Anterior Compartment Prolapse Research Articles

Pre-operative Prolapse Phenotype is Predictive of Surgical Outcome with Minimally Invasive Sacrocolpopexy

The gold-standard treatment for advanced pelvic organ prolapse is sacrocolpopexy. However, the preoperative features of prolapse that predict optimal outcomes are unknown. This study aimed to develop a clinical prediction model that uses preoperative scores on the Pelvic Organ Prolapse Quantification examination to predict outcomes after minimally invasive sacrocolpopexy for stages 2, 3, and 4 uterovaginal prolapse and vaginal vault prolapse. A 2-institution database of pre- and postoperative variables from 881 cases of minimally invasive sacrocolpopexy was analyzed. Data from patients were analyzed in the following 4 groups: stage 2 uterovaginal prolapse, stage 3 to 4 uterovaginal prolapse, stage 2 vaginal vault prolapse, and stage 3 to 4 vaginal vault prolapse. Unsupervised machine learning was used to identify clusters and investigate associations between clusters and outcome. The k-means clustering analysis was performed with preoperative Pelvic Organ Prolapse Quantification points and stratified by previous hysterectomy status. The "optimal" surgical outcome was defined as postoperative Pelvic Organ Prolapse Quantification stage <2. Demographic variables were compared by cluster with Student t and chi-square tests. Odds ratios were calculated to determine whether clusters could predict the outcome. Age at surgery, body mass index, and previous prolapse surgery were used for adjusted odds ratios. Five statistically distinct prolapse clusters (phenotypes C, A, A>P, P, and P>A) were found. These phenotypes reflected the predominant region of prolapse (apical, anterior, or posterior) and whether support was preserved in the nonpredominant region. Phenotype A (anterior compartment prolapse predominant, posterior support preserved) was found in all 4 groups of patients and was considered the reference in the analysis. In 111 patients with stage 2 uterovaginal prolapse, phenotypes A and A>P (greater anterior prolapse than posterior prolapse) were found, and patients with phenotype A were more likely than those with phenotype A>P to have an optimal surgical outcome. In 401 patients with stage 3 to 4 uterovaginal prolapse, phenotypes C (apical compartment predominant, prolapse in all compartments), A, and A>P were found, and patients with phenotype A>P were more likely than those with phenotype A to have ideal surgical outcome. In 72 patients with stage 2 vaginal vault prolapse, phenotypes A, A>P, and P (posterior compartment predominant, anterior support preserved) were found, and those with phenotype A>P were less likely to have an ideal outcome than patients with phenotype A. In 297 patients with stage 3 to 4 vaginal vault prolapse, phenotypes C, A, and P>A (prolapse greater in posterior than in anterior compartment) were found, but there were no significant differences in rate of ideal outcome between phenotypes. Five anatomic phenotypes based on preoperative Pelvic Organ Prolapse Quantification scores were present in patients with stages 2 and 3 to 4 uterovaginal prolapse and vaginal vault prolapse. These phenotypes are predictive of surgical outcome after minimally invasive sacrocolpopexy. Further work needs to confirm the presence and predictive nature of these phenotypes. In addition, whether the phenotypes represent a progression of prolapse or discrete prolapse presentations resulting from different anatomic and life course risk profiles is unknown. These phenotypes may be useful in surgical counseling and planning.

How Old Is Too Old? Outcomes of Prolapse Native-Tissue Repair through Uterosacral Suspension in Octogenarians.

