Abdominal Sacrocolpopexy Procedures Research Articles

Perioperative complications and long term consequences of sacrospinous ligament fixation and abdominal sacrocolpopexy

Objective: This retrospective study was done for comparison of early complications and long term consequences sacrospinous fixation (SSF) and abdominal sacrocolpopexy. Method: This sutdy was performed retrospectively from july 2015 to september 2017. Fifty four women were included the study. Forty women underwent vaginal sacrospinous fixation following vaginal hysterectomy for total prolapse and vaginal vault repair. Fourteen women underwent abdominal sacrocolpopexy procedure for preventing vaginal vault prolapsus. Perioperative complications were defined as any complication occurs during surgery or at the first 6 weeks postoperatively. Results: All patients were followed up for 6 weeks, 3, 6. and 12 th months postoperatively. Intraoperative presacral venous bleeding during the abdominal sacrocolpopexy were detected in two subjects. They were treated with applying pressure with gauze pad about 10 minutes. Vesical injury occured in one subject during the vaginal hysterectomy which was repaired easily via vaginally. The mean duration of follow-up was 12 months. Recurrent vaginal vault prolapses and cystocele in two cases, rectosel in one case and stress incontinence in two cases were detected following SFF. Conclusions: SSF can be used as an adjunctive and easy procedure after vaginal hysterectomy in pelvic organ prolapse. The advantage of the operation is avoiding of the laparatomy and preserve the functionality of the vagina. Abdominal sacrocolpopexy was associated with a higher succes of operative result.

Flow disruptions in robotic-assisted abdominal sacrocolpopexy: does robotic surgery introduce unforeseen challenges for gynecologic surgeons?

The purpose of this study was to apply a human factors research approach to identify flow disruptions, deviations in the optimal course of care, in robotic abdominal sacrocolpopexy procedures with the ultimate goal of developing system interventions to improve the safety and efficiency of robotic surgery. Twenty-four robotic abdominal sacrocolpopexy procedures were observed for flow disruptions. Surgeries were divided into four phases: (1) patient arrival and induction of anesthesia; (2) port placement and robot docking; (3) console time; (4) undocking of robot, incision closure, and patient exiting the OR. Flow disruptions were observed at a rate of 10.9 ± 5.1 per hour. The most frequently observed flow disruptions involved training issues (2.8 ± 2.4 flow disruptions per hour), equipment (2.2 ± 1.6 flow disruptions per hour), and poor coordination (2.0 ± 1.3 flow disruptions per hour). The rate of flow disruptions was highest in phase 2 (19.2 ± 14.4 flow disruptions per hour). Cases with more experienced surgeons involved shorter console times by 1.5h (95% CI: 0.1, 3.0, p = 0.033) and 1.8 fewer (95% CI: 1.2, 2.6, p = 0.001) flow disruptions per hour. Surgeries were 1h shorter on average (95% CI: 0.1, 1.9, p = 0.034) in cases in which the patient was > 65years old. Da Vinci S console times were 0.8h longer (95% CI: 0.01, 1.5, p = 0.047) than Si. Flow disruptions in robotic abdominal sacrocolpopexy surgery occur about every 6min. Flow disruption rates are highest during the most complex portions of the surgery. More experienced surgeons have lower flow disruption rates and operate more quickly.

