Concomitant Anti-incontinence Procedure Research Articles

Clinical and Urodynamic Findings Before and After Surgical Repair of Pelvic Organ Prolapse in Women With Lower Urinary Tract Symptoms. A Prospective Observational Study

ObjectiveTo investigate the association between urodynamic findings and lower urinary tract symptoms (LUTS) before and after surgical treatment of pelvic organ prolapse (POP). Patients and MethodsSeventy-four patients with stage II or more anterior POP associated with LUTS and eligible for surgical repair of POP were included in this prospective study. All cases had clinical evaluation and urodynamic testing (UDS) before and 6 months after surgical repair of POP. ResultsMean age was 45 ± 9 years. Mean BMI was 28 ± 6 kg/m2. Most cases were multiparous, had stage III cystocele (50/74, 68%), and an associating apical prolapse (37/74, 50%). Native tissue repair was done in 53/74 (72%) cases with a concomitant anti-incontinence procedure in 41/74 (55%) for overt (26/74, 35%) or occult (15/74, 20%) stress urinary incontinence (SUI). Preoperative UDS revealed detrusor overactivity (DO) in 19/56 (34%) patients of those presenting with storage LUTS and an obstructed detrusor pressure at maximum flow rate in 20/26 (77%) patients presenting with voiding LUTS. At the 6-month postoperative follow-up, 61/74 (82%) patients had marked improvement of their LUTS, SUI resolved in 39/41 (95%) patients and 1/33 (3%) patient developed de novo SUI. Preoperative DO and post-void residual urine volume were not related to the postoperative improvement, or persistence of LUTS. Meanwhile, detrusor underactivity was detected both on preoperative and postoperative UDS of 4 patients with persistent voiding LUTS. ConclusionPatients had significant improvement in LUTS after POP surgery with or without an anti-incontinence procedure. Detrusor underactivity was associated with persistence of voiding LUTS. Meanwhile, preoperative DO and post-void residual urine volume were of limited prognostic value.

Ultrasound-Measured Urethral Length Does Not Change following Minimally Invasive Sacrocolpopexy for Pelvic Organ Prolapse.

To compare urethral length (UL), as measured by three-dimenstional transvaginal ultrasound, before and after minimally invasive sacrocolpopexy (SCP). Secondary analysis of a prospective cohort study of women undergoing SCP for prolapse beyond the hymen with or without a concomitant anti-incontinence procedure. Participants underwent ultrasound at baseline and 14 weeks postoperatively. UL was measured in a reconstructed sagittal plane from the bladder neck to the urethral meatus. All of the participants underwent multichannel urodynamics preoperatively. Data were analyzed in SPSS using independent or paired t tests as indicated for continuous variables and the McNemar test for paired dichotomous variables. Correlations including nonparametric data are reported as Spearman rho. A total of 28 participants, with a mean ± standard deviation age of 56 ± 10 years and median (interquartile range) preoperative prolapse stage of 3 (3-3), were analyzed. There was no change in UL between the baseline and 14-week visits (29.8 ± 11.0 mm vs 29.3 ± 10.0 mm, P = 0.83). There was no difference in baseline UL (29.4 ± 11.8 mm vs 30.9 ± 8.9 mm, P = 0.74) in those with and without preoperative stress urinary incontinence (SUI), nor was there a difference in baseline functional UL on multichannel urodynamics between these groups. In total, 21 participants (75%) had preoperative SUI and 19 (90%) underwent a concomitant anti-incontinence procedure. UL at 14 weeks was similar in those with and without SUI symptoms (26.5 ± 10.9 mm vs 31.1 ± 11.3 mm, P = 0.32) when controlling for those who underwent anti-incontinence procedures. UL does not change following suspension of the anterior vaginal wall with SCP.

Risk Factors for Urinary Retention After Colpocleisis.