Medical advancements are expected to lead to a substantial increase in the population of women aged 80 and older by 2050. Consequently, a significant number of individuals undergoing corrective prolapse surgery will fall into the elderly-patient category. The research indicates a notable rise in complications associated with prolapse surgery in patients older than 80, irrespective of frailty and other risk factors. Despite these challenges, the vaginal approach has been identified as the safest surgical method for pelvic organ prolapse (POP) repair in the elderly population. For this reason, we aimed to investigate the efficacy, complication rate, and functional outcomes associated with vaginal hysterectomy and an apical suspension/high uterosacral ligaments suspension as a primary technique for prolapse repair, both within a cohort of elderly patients. We retrospectively analyzed patients who underwent transvaginal hysterectomy plus an apical suspension procedure for stage ≥ II and symptomatic genital prolapse between January 2006 and December 2013. Anatomical and functional outcomes were evaluated. The Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. Sixty-five patients were included in the analysis. The median age was 81.3 years. All individuals exhibited an anterior compartment prolapse stage II or higher, and the majority also a central prolapse stage II or higher. Notably, all participants reported symptoms of vaginal bulging. Over half of the population (58.6%) complained of incomplete bladder emptying. The intervention for all participants involved a vaginal hysterectomy with an apical suspension. Sixty-three patients (96.9%) and forty-four patients (67.6%) underwent a simultaneous anterior or posterior repair, respectively. Long-term complications (>30 days from surgery) were observed during follow-up, with a median duration of 23 ± 20 months. Seven (10.7%) anatomical recurrences were recorded, five (7.69%) concerning the anterior compartment, one (1.5%) the central, and three (4.6%) the posterior. Nevertheless, none of them necessitated further surgical intervention due to symptoms. Significant anatomical improvements for the anterior, central, and posterior compartments were noticed, compared to preoperative assessment (p < 0.001 for Aa and Ba, p < 0.001 for Ap and Bp, and p < 0.001 for C). PGI-I values established that 100% of patients were satisfied (PGI-I ≥ 2), with a median score of 1.12. Consequently, objective and subjective cure rates were 89.5% and 100%, respectively. Vaginal hysterectomy combined with apical suspension, particularly high uterosacral ligaments suspension, is a safe and effective primary surgical approach, even in elderly patients.

Anterior-apical Transvaginal Mesh (Calistar-S) for Treatment of Advanced Urogenital Prolapse: Surgical and Functional Outcomes at 1 Year.

Calistar-S is a single-incision synthetic mesh kit that addresses apical and anterior compartment prolapse. The aims of this study were to evaluate the short-term objective and subjective outcomes at the 1-year follow-up. The secondary objectives were to evaluate quality of life and lower urinary tract symptoms (LUTS) outcomes, as well as surgical complications. Records of 108 patients with symptomatic advanced pelvic organ prolapse (stages III and IV) who underwent prolapse surgery using the Calistar-S system from June 2018 to August 2022 were reviewed. The primary outcome was the objective cure of anterior and apical prolapse < stage 1, and the subjective cure was the negative response to questions 2 and 3 of the Pelvic Organ Prolapse Distress Inventory-6. Secondary outcomes measured quality of life, the presence of lower urinary tract symptoms, and complications. A total of 101 patients were evaluated. The overall objective cure rate is 97% and the subjective cure rate is 92.1%. Good outcomes were seen in all three compartments. Secondary outcomes show significant improvement in all validated questionnaires. Persistence and de novo urinary incontinence were 15.2% and 18.2% post-operatively. There is one case of bladder injury and one case of vaginal mesh exposure. The Calistar-S System is a safe and efficient method for treating advanced-stage POP. We observed good anatomical results and subjective relief with a minimal complication rate. LUTS have also been positively affected, showing a high success rate. Additional studies are needed to establish the long-term efficacy of this system.

Is Stress Urinary Incontinence Symptom Determined by the Severity of Anterior Compartment Prolapse?

Background: Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) would develop simultaneously because of the same etiopathogenesis of pelvic floor weakness. Some studies have said the association between SUI symptoms may be determined by the degree of anterior compartment prolapse. Then some incidences of occult SUI could also mask the symptom of SUI in the severe stage of POP. Methods: A total of 32 women diagnosed with POP and SUI from the urogynecology clinic were included in a cross-sectional study between 2019 and 2020. The degree of anterior compartment prolapse was measured using the POP-Q system (Ba point), while SUI's severity was measured using a 1- hour pad test in grams. The correlation between the severity of SUI (with the occurrence of occult SUI) and the anterior compartment prolapse was analyzed. Results: No correlation was observed between the degree of anterior compartment prolapse and SUI degree (r = 0.240, p = 0.182). Occult SUI was found in only 5/24 (20.8%) grade III and IV anterior compartment prolapse cases. Conclusion: SUI symptom was not determined by the severity of anterior compartment prolapse. The prevalence of occult SUI in severe POP was also low.