Updates in Minimally Invasive Approaches to Apical Pelvic Organ Prolapse Repair

The purpose of this article is to review and comment on the recent medical evidence regarding minimally invasive procedures for apical pelvic organ prolapse repair. Sacrocolpopexy remains the “gold standard” repair for apical prolapse for those who desire to maintain sexual function, and minimally invasive approaches offer equal efficacy with lower risk than open sacrocolpopexy. Similar to the impact on hysterectomy rates, the introduction of robotic technology has converted a large number of open abdominal sacrocolpopexy procedures to a minimally invasive approach in the USA. Newer surgical approaches such as nerve-sparing techniques of dissection at the sacral promontory, use of the iliopectineal ligaments, and natural orifice vaginal sacrocolpopexy offer potential improvements for apical repair. Whether using traditional laparoscopy or robotic assistance, prolapse recurrence is consistently noted in at least 10% of patients. Recent evidence has confirmed that ancillary factors including pre-operative prolapse stage, retention of the cervix and/or uterus, type of mesh implant, and genital hiatus size all adversely affect surgical efficacy. Minimally invasive apical repair procedures seem well suited to early recovery after surgery protocols. While overall complication rates are low, small bowel injury is higher with any abdominal approach and aggressive evaluation of women not meeting routine post-operative goals is advised. Minimally invasive sacrocolpopexy has achieved similar outcomes to the traditional abdominal route and should be considered the new “gold standard” in apical prolapse repair. Alterations in surgical techniques can reduce the risk of constipation.

2123 A clinically relevant rabbit surgical model of pelvic reconstruction to evaluate the immune response to novel surgical materials

OBJECTIVES/SPECIFIC AIMS: Pelvic organ prolapse, a disorder in which the muscles of the pelvic floor are weakened over time, affects over a million women each year in the United States. A quarter of these women undergo a reconstructive procedure, increasingly using polypropylene mesh as mechanical reinforcement to the pelvic floor. However, the number of complications such as chronic pain and mesh erosion/exposure in women with vaginal mesh implants were reported at rates as high as 10%–20%. This indicates a limited understanding of the host response to mesh in vaginal tissue and strategies to reduce these complications. Utilizing a novel surgical technique in New Zealand white rabbits, we implant mesh analogously to human implantation and evaluate changes in the immunologic response at early (14 d) and tissue remodeling outcomes at late stages (90 and 180 d) of implantation. The mesh-tissue complex was removed from each rabbit and processed for histological staining as well as immunolabeling of immune cells, such as macrophages. Extracellular matrix protease assays and mechanical integrity of the tissue also evaluate the overall inflammatory response associated with each implant. METHODS/STUDY POPULATION: Commercially available polypropylene mesh was used to investigate the modulation of the immune response. An adapted radio frequency glow discharge method is used to create a stable negative charge on the surface of the mesh, followed by the sequential deposition of polycationic and polyanionic polymers to provide a stable, conformal, nanoscale coating. It is well known macrophages are characterized on a spectrum ranging from a proinflammatory M1 phenotype to an M2 anti-inflammatory phenotype. Interleukin-4, an immunomodulatory cytokine known to promote the M2 phenotype, is incorporated into the coating to be released in a controlled manner upon implantation. Utilizing a novel surgical technique in New Zealand white rabbits, we implant mesh using the “gold standard” abdominal sacrocolpopexy procedure and evaluate changes in the immunologic response at early (14 d) and tissue remodeling outcomes at late stages (90 and 180 d) of implantation. The procedure begins with an initial hysterectomy removing the uterus followed by creating space along the vaginal wall on both sides between the bladder and the rectum. Two 3×10 cm2 pieces of mesh are secured along both sides of the vaginal wall. The remaining flaps at the top are then secured to a ligament in the sacral/lumbar space, creating the support to the pelvic organs. Upon closing the incision, a partial thickness defect is made in the abdominal wall, and mesh is implanted inside to repair the abdominal muscle. Both of these implantations of mesh allow for the assessment of the immune response in the pelvic area (relevant for prolapse patients) and in the abdominal area (relevant for translation from hernia repair).The mesh-tissue complex was removed from each rabbit and processed for histological staining as well as immunolabeling of immune cells, such as macrophages. Extracellular matrix protease assays and mechanical integrity of the tissue also evaluate the overall inflammatory response associated with each implant. RESULTS/ANTICIPATED RESULTS: The results of this study show that implants into vaginal tissues elicited an increased host inflammatory response at 14 days as compared with those in the abdominal wall. However, at chronic time points the inflammatory response in the vagina was reduced as compared to that in the abdominal cavity. The present study also demonstrates the scale-up of a previous methodology for a nanoscale coating. We present a nanometer thickness, tunable, and uniform coating capable of releasing bioactive interleukin-4. We evaluated the biological functionality of the coated mesh via bioactivity studies and in vivo implantation. An ideal mesh would provide mechanical support to the pelvic floor while decreasing the inflammatory response and increasing integration with the surrounding native tissue. DISCUSSION/SIGNIFICANCE OF IMPACT: We developed an in vivo model clinically relevant to understanding the early host response to mesh in an anatomically relevant area, the vaginal microenvironment. Previous studies have been conducted in a rodent abdominal defect model while other work has been done in a nonhuman primate vaginal model, but the host response is only observed at later time points (>3 mo). Thus, we developed a rabbit model to investigate early responses and a novel coating to actively working towards improved tissue integration.