Transient urinary retention occurs frequently after pelvic organ prolapse surgery. While the prevalence of postoperative urinary retention has been reported for reconstructive procedures, a paucity of data exists for colpocleisis. The objectives of this retrospective cohort study were to identify risk factors for transient urinary retention after colpocleisis and to determine the rate of its occurrence. A retrospective chart review was performed for patients undergoing colpocleisis from January 2015 to December 2019 in a high-volume urogynecology practice. Patients were excluded if they required prolonged catheterization postoperatively because of a surgical complication or used a catheter before surgery, or if a suprapubic catheter was placed during surgery. Potential patient and procedural risk factors were analyzed. Transient urinary retention was diagnosed if patients failed their postoperative voiding trial and went home with a catheter. A total of 172 patients met the inclusion criteria. The incidence of transient postoperative urinary retention was 55%, with rates of 36.7% with LeFort colpocleisis, 51.5% with posthysterectomy colpocleisis, and 64.9% with colpocleisis with concomitant hysterectomy. Logistic regression revealed an increased risk of postoperative urinary retention if hysterectomy was performed at the time of colpocleisis (odds ratio, 2.9; confidence interval, 1.23-6.84; P = 0.015). Patient age, prolapse severity, preoperative postvoid residual volume, and concomitant anti-incontinence procedure were not associated with transient postoperative urinary retention. Transient urinary retention occurs in more than half of patients after colpocleisis. Patients undergoing concomitant hysterectomy have the highest risk of postoperative urinary retention. Surgeons can use this information both for counseling and management decisions for individual patients.

01: Randomized controlled trial assessing the effect of patient education on postoperative opioid consumption after prolapse surgery

The aim of the study was to determine whether providing specialized perioperative counseling decreases opioid consumption within 2 weeks following pelvic organ prolapse (POP) surgery. This was a randomized, controlled, study of women undergoing POP surgery at a large academic medical center and community HMO. Subjects were randomized to either standard or specialized counseling; the latter included educational handouts with FDA recommendations regarding opioid consumption, storage, and disposal methods. Subjects in both groups were prescribed a standard analgesic regimen including ibuprofen, acetaminophen, and 150 oral morphine equivalents (OME) of oxycodone. The primary outcome was postoperative OME consumption. Secondary outcomes included pain scores, additional postoperative opioid prescriptions, patient satisfaction, and opioid storage/disposal patterns. An a priori sample size calculation demonstrated that 63 subjects were required in each group to detect a consumption difference of 37.5mg OME (∼ 5 tablets of oxycodone) between groups with an alpha of 0.05 and 80% power. One hundred thirty-five subjects were included in the final analysis (65 standard and 70 specialized counseling). There were no significant demographic differences between subjects in the two groups. Subjects in the educational group were more likely to have a concomitant perineorrhaphy (61.4% vs. 40%, p=0.01), but otherwise there were no significant differences between the 2 groups in type and duration of surgery, concomitant anti-incontinence procedures, perioperative complications, or length of postoperative hospitalization (all p>0.05). Subjects in the standard and specialized counseling groups consumed similar quantities of OME, both during the postoperative hospitalization (32.5 mg vs. 35.9 mg) and 2 weeks postoperatively (38.5 mg vs. 61.8 mg). The overall median OME consumed at 2 weeks after surgery was 15 mg (IQR 0,75), which is the equivalent of 2 tablets of oxycodone 5 mg. Fifty-four subjects (40%) did not consume any opioids post discharge. Subjects in both groups were found to have similar opioid storage/disposal patterns, opioid refill rates, satisfaction with the prescription, and pain scores (all p > 0.05). Subjects whose OME consumption were in the top quartile (≥75 mg) were more likely to be younger and have a history of depression, anxiety or chronic pain. They were also more likely to have a preexisting opioid prescription, consume more OME during the postoperative hospitalization, and have an opioid refill within 2 weeks (all p < 0.05). Specialized perioperative counseling did not affect postoperative opioid consumption, storage, or disposal after POP surgery. Forty percent of subjects did not consume opioids after hospital discharge. Postoperative opioid consumption was low with acceptable pain scores, which could help inform future prescribing patterns.

Retrospective Cohort Study on the Perioperative Risk Factors for Transient Voiding Dysfunction After Apical Prolapse Repair.