A comparison between the vaginal patch plastron associated with the anterior sacrospinous fixation and the Uphold™ LITE vaginal support system for the treatment of advanced anterior vaginal wall prolapse

ObjectiveThe aim of the present study was to compare efficacy and safety of the vaginal patch plastron (VPP) associated to the anterior sacrospinous fixation (SSLF-A) with a TVM procedure (Uphold™ LITE support-system) for the treatment of the advanced anterior vaginal wall prolapse.Study design.Single-center retrospective study. Women with symptomatic anterior prolapse ≥ III stage according to the POP-quantification (POP-Q) system and submitted to the VPP associated with the SSLF-A or to the Uphold™ procedure were included. Primary outcome was to compare objective and subjective cystocele relapse and reoperation rate at 6- and 12-month follow-up. Secondary outcome was to describe peri- and postoperative complications. Pearson chi-square test and exact Fisher test were adopted for categorical variables, while intergroup Mann-Whitney U test and intragroup Wilcoxon Rank Sum Test for continuous variables; the statistical analysis was conducted at 95 % confidence level. ResultsFifty-five women in VPP-group and 118 women in Uphold-group were included. At 6-month follow-up, objective anterior relapse in VPP-group (3/55, 5.4 %) was like Uphold-group (5/118, 4.2 %; p = 0.71), as well as objective apical relapse (0/55, 0 % vs 3/118, 2.5 %; p = 0.55); no significant difference emerged in bulge symptoms (1/55, 1.8 % vs 5/118, 4.2 %; p = 0.67). At 12-month follow-up women were telephonically investigated; no significant difference emerged in bulge symptoms (1/55, 1.8 % vs 6/118, 5.1 %; p = 0.43). Reoperation rate for the composite outcome POP relapse, stress urinary incontinence (SUI) and remotion of the TVM resulted lower in the VPP group (1/55, 1.8 % vs 13/118, 11 %; p = 0.03). Post-operative buttock pain (32/55, 58.2 % vs 24/118, 20.3 %; p < 0.0001) and post-operative urinary retention (16/55, 29.1 % vs 6/118, 5.1 %; p < 0.0001) were higher in VPP-group, with a complete resolution between 2 and 3 weeks after treatment. ConclusionVPP associated with SSLF-A was as effective as Uphold™ LITE support-system for both anterior and central compartment prolapse treatment at 6- and 12-month follow-up. VPP-group presented a lower reoperation rate for the composite outcome prolapse relapse repair, SUI, and removal of the mesh.

Simulación de soporte apical al evaluar el prolapso del compartimiento anterior y posterior

Objective: To evaluate whether simulated correction of apical prolapse determines the reduction or disappearance of anterior and posterior vaginal prolapse, using the Pelvic Organ Prolapse Quantification (POPQ) system. Methods: Cross-sectional study. The population consisted of patients who attended to the Hospital Universitario de Caracas with pelvic organ prolapse stage II or greater and who had involvement of the apical compartment between 2021 and 2022. The selection of the sample was made in a non-probabilistic, sequential way. Each patient underwent POPQ before and after simulation of apical support with the posterior blade of a standard Graves speculum. The Aa Ba Ap and Bp points were evaluated before and after simulation and the proportion of patients in whom the stage of anterior or posterior prolapse changed when simulating apical support was also determined. Results: We included 100 patients, most of them with prolapse stage III and IV. After apical support, the anterior compartment points were corrected to a value between 0 to -2 or -3 in most cases (p&lt; 0.05). The points corresponding to the posterior vaginal wall changed to -3 in most patients (p&lt; 0.05). The prolapse stage of the anterior compartment, changed to stage ≤ II in 99 % of cases (p&lt; 0.05), and in 100% in the posterior compartment (p&lt;0.05). Conclusion: Simulation of apical support during POPQ demonstrated correction of anterior and posterior compartment prolapse in a high percentage of patients.

Surgical outcomes of sacrospinous ligament fixation at the time of vaginal hysterectomy for vaginal vault prolapse prevention: 10 years review.

To study the non-recurrent prolapse rate after vaginal hysterectomy colpoperineorrhaphy and sacrospinous ligament fixation (SSLF) with or without anterior colporrhaphy, with or without posterior colpoperineorrhaphy. A retrospective cohort study was carried out at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, during January 1, 2012-December 31, 2021. The inclusion criteria were Thai women diagnosed with uterovaginal prolapse and undergone vaginal hysterectomy, with or without anterior colporrhaphy, with or without posterior colpoperineorrhaphy, with SSLF and had the complete pelvic organ prolapse quantification (POP-Q) information at the 12 months follow up. The recurrent case was defined as any compartment prolapse ≥ stage II by POP-Q classification at 1, 3, 6, 12 months follow up. Of 71 cases included, 20 cases had recurrent prolapse at 12 months. The incidences of non-recurrent prolapse rate at 1, 3, 6, and 12 months were 70/71 (98.59%), 65/70 (92.86%), 58/65 (89.23%), and 51/58 (87.93%). The overall PHVP prevalence at 12 months was 2/71 (2.81%). The anterior compartment prolapse were 18/71 (25.35%) at 12 months. The most common postoperative complications were the urinary tract infection (4.23%). There were one case of nerve entrapment and one case of stitches exposure that required stitches removal. SSLF at the time of vaginal hysterectomy is safe and effective in post hysterectomy vaginal vault prolapse prevention. But there are high recurrence rate of anterior compartment prolapse at 12 months. Preoperative counseling and long-term follow up after SSLF is advocated.