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Does menopausal status impact urinary continence outcomes following abdominal sacrocolpopexy without anti-incontinence procedures in continent women?

Objective:We investigated the impact of menopausal status on urinary continence following abdominal sacrocolpopexy (ASC) without an anti-incontinence procedure in continent women.Methods:We conducted a clinical follow-up study of 137 patients diagnosed with stage 3 or higher pelvic organ prolapse (POP) without urinary incontinence between January 2012 and December 2014. Patients were provided with detailed a priori information pertaining to the abdominal sacrocolpopexy procedure and were invited to attend follow-up visits at 1, 3, 12, and 24 months. Follow-up visits included a gynecological examination, cough test, and validated Urinary Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7) questionnaires.Results:The mean follow-up time for the cohort was 16.5±3.45 months. The study group was divided according to menopausal status: premenopausal (Group-1) and postmenopausal women (Group-II). Anatomical recurrence was not detected during the follow-up period in either group, but de novo stress urinary incontinence was seen in 15 of 53 (28.3%) Group-I patients and in 6 of 84 (7.1%; p < 0.01) Group-II patients.Conclusions:The risk of de novo stress urinary incontinence in postmenopausal women after ASC is low. However, premenopausal patients have a higher incidence of de novo stress incontinence which affect quality of life.

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.

Strangulated small bowel 14 years after abdominal sacrocolpopexy

Abdominal sacrocolpopexy is a well-established procedure for the reconstruction of apical support in pelvic organ prolapse. Its long-term efficacy is well known; however, it is also associated with higher perioperative morbidity when compared with the less invasive transvaginal approach. Long-term risk of bowel-related complication from abdominal sacrocolpopexy is rare, but can be significant as it is often serious and requires major surgical intervention. Here we highlight an unusual case of strangulated small bowel (in this instance complicated with sepsis secondary to peritonitis), 14 years after an abdominal sacrocolpopexy procedure. This example amplifies the need for proper preoperative counseling; also, life-long follow-up is necessary for patients undergoing this procedure.

Remote discovery of an asymptomatic bowel perforation by a mid-urethral sling

Bowel perforation is a rare complication of mid-urethral sling procedures and is usually reported shortly after the surgery. We report a remotely discovered asymptomatic bowel injury found at the time of subsequent surgery. The patient with a history of several prior pelvic surgeries underwent an uneventful retropubic mid-urethral sling placement. Five years later, during an abdominal sacrocolpopexy procedure, mesh from the mid-urethral sling was found perforating the wall of the cecum and fixating it to the right pelvic sidewall. Cecal wedge resection was performed to excise the sling mesh. Asymptomatic bowel perforation by mid-urethral sling mesh has not been previously reported. Pelvic and abdominal surgeons should be aware of the possibility of finding this injury in patients with prior sling surgeries.