The primary aim was to compare the incidence of transient voiding dysfunction (TVD) between vaginal uterosacral ligament suspension, sacrospinous ligament fixation, and robotic sacrocolpopexy. Secondarily, we identified risk factors for TVD and associated postoperative complications. This was a retrospective cohort study of women who underwent apical repair at 1 institution. Data were collected from electronic medical records and were presented as means (SD) or numbers (percent) as appropriate. Univariate and multivariate analyses were performed to identify risk factors for TVD and its associated postoperative complications. Three hundred sixty women were included in analysis. Two hundred nineteen (60.8%) passed their voiding trial and 141 (39.2%) experienced TVD. The TVD group demonstrated a higher age, age-adjusted Charlson Comorbidity Index score, and preoperative postvoid residual (all P < 0.05). Univariate analysis demonstrated higher rates of TVD in the vaginal uterosacral ligament suspension and sacrospinous ligament fixation groups compared with the robotic sacrocolpopexy group (P = 0.012). Transient voiding dysfunction occurred more frequently with a concomitant anti-incontinence procedure, anterior repair, and/or posterior repair (all P < 0.05). In multivariate analysis, only an anti-incontinence procedure and concomitant anterior repair were independently associated with a risk of TVD (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.37-3.62, and OR, 2.20; CI, 1.14-4.27, respectively). Transient voiding dysfunction was associated with a culture-proven urinary tract infection within 6 weeks (OR, 3.2; CI, 1.3-8.55). There was no difference in TVD between types of apical repair. Concomitant anti-incontinence procedure and anterior repair were associated with TVD. Women with TVD have an increased risk of postoperative urinary tract infections.

What happens to urinary incontinence after pelvic organ prolapse surgery?

The beneficial effect of pelvic organ prolapse (POP) surgery on urge urinary incontinence (UI) is well described in the literature, while effect on preoperative stress UI (SUI) is still unclear. The aim of this study was to investigate changes concerning UUI following POP surgery without concomitant anti-incontinence procedures and to identify possible factors influencing the changes. We conducted a retrospective study of 678 women with prolapse surgery using native tissue repair during a 3-year period. Patients completed three prolapse questions from the International Consultation on Incontinence-Vaginal Symptoms (ICIQ-VS) questionnaire and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) before undergoing surgery and 3months postoperatively. Patients who scored >0 on the ICIQ-UI SF before surgery were included in the study. A total of 379 patients (55.9%) with POP had concomitant UI. At 3months' follow-up, 174 patients (46%) became continent compared with 205 patients (54%) with UI. Patients with remaining UI had statistically significant higher mean preoperative ICIQ-UI SF score than patients who became dry. The risk of remaining UI after POP surgery was greater in patients with previous anti-incontinence repair. UI type was not a risk factor for its persistance. Almost half of the patients with UI before POP surgery became completely dry after prolapse surgery alone. Severity of incontinence and previous anti-incontinence surgery were identified as risk factors for persisting UI after POP surgery. We found a reduction of incontinence after an operation in any of the three compartments.

Risk factors for stress urinary incontinence after native-tissue vaginal repair of pelvic organ prolapse.

To identify risk factors for postoperative stress urinary incontinence (POSUI) after native-tissue prolapse repair without a concomitant anti-incontinence procedure. The present single-center retrospective study included women with genital prolapse who underwent high uterosacral ligament suspension without a concomitant anti-incontinence procedure during 2008-2013. Univariate and multivariate analyses were performed to identify risk factors for POSUI (identified through clinical interview and International Consultation on Incontinence Modular Questionnaire-Short Form [ICIQ-SF] self-administration) at 6months. In total, 87 (20.9%) of 417 women developed POSUI. Preoperative stress urinary incontinence (SUI) and urodynamically diagnosed SUI were significantly associated with POSUI; moreover, women with POSUI had a higher preoperative ICIQ-SF score, a lower opening detrusor pressure, and a lower detrusor pressure at maximum flow than did women without POSUI (P<0.05 for all comparisons). In the multivariate analysis, preoperative SUI (odds ratio 3.11), a detrusor pressure at maximum flow of less than 30cm H2 O (odds ratio 2.93), and urodynamically diagnosed SUI (odds ratio 2.26) were independent risk factors for POSUI. Preoperative urodynamic parameters, obtained before prolapse repair surgery, were associated with POSUI and could be useful in providing adequate counseling to facilitate decision making on whether to add a concomitant anti-incontinence procedure.