Rate of Postoperative Urinary Retention after Anterior Compartment Prolapse Surgery: A Randomized Controlled Trial Comparing Early versus Conventional Transurethral Catheter Removal.

Pelvic organ prolapse is a common condition of pelvic floor dysfunction in women, especially in adult vaginally parous and elderly women. Because of its anatomy, the anterior compartment has a significant effect on urinary symptoms. Anterior colporrhaphy and colpocleisis are major anterior compartment prolapse-related surgeries. As we know, postoperative urinary retention (POUR) is one of the most common complications following pelvic floor surgery. To prevent this complication, indwelling bladder catheterization is routinely applied. In contrast, to minimize risk of infection and the patient's discomfort, the catheter should be removed as soon as possible. However, there is a lack of clarity regarding the optimal timing for catheter removal. Therefore, the aim of this trial is to compare the rate of POUR after anterior prolapse surgery between early transurethral catheter removal (24 h postoperatively) and our standard practice (on postoperative day 3). We conducted a randomized controlled trial among patients undergoing anterior compartment prolapse surgery between 2020 and 2021 at a university hospital. Women were randomized into two groups. After removal, if the second void residual urine volume exceeded 150 mL, POUR was diagnosed, and intermittent catheterization was performed. The primary outcome was the POUR rate. The secondary outcomes included urinary tract infection, asymptomatic bacteriuria, time to ambulation, time to spontaneous voiding, length of hospitalization, and patient satisfaction. Analysis was performed according to the intention to treat principle. The calculated sample size was 68 patients (34 patients in each group) for a 95% confidence interval, 80% power, 5% probability of type I error, and 10% data loss. This study demonstrated that early catheter removal was comparable in POUR rate to conventional treatment with shorter hospitalization among patients undergoing anterior compartment prolapse surgery. Additionally, we observed no re-hospitalization owing to POUR. Therefore, early transurethral catheter removal is preferable following anterior compartment prolapse-related surgery.

Hysteropexy and Anterior Vaginal Native Tissue Repair in Women with Anterior and Central Compartment Prolapse: A Long Term Follow-Up.

Although it is known that hysterectomy (HY) alone cannot resolve apical prolapse, vaginal hysterectomy (VH) remains the most common surgical procedure for this issue. In recent years, various procedures for uterine conservation have been proposed to avoid the surgical risks of HY. Furthermore, most women with symptomatic pelvic organ prolapse (POP) prefer uterine conservation in the absence of considerable benefit in uterine removal. In 2017, we proposed a new technique for hysteropexy and anterior vaginal native tissue repair (NTR) in women with cystocele and apical prolapse. The objective of this study is to assess the efficacy and safety of this new procedure after at least 5 years of follow-up. We included only patients with stage II or greater prolapse of the anterior vaginal wall and a concomitant stage II uterine prolapse in accordance with Pelvic Organ Prolapse Quantification (POP-Q) system. A Patient Global Impression of Improvement (PGI-I) score ≤ 2 in addition with the absence of POP symptoms was defined as subjective success. A descensus with a maximum point of less than -1 in any compartment was considered objective cure. A total of 102 patients who fulfilled the inclusion criteria were enrolled. At 60 months follow-up, 90 out of 102 patients (88%) were subjectively cured, whereas 88 out of the 102 (86%) patients were objectively cured. Subjective and objective cure rates persisted during the entire study period. Uni- and multivariate analysis of possible predictive factors associated with recurrence of prolapse showed that only a preoperative point C > 0 cm and BMI ≥ 25 kg/m2 were risk factors for failure. In conclusion, our study showed that hysteropexy with anterior vaginal native tissue repair may be an effective and safe option for the treatment of anterior vaginal prolapse and concomitant stage II uterine prolapse by at least 5 years of follow-up.