Cost-Minimization Analysis of Robotic-Assisted, Laparoscopic, and Abdominal Sacrocolpopexy

Study Objective To perform a cost-minimization analysis comparing robotic-assisted, laparoscopic, and abdominal sacrocolpopexy. Design Cost-minimization analysis using a micro-costing approach (Canadian Task Force classification III). Measurements and Main Results A decision model was developed to compare the costs (2008 US dollars) of robotic, laparoscopic, and abdominal sacrocolpopexy. Our model included operative time, risk of conversion, risk of transfusion, and length of stay (LOS) for each method. Respective baseline estimates for robotic, laparoscopic, and abdominal sacrocolpopexy procedures included operative time (328, 269, and 170 minutes), conversion (1.4%, 1.8%, and 0%), transfusion (1.4%, 1.8%, 3.8%), and LOS (1.0, 1.8, and 2.7 days). Two models were used, the Robot Existing model, that is, current hospital ownership of a robotic system, and the Robot Purchase model, that is, initial hospital purchase of a robotic system, with purchase and maintenance costs amortized and distributed across robotic procedures. Sensitivity analyses were performed to assess the effect of varying each parameter through its range. For the Robot Existing robot model, robotic sacrocolpopexy was the most expensive, $8508 per procedure compared with laparoscopic sacrocolpopexy at $7353 and abdominal sacrocolpopexy at $5792. Robotic and laparoscopic sacrocolpopexy became cost-equivalent only when robotic operative time was reduced to 149 minutes, robotic disposables costs were reduced to $2132, or laparoscopic disposable costs were increased to $3413. Laparoscopic and abdominal sacrocolpopexy became cost-equivalent only when laparoscopic disposable costs were reduced to $668, mean LOS for abdominal sacrocolpopexy was increased to 5.6 days, or surgeon reimbursement for abdominal sacrocolpopexy exceeded $2213. The addition of robotic purchase and maintenance costs resulted in an incremental increase of $581, $865, and $1724 per procedure when these costs were distributed over 60, 40, and 20 procedures per month, respectively. Conclusion Robotic sacrocolpopexy was more expensive compared with the laparoscopic or abdominal routes under the baseline assumptions.

Non-Oral Poster 47

OBJECTIVES: To determine the effect the Da Vinci robotic system made on our surgical approach to apical pelvic support defects during the first year of its institution at our medical center. MATERIALS AND METHODS: A retrospective review of our surgical database from June 2007 to June 2009 was conducted. The total number of uterosacral suspensions, sacrospinous ligament fixations, iliococcygeus fascia suspensions and abdominal sacrocolpopexy procedures during the year prior to the introduction of the robotic system (June 2007 to June 2008) was compared to the corresponding numbers in the following year after the robotic system was in use. The total number of robotic sacrocolpopexy procedures was also determined. Statistical analysis was performed using the chi-square statistical test with a P-value <0.05 was considered significant. RESULTS: During the two-year period, there were 135 total cases (39 in the first year, 96 in the second) performed for apical prolapse repair. In the first year, the primary surgery for apical prolapse was the uterosacral suspension with a rate of 72% (28/39). In the following year there was a notable decline in this procedure to only 27% (26/96) with a difference of 45% (P < 0.0001). Similarly, the rates of abdominal sacrocolpopexy declined from 17.9% (7/39) in the first year to 4.16% (4/96) in the year following the introduction of the robot with a difference of 13.7% (P < 0.004). There were no statistically significant changes in the rates of sacrospinous ligament fixation and iliococcygeus fascia suspensions in the two years with total rates less than 8%. During the second year, with the addition of the da Vinci system, the rates of robotic sacrocolpopexy were 57% (55/96), making this the primary method of apical prolapse repair during this year. In comparing vaginal to abdominal approaches there was a decline in the overall percentage of vaginal cases from 82% in the year prior to the robot to 38.5% the year following, which was a statistically significant change (P < 0.0001). CONCLUSION: At our institution, the surgical approach to apical prolapse repair significantly changed after the introduction of robotic technology. Evaluation of surgical outcomes following this paradigm shift are ongoing.