Colpocleisis: A Survey of Current Practice Patterns.

Currently, there are no standard treatment guidelines for colpocleisis. Clinical practice varies widely for this safe and effective procedure. The aim of this study was to evaluate the current practice patterns in the United States among surgeons who perform colpocleisis. A 27-item anonymous Web-based survey was sent to all practicing physicians affiliated with the American Urogynecologic Society. It consisted of questions regarding the demographic background of the physicians and their current practice as it relates to colpocleisis. Of the 1422 physicians contacted, 322 responded (23%) to the questionnaire. Slightly more than half were female with an average time of 15 years in practice. The majority of respondents (79%) were urogynecologists. Most surgeons chose colpocleisis for its high success rate, short operating time, and low risk of complications. Approximately half of the providers performed both LeFort and total colpocleisis. Only 18% performed a routine hysterectomy at the time of surgery. Routine preoperative endometrial evaluation was preferred by 68% of the respondents, with 81% utilizing a transvaginal ultrasound first. Almost all providers would perform concomitant incontinence procedures, with 54% requiring a positive cough stress test and normal postvoid residual. There is variation in the current practice of colpocleisis in the United States. LeFort colpocleisis is most commonly performed, and routine hysterectomy is uncommon. Two thirds of surgeons evaluate the endometrium prior to surgery. Concomitant anti-incontinence procedures appear to be standard.

Use of Concomitant Stress Incontinence Surgery at Time of Pelvic Organ Prolapse Surgery Since Release of the 2011 Notification on Serious Complications Associated with Transvaginal Mesh

There is controversy regarding the performance of concomitant anti-incontinence procedures at the time of pelvic organ prolapse repair. Data support improvement in stress urinary incontinence with a concomitant sling but increased adverse events. We assessed trends in preoperative stress urinary incontinence evaluation, concomitant anti-incontinence procedure at pelvic organ prolapse surgery and postoperative anti-incontinence procedures at our institution before and after the 2011 FDA (U.S. Food and Drug Administration) Public Health Notification pertaining to vaginal mesh. We retrospectively reviewed the records of patients who underwent pelvic organ prolapse surgery from 2009 to 2015. Preoperative workup included assessment of subjective stress urinary incontinence and/or evaluation for leakage with reduction of pelvic organ prolapse on physical examination, urodynamics or a pessary trial. The percentages of concomitant and postoperative anti-incontinence procedures were compared before and after the 2011 FDA notification. A total of 775 women underwent pelvic organ prolapse repair. The percentage of anti-incontinence procedures at pelvic organ prolapse repair decreased from 54.8% to 38.0% after the FDA notification (p = 0.002) while the incidence of preoperative objective stress urinary incontinence on examination, urodynamics and pessary trials remained constant. The incidence of postoperative anti-incontinence procedures within 1 year of the index surgery remained low. We found a decrease in the incidence of concomitant anti-incontinence procedures at the time of pelvic organ prolapse repair following the 2011 FDA notification despite no significant decline in subjective stress urinary incontinence or demonstrable stress urinary incontinence on preoperative evaluation. Further analysis is warranted to assess the impact of the FDA notification on treatment patterns in women with pelvic organ prolapse and stress urinary incontinence.