Pelvic Floor Pressures Differ Based on Location in the Pelvis and Body Position: A Cadaver Mode

The pelvic floor is a bowl-shaped complex of multiple muscles and fascia, which functions to support the pelvic organs, and it aids in controlling continence. In pelvic floor disease, this complex becomes weakened or damaged leading to urinary, fecal incontinence, and pelvic organ prolapse. It is unclear whether the position of the body impacts the forces on the pelvic floor. The primary objective of this work is to measure force applied to the pelvic floor of a cadaver in sitting, standing, supine, and control positions. The secondary objective is to map the forces across the pelvic floor. An un-embalmed female cadaver without pelvic floor dysfunction was prepared for pelvic floor pressure measurement using a pressure sensory array placed on top of the pelvic floor, and urodynamic catheters were placed in the hollow of the sacrum, the retropubic space, and at the vaginal apex. Pressure measurements were recorded with the cadaver in the supine position, sitting cushioned without external pelvic floor support, and standing. Pressure array data were analyzed along with imaging of the cadaver. Together, these data were mapped into a three-dimensional reconstruction of the pressure points in pelvic floor and corresponding pelvic organs. pressures were higher at the symphysis than in the hollow of the sacrum in the standing position. Pressure array measurements were lowest in the standing position and highest in the sitting position. Three-dimensional reconstruction confirmed the location and accuracy of our measurements. The findings of increased pressures behind the symphysis are in line with the higher incidence of anterior compartment prolapse. Our findings support our hypothesis that the natural shape and orientation of the pelvis in the standing position shields the pelvic floor from downward forces of the viscera.

Management of full thickness rectal prolapse

Rectal prolapse occurs when the rectum invaginates and descends into the anal canal or beyond the anal sphincter muscles. Patients often report fecal incontinence, obstructed defecation, pain, and urgency and of patients who present with rectal prolapse, up to 30% will also have anterior or middle compartment prolapse. This review describes the preoperative management of patients with rectal prolapse and principles for determining the operative approach.All patients should be optimized ahead of surgery with attention to bowel habits, pelvic floor strength and coordination, and baseline nutrition and fitness. If multi-compartment prolapse is identified, those patients should be referred for multidisciplinary management. Determining the best operation for an individual patient is best done through a shared decision-making model weighing the risks and benefits of abdominal versus perineal operations. Many patients can tolerate minimally invasive abdominal operations, but for those who cannot, perineal operations are a safe and effective option.

Coexisting overactive-underactive bladder and detrusor overactivity-underactivity in pelvic organ prolapse.

The coexisting overactive-underactive bladder (COUB) syndrome could be related to the increased urethral resistance caused by severe pelvic organ prolapse (POP). We aimed to evaluate the clinical and urodynamic findings of patients with COUB and/or detrusor overactivity-underactivity (DOU) in a cohort of patients scheduled for POP surgery and the possible risk factors of COUB after surgery. This retrospective study analyzed all patients who underwent POP repair between 2008 and 2013, excluding women with a history of pelvic floor surgery. Patients were divided into COUB and non-COUB according to baseline symptoms and into DOU and non-DOU based on urodynamic findings. A multivariate model was performed to identify risk factors for COUB symptoms after surgery. A total of 533 women underwent POP surgery. Preoperatively, patients with COUB had more severe anterior compartment prolapse (Pelvic Organ Prolapse Quantification staging system Aa point, P= 0.008) and more frequently had overactive bladder compared with controls (P= 0.023). The rate of COUB decreased significantly after surgery. Preoperative opening detrusor pressure resulted as the only independent predictor of postoperative COUB symptoms (P= 0.034). POP is a valid pathogenetic model for COUB development. POP repair induced a significant decrease in COUB symptoms with low opening detrusor pressure resulting as the only independent predictor of postoperative COUB.