Abdominal Sacrocolpopexy: Anatomic Outcomes and Complications With Pelvicol, Autologous and Synthetic Graft Materials

In abdominal sacrocolpopexy (ASC), a graft is used to secure the apex of the prolapsed vagina to the anterior longitudinal ligament of the sacrum. This retrospective cohort study enrolled women having ASC (abdominal sacrohysteropexy or abdominal sacral colpoperineopexy) in the years 2001–2005. Synthetic mesh was used in 52% of 259 ASC procedures; porcine dermis (Pelvicol) in 39%; and autologous fascia in 9%. Patients in whom synthetic mesh was used were older than others, more likely to have had hysterectomy, and likelier to be postmenopausal. Concomitant surgery was performed least often in the synthetic mesh group. Postoperative follow-up averaged 1.1 years. The primary outcome was anatomical failure of ASC at the apical compartment. Rates of apical failure were 11% when Pelvicol was used, 7% with autologous fascia, and 1% with synthetic mesh. All 7 reoperations necessitated for apical prolapse were in the Pelvicol group. Intraoperative and immediate postoperative complications were comparably frequent in the 3 treatment groups. Intraoperative problems included cystotomy in 6% of patients, enterotomy in 1.5%, and a single ureteral injury. Erosions occurred in 11% of the Pelvicol group. Similar numbers of reoperations for graft-related complications were required in all groups. The most common such complications were granulation tissue formation and erosion. These results show that ASC is likelier to fail when Pelvicol is used rather than synthetic mesh or autologous fascia. In addition, using Pelvicol did not lessen the risk of graft-related complications in this study population.

Abdominal sacrocolpopexy: anatomic outcomes and complications with Pelvicol, autologous and synthetic graft materials

The purpose of this study was to compare anatomic outcomes and graft-related complications (GRCs) for abdominal sacrocolpopexy (ASC) with Pelvicol (CR BARD, Murray Hill, NJ), autologous fascia, and synthetic grafts. This is a retrospective cohort study of ASC from 2001-2005. We reviewed anatomic outcomes and GRCs. Apical failure was defined as >stage 0. Of 259 ASC procedures, Pelvicol was used in 102 procedures (39%); synthetic mesh in 134 procedures (52%), and autologous fascia in 23 procedures (9%). Mean postoperative follow up was 1.1 years. Apical failure by graft group were Pelvicol 10 (11%), synthetics 1 (1%), and autologous 1 (7%; P = .011). All 7 reoperations for apical prolapse were in the Pelvicol group. GRCs occurred in 16% of the cases, with a higher proportion of erosions in the Pelvicol group (11% vs 3% and 4%; P = .045). Reoperations as a result of GRC were similar between groups. ASC is more likely to fail with Pelvicol than with synthetic or autologous grafts. The use of Pelvicol did not reduce graft-related complications in this population.

Incidence and management of abdominal sacrocolpopexy mesh erosions

This study was undertaken to evaluate the occurrence and management of mesh erosions in patients undergoing abdominal sacrocolpopexy. A retrospective chart review of the abdominal sacrocolpopexy procedure (n = 92) between 1997 and 2003 was performed. Patients with mesh erosion were identified. Incidence by graft type and treatment required for erosion resolution was analyzed with chi 2 and Fisher exact test. Erosions occurred in 7.6 % (7/92). Erosions were identified only in patients with Gore-Tex (3/33, 9%) or silicone-coated mesh (4/21, 19%) compared with none of 38 patients with polypropylene mesh (n = 24) or fascia (n = 14) grafts ( P = .068.). Partial excision of exposed graft resolved all 3 Gore-Tex erosions, compared with none of the silicone-coated mesh erosions ( P = .03). Complete graft removal was required to resolve silicone-coated mesh erosions. We observed a high rate of erosion with Gore-Tex and silicone-coated mesh. Partial graft excision was adequate for Gore-Tex erosions, but complete graft removal was necessary to resolve erosions associated with silicone-coated mesh.