The Prevalence and Risk Factors of Occult Stress Urinary Incontinence in Women Undergoing Genitourinary Prolapse Surgery

De novo stress urinary incontinence (SUI) may occur in up to 80% of clinically continent women following genitourinary prolapse surgery. This had resulted in an increase in the rate of concurrent continence surgery during prolapse repair from 38% in 2001 to 47% in 2009 in the United States. To date, there is no local data available to estimate the prevalence of occult SUI (OSUI) among Malaysian women awaiting surgery. Therefore, this study was conducted to elicit the prevalence of occult SUI and its associated risks factors in patients awaiting prolapse surgery. We retrospectively studied the records of 296 consecutive women with significant pelvic organ prolapse awaiting reconstructive repair. All patients attended the Urogynaecology Unit in Hospital Kuala Lumpur Malaysia between October 2007 and September 2011. They had undergone standardized interviews, clinical examinations and urodynamic studies. During the urodynamic testings, all prolapses were reduced using ring pessaries to elicit OSUI. Primary outcome was the prevalence of OSUI with prolapse reduction to predict possibility of developing de novo SUI following prolapse surgery. Secondary outcome was the assessment of potential risk factors for OSUI. Among the 296 women studied, 121 (40.9%) were found to have OSUI. The risk factors associated with OSUI included age, BMI, numbers of SVD, recurrent UTI, reduction of urinary flow symptoms and grade 2 to 4 central compartment prolapses. We concluded that preoperative urodynamic testing with reduction of prolapse is useful to identify women with OSUI. This is important for preoperative counselling as well as planning for one step approach of prophylactic concomitant anti-incontinence procedures during prolapse surgery in order to avoid postoperative de novo SUI.

Study on reductive surgery for pelvic organ prolapse concomitant with anti-incontinence sling for treatment of occult stress urinary incontinence

To evaluate the clinical outcome of anti-incontinence sling in the treatment of occult stress urinary incontinence (OSUI) during reductive surgery for advanced pelvic organ prolapse (POP). From Jun. 2003 to Dec. 2012, 78 patients with OSUI underwent reductive surgery for advanced POP such as high uterosacral ligament suspension, sacrospinous ligament suspension and sacral colpopexy in the First Affiliated Hospital, General Hospital of People's Liberation Army. Among them, 41 patients received reductive surgery alone was enrolled in non-concomitant anti-incontinence group and the other 37 patients who underwent same surgery with tension-free vaginal tape (TVT) or tension-free vaginal tape-obturator technique (TVT-O) was in anti-incontinence group. The patient's demography, objective and subjective outcomes, as well as complications and injures were compared between the two groups. The pelvic organ prolapse quantitation (POP-Q) was used to evaluate the objective outcomes of POP. Urinary distress inventory (UDI-6) and incontinence impact questionnaire short form (IIQ-7) were used to evaluate the subjective outcomes of stress urinary incontinence (SUI). Compared with the non-concomitant anti-incontinence group, the objective outcomes of reductive surgery exhibited no significant differences (100%, 78/78), and only the operation time of anti-incontinence group slightly increased 16 minutes. The occurrence rate of postoperative SUI was 12% (5/41), 15% (6/41), 17% (7/41) respectively after the operation at 2-month, 6-month and 12-month follow up in the non-concomitant anti-incontinence group; and the occurrence rate of the anti-incontinence group was 3% (1/37), 3% (1/37), 3% (1/37); but none of patients in the two groups require further surgery for stress urinary incontinence. Mean score of UDI-6 and IIQ-7 in all the patients decreased significantly after operation at 2-month, 6-month and 12-month follow up (all P < 0.01). However, there was no statistic difference between the two groups (P > 0.05). It is still difficult to make decision for concomitant anti-incontinence procedure in those patients with OSUI, who are undergoing reductive surgery because of advanced POP. Whether the patients will benefit more from anti-incontinence sling depends largely on strict preoperative evaluation for the severity of SUI. The patients with severe SUI are supposed to benefit most from anti-incontinence sling. However, a two-step approach to correct the postoperative stress urinary incontinence is also reasonable.