PD44-04 NATIVE TISSUE REPAIR OF ANTERIOR COMPARTMENT PROLAPSE FROM MULTIPLE INSTITUTIONS IS DURABLE OVER 3 YEARS

You have accessJournal of UrologyCME1 May 2022PD44-04 NATIVE TISSUE REPAIR OF ANTERIOR COMPARTMENT PROLAPSE FROM MULTIPLE INSTITUTIONS IS DURABLE OVER 3 YEARS Ramzy Burns, Leo Song, Feras Alhalabi, Lauren Snodgrass, Philippe Zimmern, and CR Powell Ramzy BurnsRamzy Burns More articles by this author , Leo SongLeo Song More articles by this author , Feras AlhalabiFeras Alhalabi More articles by this author , Lauren SnodgrassLauren Snodgrass More articles by this author , Philippe ZimmernPhilippe Zimmern More articles by this author , and CR PowellCR Powell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002605.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The US Food and Drug Association has recommended removal of all transvaginal mesh kits from the market for anterior compartment pelvic organ prolapse (POP) repair, stimulating renewed interest in native tissue POP repair. Specifically, anterior vaginal wall suspension (AVWS) has emerged as a reproducible option for stage 2-3 isolated anterior compartment prolapse repair using native tissue. Zimmern et al. (2016) found a 7.4% rate of failure after AVWS in 121 patients over a follow-up of 5.8 years. We sought to update this experience in multiple institutions. The hypothesis is that well selected patients will have durable results supported by validated patient reported outcome measures and pelvic organ prolapse - quantification (POP-Q) exam. METHODS: We reviewed an institutional review board approved prospectively maintained database of women undergoing anterior vaginal wall suspension without concomitant apical support procedures across multiple institutions. The primary outcome was prolapse recurrence in the anterior compartment. Secondary outcomes included preoperative and postoperative POPQ values, Urinary Distress Inventory-6 (UDI6), and Incontinence Impact Questionnaire-7 (IIQ7) scores. Statistical analysis was performed using STATA 17.0. Significance for continuous variables was by 2-tailed T-test. Predictive modeling was logistic regression. RESULTS: 651 patients underwent AVWS at participating institutions. Table 1 displays preoperative and postoperative POP-Q and validated patient reported outcomes. Failure as defined by Aa>=0 was seen in 8% of patients at 38.3 months follow up. Logistic regression revealed that preoperative POP-Q “Aa” severity was predictive of failure in the anterior compartment (OR 2.6, p<0.05). Preoperative POP-Q “C” severity also weakly predicted failure (OR 1.1, p<0.05). UDI6 item 5 “difficulty emptying your bladder” score was predictive of failure (OR 1.6, p<0.05), however there were no parameters that predicted failure using IIQ7. CONCLUSIONS: AVWS is durable and re-producible. Validated questionnaires are sensitive to improvement in POP-Q measurements and failures in the anterior compartment. Source of Funding: This project was supported by a Project Development Team within the ICTSI NIH/NCRR Grant Number RR025761 SUBAWARD (Powell, PI) and NIDDK DiaComp Pilot & Feasibility project, sub-award DK076169 (Powell, PI) and Indiana University CTSI MedSTAR program (Song). Indiana Clinical and Translational Sciences Institute is funded in part by Award Number UL1TR002529 from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Awtard © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e709 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ramzy Burns More articles by this author Leo Song More articles by this author Feras Alhalabi More articles by this author Lauren Snodgrass More articles by this author Philippe Zimmern More articles by this author CR Powell More articles by this author Expand All Advertisement PDF DownloadLoading ...

93 Transvaginal mesh repair of primary anterior compartment prolapse – surgical outcomes of a portuguese secondary center

Introduction and aims of the study: In 2019 Food and Drug Administration banned transvaginal mesh products for pelvic organ prolapse. We evaluated the surgical outcomes of primary anterior compartment prolapse (ACP) repair with transvaginal mesh (TM) in a Portuguese Secondary Center. Methods: Retrospective unicenter study that evaluated the surgical outcomes of primary ACP repair with TM between january/2015 and december/2018. Prolapse stage was registered using Balden-Walker Classification. Propylene mesh were inserted as described by Fatton et al.

A blind spot: Manchester Fothergill operation for cervical elongation without uterine descensus

ObjectiveTo evaluate the anatomical results of Manchester Fothergill operation performed due to cervical elongation cases without uterine descensus and its effects on quality of life and sexual function. Materials and methodsThirty-six women who underwent Manchester Fothergill operation for cervical elongation without uterine descensus were analyzed retrospectively. Pre- and postoperative Pelvic Organ Prolapse-Quantification (POP-Q) measurements, Prolapse Quality of Life (P-QoL) Questionnaire and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) scores were collected. ResultsThere were significant improvements in POP-Q measurements, P-QoL Questionnaire and PISQ-12 scores postoperatively. There was no relationship between the change in POP-Q measurements and the changes in questionnaires scores. Reoperation was performed in only one patient due to anterior compartment prolapse. No serious complications were detected. ConclusionManchester Fothergill operation is an effective and safe surgical option in the surgical treatment of cervical elongation cases without uterine descensus. It provides anatomical improvement, increases the quality of life and improves sexual function in women.

