greater depth), large recurrent rectoceles, echogenic stools or folding of mesh remnants. Folding of the mesh was seen in 46 (74.2%) women, folding of the anterior arm in five (8.1%) and folding of the posterior arm in 23 (37.1%). Folding occurred caudally in 26 (41.9%) women, proximally in 11 (17.7%) and in both areas in nine (14.5%). There were no erosions. Mesh visualization following minimally invasive abdominal sacrocolpopexy procedures using transperineal 3D/four-dimensional (4D) ultrasound is feasible. Studies are needed to evaluate the correlation between ultrasound measures and prolapse recurrence or mesh erosion.

V1-08 SACROCOLPOPEXY WITH AUTOLOGOUS FASCIA

You have accessJournal of UrologyFemale Pelvic Medicine & Reconstructive Surgery1 Apr 2014V1-08 SACROCOLPOPEXY WITH AUTOLOGOUS FASCIA Judy M. Choi, Diana C. Kang, Leah Nakamura, and Shlomo Raz Judy M. ChoiJudy M. Choi More articles by this author , Diana C. KangDiana C. Kang More articles by this author , Leah NakamuraLeah Nakamura More articles by this author , and Shlomo RazShlomo Raz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.602AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Abdominal sacrocolpopexy (ASC) with mesh has been regarded as the most durable operation for advanced pelvic organ prolapse (POP). However, recent reports estimate that there is a 10.5% risk of mesh erosion at 7 years, with either symptomatic or anatomic failure in 34-48% of cases. There are few alternatives noted in the literature to manage severe mesh complications. We propose a novel technique using a patient’s own rectus fascia in lieu of mesh to perform ASC, in the setting of SCP mesh removal. METHODS After IRB approval was obtained, a retrospective review was performed using medical records of patients referred to our tertiary care center for mesh complications following ASC from January 2012 to October 2013. All patients underwent complete ASC mesh removal transabdominally, with concomitant ASC with autologous fascia. A lower midline incision was used to remove the previous mesh, and a 10x2 cm segment of anterior rectus fascia was harvested longitudinally. The fascial segment was then configured into an “L”-configuration; the superior aspect was sutured to the sacral promontory, and the inferior portion was sutured to the vaginal cuff, both using #1 delayed absorbable sutures. RESULTS 10 patients were included in the study. Mean age was 56.5 years. Mean BMI was 28.0 (22.8-38). Mean time from original SCP was 61.9 months (15-128 months). Prior SCP consisted of 7 open, 2 robotic, and 1 laparoscopic SCP. The original SCP was performed with polypropylene (n=4), Prolene (3), Mersilene (1), or Goretex (1) mesh, and all were placed with permanent sutures (Prolene, Gore-Tex, Ethibond). Presenting symptoms included dyspareunia (7), vaginal pain (5), vaginal bleeding (4), lower back pain (5), lower abdominal pain (5), hip pain (4), recurrent urinary infections (3), and defecatory dysfunction (4), as well as one rectovaginal fistula. On presentation, 3 had cystoceles, 2 had enteroceles, and 2 had rectoceles. Mesh could be palpated or seen on 5 patients. During the ASC with autologous fascia, mean EBL was 317 cc, and mean hospital length of stay was 7 days. All patients reported significant improvement of their original symptoms at follow-up (mean 180 days) without any recurrent POP. CONCLUSIONS This is the first report to address the simultaneous management of severe mesh complications from ASC, and POP following ASC mesh removal. Abdominal sacrocolpopexy using autologous fascia is a safe and feasible alternative to the traditional SCP using mesh, although greater follow-up time is necessary to assess its durability and outcomes. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e293-e294 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Judy M. Choi More articles by this author Diana C. Kang More articles by this author Leah Nakamura More articles by this author Shlomo Raz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Fascia Lata Harvest and Hybrid Sling for Robotic Abdominal Sacrocolpopexy