De novo stress urinary incontinence after vaginal repair for pelvic organ prolapse: one-year follow-up

ObjectiveA few studies have reported a wide range (2–43%) in incidence of de novo stress urinary incontinence (SUI) following surgical repair of pelvic organ prolapse (POP) in previously continent women. The aim of this study was to re-examine this incidence up to one year following vaginal repair of prolapse. Study designRetrospective review of a cohort of women who underwent reconstructive vaginal repair of POP without a concomitant anti-incontinence procedure between 2003 and 2007 at two tertiary referral centers. Women were considered eligible if they were stress continent by symptoms and objective assessment (including urodynamics testing) prior to surgical repair. All women who had had any anti-incontinence procedure previously were excluded. The endpoint was subjective SUI that prompted the patient to undergo any treatment within one year from their prolapse surgery. Results64 women, with a mean age of 61 (±11) years, were eligible for the study: 26 (41%) had preoperative symptoms of overactive bladder. Fifty-four patients were available for analysis at the one-year visit. Seven women (13.5%) had symptoms of SUI but only one (2%) was found to have SUI objectively. Another patient underwent anti-incontinence surgery following her prolapse surgery. ConclusionThe incidence of de novo SUI requiring treatment in previously continent women who underwent vaginal repairs for POP without concomitant anti-incontinence surgery is low (4%). A large-scale prospective study is necessary to further evaluate this finding.

Sacrospinous vaginal fixation - current status

There has been a trend towards increased use of synthetic meshes and abdominal procedures with decreased use of sacrospinous fixation (SSF). A Medline search was performed for the MeSH terms 'sacrospinous ligament', 'sacrospinous fixation', 'sacrospinous ligament suspension' and 'sacrospinous colpopexy'. Published papers from 1996-2010 were selected for analysis. Outcome measures were assessed in terms of efficacy, complications and quality of life after sacrospinous vaginal fixation. Studies on bilateral SSF and fixing uterus to the sacrospinous ligament, use of concomitant anti-incontinence procedures along with SSF were not included in this review. Sacrospinous vaginal fixation provides good long-term objective and subjective outcomes and improves quality of life of women with pelvic organ prolapse. Further, complication rates of SSF are comparable to abdominal sacrocolpopexy and are much less than transvaginal mesh procedures and SSF is a cost-effective procedure. SSF is a time-tested surgical procedure with a reduction in surgical extent and has a definite place in modern pelvic reconstructive surgery.

Le cloisonnement vaginal : indications, technique et résultats

The aim of this review was to summarize recent published data about indications, surgical technique and results of colpocleisis. We conducted a literature search on Medline using PubMed from 1990 to 2008. Anatomical and functional results were assessed for each selected study according to the age and the morbidity of the surgical procedure. As the colpocleisis was complete or partial, anatomic success rates were reported near 100 % with a follow-up ranged from one month to six years. Colpocleisis is an effective procedure for treatment of advanced pelvic organ prolapse in selected patient who no longer desire preservation of coital function. Concomitant anti-incontinence procedure is not associated with increased postoperative morbidity. However, preoperative urodynamics remain to be established for an optimal management of urinary incontinence.

Stress urinary incontinence after transobturator mesh for cystocele repair

Cystocele repair can lead to de novo stress urinary incontinence (SUI) or exacerbate pre-existing SUI. This study was designed to determine the effect of cystocele repair by transobturator mesh on SUI. In a retrospective observational study, we saw 93 patients after a transobturator mesh procedure. Of those, 57 women had not undergone a concomitant anti-incontinence procedure. We analyzed their clinical data and ultrasound datasets. At a median follow-up of 9 months, 21 of 24 preoperatively stress incontinent women reported cure/improvement, one patient reported worsened SUI. Seven of 33 preoperatively continent women complained of de novo SUI. There is a net positive effect on SUI (McNemar chi(2) exact test p = 0.013) after transobturator mesh. A narrower gap between symphysis pubis and mesh was associated with a positive outcome (p = 0.015 on ANOVA). Transobturator mesh for cystocele repair appears to have a net positive effect on SUI.