Surgical treatment of advanced anterior wall and apical vaginal prolapse using the anchorless self-retaining support implant: long-term follow-up

Introduction and hypothesisFollowing health notification by the FDA in 2008 of serious complications with transvaginal mesh for anterior pelvic organ prolapse, there has been a return to native tissue repairs. Earlier work with a self-retaining support (SRS) implant showed a high anatomical success rate with minimal implant-related complications over a medium-term follow-up. It is proposed that post-implant complications are more a consequence of the method of mesh anchoring rather than the implant itself. Our system incorporates an ultralight mesh with a frame that provides level I, II, and III support without the need for fixation. The first long-term outcomes of SRS implantation are presented.MethodsA prospective multicenter trial was conducted using two consecutive identical protocols of the use of the SRS implant in women with symptomatic anterior compartment prolapse extending their follow-up to 36 months. Anatomical success (Pelvic Organ Prolapse Quantification stage 0 or 1 or a Ba ≤ −2) was recorded along with subjective success as defined by regular quality-of-life (PFDI-20 and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire) assessments.ResultsSixty-seven patients completed 36 months of follow-up. Mean Ba measurements improved from 3.1 (−1 to 6) cm to −2.8 (−1 to −3) cm and C point from 0.4 (−8 to 6) cm to −6.9 (−10 cm to 1) cm. accumulating to a significant anatomical success rate of 94.3%. Subjective success based on question #3 of the PFDI-20, analyzed for the index surgical compartment, reached 95.7%. Post-operative complications included 2 cases of urinary retention, 1 minor frame exposure, 1 case of delayed voiding dysfunction, and 2 cases of de novo stress urinary incontinence. Untreated pre-operative second-degree Bp measurements had increased in 27% at follow-up.ConclusionThe long-term outcome of the SRS implant shows an excellent subjective and objective success with minimal risk of complications or need for reintervention.

Long-term outcomes of transvaginal mesh surgery for pelvic organ prolapse: a retrospective cohort study

BackgroundThe objective of this study was to evaluate the overall outcomes and complications of transvaginal mesh (TVM) placement for the management of pelvic organ prolapse (POP) with different meshes with a greater than 10-years of follow-up.MethodsWe performed a retrospective review of patients with POP who underwent prolapse repair surgery with placement of transvaginal mesh (Prolift kit or self-cut Gynemesh) between January 2005 and December 2010. Baseline of patient characteristics were collected from the patients’ medical records. During follow-up, the anatomical outcomes were evaluated using the POP Quantification system, and the Patient Global Impression of Improvement (PGI-I) was used to assess the response of a condition to therapy. Overall postoperative satisfaction was assessed by the following question: “What is your overall postoperative satisfaction, on a scale from 0 to 10?”. Relapse-free survival was analyzed using Kaplan–Meier curves.ResultsIn total, 134 patients were included. With a median 12-year (range 10–15) follow-up, 52 patients (38.8%) underwent TVM surgery with Prolift, and Gynemesh was used 82 (61.2%). 91% patients felt that POP symptom improved based on the PGI-I scores, and most satisfied after operation. The recurrence rates of anterior, apical and posterior compartment prolapse were 5.2%, 5.2%, and 2.2%, respectively. No significant differences in POP recurrence, mesh-associated complications and urinary incontinence were noted between TVM surgery with Prolift versus Gynemesh.ConclusionsTreatment of POP by TVM surgery exhibited long-term effectiveness with acceptable morbidity. The outcomes of the mesh kit were the same as those for self-cutmesh.

Solitary rectal ulcer syndrome (SRUS): observational case series findings on MR defecography.