Fascia Lata Harvest and Hybrid Sling for Robotic Abdominal Sacrocolpopexy

Knowing the Relevant Anatomy Related to the Abdominal Sacrocolpopexy

Knowing the Relevant Anatomy Related to the Abdominal Sacrocolpopexy

A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Reply to comment

Dear Editor, We would like to thank Dr Long and colleagues for pointing out the error in our paper [1], i.e. we inadvertently used the word “grade” instead of “stage” for the POPQ. This is a good example of how even those who purport to understand and use the POPQ, still make errors, in our case with terminology. Unfortunately, Dr Long and colleagues [2] have done likewise! In their letter they state that “at least 1 cm above or beyond the hymeneal remnants should be the stage 3 or more of POP-Q”. In fact (as we stated) this is stage II, i.e. leading edge greater than or equal to −1, but less than or equal to +1 [3]. Our baseline data are presented in the results section of the paper [1]: point C was +0.12 for the abdominal and +0.28 for the laparoscopic sacrocolpopexy (i.e. POPQ stage II). At 3 months this was −6.65 (SD 138) and −6.48 (SD 1.50) and the corresponding results at 1 year were −6.63 (SD 1.35) and −6.65 (SD 1.15) for abdominal and laparoscopic sacrocolpopexy respectively. The IUGA/ICS standardization report for the outcomes of prolapse surgery [4] recommends that the leading edge of the prolapse at each site should be reported in detail. This includes all the points as well as the ordinal stage. It could be argued that the points are more meaningful than the stage, but these seem to be reported inconsistently with a recent literature review showing that 47 % of studies used the ordinal stage only and not the points [5]. It is important that there is some form of staging or grading of prolapse and maybe the “simplified POPQ”, which uses the ordinal stage, could be used in routine practice [6], as some clinicians perceive the full POPQ to be “too complex”. The “simplified” system has been validated and shown to have a good association with the full POPQ [6]. However, the latter should be used in all research [4] and those undertaking the examination must be fully trained in the technique to ensure accurate data and reporting. Whether this occurs or not is unclear. It is encouraging to see the improved uptake in the use of the POPQ since our study in 2004, which showed that only 40 % of IUGA and AUGS members used it routinely in their clinical practice [7]. A recent study has suggested that 76 % of AUGS and ICS members are now using the POPQ, but the authors state that the technique “varied considerably” [8]. This raises further concern about training and maybe the reliability of some data. Dr Long’s comments are helpful and allow us to highlight these concerns. The POPQ was originally described in 1998 and maybe now is the time for the ICS, AUGS, SGS and IUGA to revisit it and, more importantly, the training. R. M. Freeman (*) :K. Pantazis : L. Bombieri :M. Waterfield Urogynaecology Unit, Directorate of Women’s Health, Derriford Hospital, Derriford Road, Crownhill, Plymouth PL6 8DH, UK e-mail: robert.freeman@nhs.net

A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Comment

Dear Editor, We read with great interest the article by Freeman et al. [1] and commend the authors for further investigating the efficacy of abdominal versus laparoscopic sacrocolpopexy. The study design was good and obtained important evidence of the discrepancy between two different routes. However, we feel that the text of “Patients and methods” is flawed in its description of the pelvic organ prolapse quantification (POP-Q) system [2]. The authors state: “Patients referred with symptomatic grade 2 or more post-hysterectomy vaginal vault prolapse (i.e. vaginal angles/“dimples” seen at least 1 cm above or beyond the hymeneal remnants)”. It is apparent that this statement is contradictory. It is well known that grade classification belongs to the Baden– Walker half-way system. Women with grade 2 or more vault prolapse means that their leading portions of prolapse are over the mid-plane of the vagina, while the latter sentence showing “at least 1 cm above or beyond the hymeneal remnants” should equate to stage 3 or more of the POP-Q system. Moreover, the “Inclusion criteria” showed “patients with symptomatic and bothersome vault prolapse of greater than or equal to grade 2 on the POP-Q”. I wonder about the real extent of POP in all the participants in this study. Over the last decades, the POP-Q system has gained international recognition as the “gold standard” for classifying pelvic support and a number of reports in the literature document excellent intraand inter-examiner reliability [3]. The Baden–Walker half-way system remains commonly employed in clinical practice because of its ease of use. However, it should not continue to replace the POP-Q system in scientific studies [3]. Although this is simple knowledge in POP, a number of clinical surgeons ignore it. We hope that this letter might remind reviewers or authors to take a look at the discrepancies between the two classification systems.