Occult stress incontinence in women with pelvic organ prolapse

Objectives To study the prevalence of occult stress urinary incontinence (SUI) among Indian women with genitourinary prolapse, and determine the risk of developing SUI after vaginal hysterectomy and pelvic floor repair in Indian women with occult SUI. Methods A prospective cohort study of 78 women with significant genitourinary prolapse without symptoms of SUI was conducted at Christian Medical College, Vellore, India. Before the surgical intervention, the prolapse was repositioned using a pessary and a Pyridium (Parke Davis, Morris Plains, NJ, USA) pad test was performed to detect occult SUI. The primary outcome studied was the risk of developing postoperative urinary incontinence. Results Preoperatively, 67.9% of women were found to have occult SUI. The prevalence of SUI was 43.6% postoperatively, and 64.2% of the women with a positive result to the preoperative Pyridium pad test after pessary insertion were found to have urinary incontinence postoperatively. Postmenopausal women had twice the risk of developing occult SUI. Conclusion Preoperative testing is useful to identify women with genitourinary prolapse who have occult SUI. Women with a positive result may need a systematic clinical evaluation and urodynamic studies to characterize the incontinence. They can be then counseled preoperatively regarding concomitant anti-incontinence procedures.

Traitement du prolapsus du dôme vaginal par sacrocolpopexie laparoscopique assistée par robot

Transabdominal sacrocolpopexy offers an excellent definitive treatment option for patients with high grade vaginal vault prolapse with long-term success rates ranging from 93-99 %. However, because it is a transabdominal procedure it is associated with increased morbidity compared with vaginal repairs. We describe a novel minimally invasive technique of vaginal vault prolapse repair and present out initial experience. The surgical technique involves placement of five laparoscopic ports: three for the Da Vinci ® robot and two for the assistant. A polypropylene mesh is then attached to the sacral promontory and to the vaginal apex using Gortex sutures. At the end of the case, the mesh material is the covered by the peritoneum. We also present our initial experience with this technique in 18 consecutive patients. The analysis focused on complications, urinary continence, patient satisfaction, and morbidity. Follow-up was conducted by provider-patient interview. Twenty-five patients underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution in the past 24 months for severe symptomatic vaginal vault prolapse. 10/25 (40 %) underwent a concomitant anti-incontinence procedure. Mean follow-up was 5. (1-12) months and mean age was 66 (47-82) years. Mean total operative time was 3.2 (2.25-4.75) hours. One patient had to be converted to an open procedure secondary to unfavorable anatomy. All but one patient were discharged from the hospital after an overnight stay; one patient left on postoperative day #2. Complications were limited to mild port site infections in two patients, which resolved with oral antibiotic therapy. One patient developed recurrent grade 3 rectocele, but had no evidence of cystocele or enterocele. We present a novel technique for vaginal vault prolapse repair that combines the advantages of open sacrocolpopexy with the decreased morbidity and improved cosmesis of laparoscopic surgery. It is associated with decreased hospital stay, low complication and conversion rates, and high patient satisfaction. While our early experience is encouraging, long-term data is needed to confirm these findings and establish longevity of the repair.

Perioperative complications of surgery for genital prolapse: Does concomitant anti-incontinence surgery increase complications?

Objectives To establish whether the short-term risks of prolapse surgery are increased by a concomitant anti-incontinence procedure. Methods Using data from the past 4 years of the National Hospital Discharge Survey, we identified women admitted for surgery for pelvic organ prolapse (specifically, suspension of the vagina or obliteration of the cul-de-sac, with or without concomitant hysterectomy or vaginal repairs). We identified women diagnosed with complications (including infections, bleeding complications, surgical injuries, pulmonary complications, and cardiovascular complications). We used multiple logistic regression analysis to compare women with and without complications with respect to concurrent continence procedures, controlling for demographic characteristics, concurrent procedures, and medical comorbidity (using the Charlson index). Results Of the 1931 women who underwent prolapse surgery, concomitant anti-incontinence procedures were performed in 514 (26.6%). Complications were reported in 288 patients (14.9%) and were associated with medical comorbidity (odds ratio 11.2) and concomitant hysterectomy (odds ratio 1.5). Concomitant surgery for incontinence was not associated with an increased risk of complications. Conclusions These data suggest that medical comorbidity is strongly associated with complications after surgery for pelvic organ prolapse. A concomitant anti-incontinence procedure did not significantly increase the immediate morbidity of prolapse surgery.