Radiological findings in solitary rectal ulcer syndrome (SRUS) are well described for evacuation proctography (EP) but sparse for magnetic resonance defecography (MRD). In order to rectify this, we describe the spectrum of MRD findings in patients with histologically proven SRUS. MRD from twenty-eight patients (18 female; 10 males) with histologically confirmed SRUS were identified. MRD employed a 1.5-T magnet and a standardized technique with the rectal lumen filled with gel and imaged sagittally in the supine position, before, during, and after attempted rectal evacuation. A single radiologist observer with 5 years' experience in pelvic floor imaging made the anatomical and functional measurements. Sixteen patients (10 female) demonstrated internal rectal intussusception and 3 patients (11%) demonstrated complete external rectal prolapse. Anterior rectoceles were noted in 12 female patients (43%). Associated anterior and middle compartment weakness (evidenced by excessive descent) was observed in 18 patients (64%). Cystocele was found in 14 patients (50%) and uterine prolapse was noted in 7 patients (25%). Enterocoeles were detected in 5 patients (18%) and peritoneocoele in 5 patients (18%). None had sigmoidocoele. Sixteen patients (57%) demonstrated delayed voiding and 13 patients (46%) incomplete voiding, suggesting defecatory dyssynergia. MRD can identify and grade both rectal intussusception and dyssynergia in SRUS, and also depict associated anterior and/or middle compartment descent. Distinction between structural and functional findings has important therapeutic implications. MRD can identify and grade both rectal intussusception and dyssynergia in patients with SRUS. MRD is an acceptable substitute to evacuation proctography in assessing anorectal dysfunctions when attempting to avoid ionizing radiation. SRUS influences the pelvic floor globally. MRD depicts associated anterior and/or middle compartment prolapse.

Pelvic organ prolapse surgery and overactive bladder symptoms\u2014a population-based cohort (FINPOP)

Introduction and hypothesisIt is unclear how compartment of pelvic organ prolapse (POP) impacts overactive bladder (OAB) symptom severity or improvement after POP surgery. We hypothesized that anterior and apical prolapse are more strongly associated with OAB symptoms than posterior compartment prolapse.MethodsA total of 2933 POP surgeries from a prospective population-based cohort were divided into two groups: (1) anterior and/or apical compartment surgery (± posterior repair), N = 2091; (2) posterior repair only, N = 478. Urinary frequency and urgency urinary incontinence (UUI) were evaluated using PFDI-20 (bothersome symptom: score 3–4) at baseline, 6, and 24 months. Association between degree of POP in specific compartments and symptoms at baseline was estimated with generalized linear models and between compartment of surgery and symptom improvement with generalized estimating equations.ResultsAt least one bothersome symptom was reported by 40% at baseline, 14% at 6, and 19% at 24 months. At baseline, urinary frequency was associated with degree of anterior and apical and UUI with anterior compartment prolapse. Women undergoing surgery for anterior/apical compartment started with worse symptoms and experienced greater improvement than women undergoing posterior compartment surgery. Bothersome frequency resolved in 82% after anterior/apical and in 63% after posterior compartment surgery. Bothersome UUI resolved in 75% after anterior/apical and in 61% after posterior compartment surgery. After surgery, symptom severity was comparable between groups. Bothersome de novo symptoms occurred in 1–3%.ConclusionsOAB symptoms are more strongly related to anterior and apical than to posterior compartment prolapse, but improvement is seen after surgery for any vaginal compartment.

Transperineal pelvic floor ultrasound for analyzing the outcomes of pelvic floor surgery for the treatment of anterior compartment prolapse: A comparative study of transvaginal mesh and native-tissue repair.

To compare the outcomes of transvaginal mesh (TVM) and native-tissue repair (NTR) for the repair of anterior compartment prolapse. This retrospective study involved 90 patients with anterior compartment prolapse who underwent pelvic organ prolapse surgery between January 2018 and October 2020. A TVM was used to treat 53 patients and 37 underwent NTR. All patients underwent a standardized interview, clinical examination, and four-dimensional pelvic floor ultrasound (PFUS) before and after the surgery. The primary outcome was anatomic recurrence evaluated by ultrasonic parameters. The secondary outcomes were subjective recurrence and complications. Subjective recurrence was 9.43% (5/53) for TVM and 16.22% (6/37) for NTR (P=.522). Significant recurrence of prolapse on ultrasound occurred in five patients (9.43%) after TVM and 12 (32.43%) after NTR; there was a significant difference between the TVM and NTR groups (P=.006). In the TVM group, the mesh was visible on ultrasound in each patient. The mesh exposure rate was 1.89% (1/53). The postoperative hiatal area reduction in the TVM group, compared with the NTR group, was statistically significant (5.55 ± 4.71 cm2 vs 3.09 ± 5.61 cm2 , P=.027). The incidence of de novo stress urinary incontinence was higher in the TVM group (20.75% vs 2.70%, P=.03). After surgery, there were significant differences between the two groups based on bladder descent (12.02 ± 8.64 mm vs 22.41 ± 13.95 mm, P=.000) and urethral rotation angle (25.26 ± 13.92° vs 40.27 ± 23.72°, P=.001). PFUS is effective for evaluating postoperative outcomes. TVM facilitates a better anatomic cure than NTR for anterior compartment prolapse.