Gynecologic use of robotically assisted laparoscopy: Sacrocolpopexy for the treatment of high-grade vaginal vault prolapse

Transabdominal sacrocolpopexy is an excellent treatment option for patients with high-grade vaginal vault prolapse, with long-term success rates ranging from 93% to 99%. However, it is associated with increased morbidity compared with vaginal repairs. In this article, we describe a novel minimally invasive technique of vaginal vault prolapse repair and present our initial experience. The surgical technique involves placement of 4 laparoscopic ports, 3 for the surgical robot and 1 for the assistant. A prolene mesh is then attached to the sacral promontory and to the vaginal apex using nonabsorbable expanded polytetrafluoroethylene sutures. At the end of the case, the mesh material is covered by the peritoneum. A total of 20 patients underwent a robot-assisted laparoscopic sacrocolpopexy at our institution in the past 18 months for severe symptomatic vaginal vault prolapse; 8 of the 20 (40%) underwent a concomitant anti-incontinence procedure. Mean follow-up was 5.1 (range, 1–12) months and mean age was 66 (range, 47–82) years. The mean total operative time was 3.2 (range, 2.25–4.75) hours. Of these patients, 1 was converted to an open procedure secondary to unfavorable anatomy. All but 1 patient, who left on postoperative day 2, were discharged from the hospital after an overnight stay. Complications were limited to mild port-site infections in 2 patients, which resolved with oral antibiotic therapy. Recurrent grade 3 rectocele developed in 1 patient, but there was no evidence of cystocele or enterocele. Significant incontinence (>1 pad/day) was present in 2 patients. All 18 patients reported being satisfied with the outcome of their surgery and all 10 would recommend it to a friend. This novel technique for vaginal vault prolapse repair combines the advantages of open sacrocolpopexy with the decreased morbidity and improved cosmesis of laparoscopic surgery. It is associated with decreased hospital stay, low complication and conversion rates, and high rates of patient satisfaction. Although our early experience is encouraging, long-term data are needed to confirm these findings and establish longevity of the repair.

Le Fort Colpocleisis

In Brief Objectives To evaluate the efficacy of Le Fort colpocleisis on bladder, bowel function, and quality of life (QOL) in elderly women with advanced genital prolapse. Methods Women with severe genital prolapse who were unable to satisfactorily wear a vaginal pessary underwent a Le Fort colpocleisis with concomitant anti-incontinence procedure, if required. During 2-week, 6-week, and 6-month postoperative visits, patients were examined and questioned about irritative voiding symptoms (voids > 10/day, nocturia > 2/night, urgency), incontinence, constipation, and overall well-being. Quality-of-life impact was evaluated with an instrument for pelvic prolapse, which was sent to all patients at least 12 weeks after operation. Follow-up by telephone was attempted to encourage completion of the questionnaire. Results Forty-five women underwent a Le Fort colpocleisis and high perineoplasty. Thirty-one (69%) also had a tension-free vaginal tape procedure. Mean age was 83 ± 5.2 years. Ninety-three percent (42/45) of the women had failed previous pessary use. One patient (2%) had recurrence of her prolapse. There were no significant differences in preoperative and postoperative incidence of irritative voiding and constipation symptoms. Eighty-two percent (37/45) of the QOL questionnaires were returned for analysis. The possible range of total score on the questionnaire is 15 to 75. Mean QOL score for the population was 24.8 ± 8.6. Patients with postoperative irritative voiding symptoms, constipation, or SUI symptoms had a mean score of 25.8 ± 9.1, and patients without these symptoms had a mean score of 21.4 ± 6.0 (P = 0.19). Conclusions Le Fort colpocleisis is a feasible treatment option for severe vaginal prolapse in the elderly patient. Low QOL impact scores after operation, despite irritative bladder symptoms and constipation, demonstrate the beneficial outcome of colpocleisis in elderly women who have advanced genital prolapse and are not sexually active. The evaluation of the efficacy of Le Fort colpocleisis on the bladder, bowel function and quality of life in elderly women with advanced genital prolapse.