Concomitant Total Hysterectomy Research Articles

Sacrocolpopexy: The Way I Do It.

Sacrocolpopexy (SCP) is an established surgical procedure for apical vaginal vault prolapse. There remains significant variation amongst surgeons in both the surgical steps and concomitant surgeries utilised when undertaking an SCP. This review article is aimed at summarising the evidence and providing a detailed update of SCP in modern practice, reviewing contemporary evidence behind its indications, efficacy, outcomes, surgical steps, and complications. Sacrocolpopexy remains the gold standard for post-hysterectomy apical prolapse based on good long-term outcomes, patient satisfaction and low complication rates. SCP with concomitant total hysterectomy is not recommended owing to high rates of mesh exposure. The laparoscopic approach remains the preferred option in terms of low morbidity, quicker recovery and lower cost than alternative access options. For optimal outcomes an SCP should be performed with monofilament mesh, using absorbable sutures and with a paravaginal repair for cystocele. Although SCP has become increasingly utilised for apical prolapse, its established efficacy regarding anatomical outcomes, patient satisfaction, and complications is in the context of post-hysterectomy prolapse. SCP with concomitant total hysterectomy has higher rates of mesh exposure. The efficacy and safety of SCP with sub-total hysterectomy or hysteropexy have not been clearly established and require further assessment through well-designed, rigorous randomised controlled trials.

Thermodynamic Work of High-Grade Uterine Prolapse Patients Undergoing Transvaginal Mesh Repair with Total Hysterectomy.

The objective benefit of transvaginal mesh with concomitant total hysterectomy (TVM-HTX) repair to high-grade uterine prolapse (UP) patients has not been fully established. This study aimed to clarify the impact of TVM-HTX on the voiding function of high-grade UP patients by comparing pre- and post-operatively measured pressure-flow and pressure-volume investigations. Urodynamic and thermodynamic studies were conducted on 15 high-grade UP patients (stage III/IV, POP-Q system) who underwent TVM-HTX (January 2019-December 2022) in a tertiary-care university hospital. The parameters analyzed included voiding resistance (Rvod), voiding pressure (Pvod), voiding flow (Fvod), voided volume (Vvod), voiding time (Tvod), and the trajectory-enclosed area of the pressure-volume loop (Apv). Post-operative results showed a significant reduction in Rvod (p < 0.001, N = 15), Pvod (p = 0.021, N = 15), and Apv (p = 0.006, N = 15), along with an increase in Fvod (p = 0.003, N = 15) and a decrease in Tvod (p < 0.001, N = 15). The operation-associated changes in Rvod (ΔRvod) correlated with alterations in Pvod and Fvod (ΔPvod and ΔFvod, r = 0.444, p = 0.004, r = 0.717, p = 0.003, respectively; both N = 15); ΔFvod correlated with the change in Tvod (ΔTvod, r = 0.629, p = 0.012, N = 15) but not with that in ΔVvod (r = 0.166, p = 0.555, N = 15). Changes in Apv (ΔApv) correlated with ΔPvod (r = 0.563, p = 0.029, N = 15) but not with ΔVvod (r = 0.353, p = 0.197, N = 15). Collectively, TVM-HTX reduced the voiding resistance, which improved the voiding efficacy and decreased the pressure gradient required for driving urine flow, thereby lessening the bladder's workload.

Intraoperative Complications and Perioperative and Surgical Outcomes of Single-Port Robotics-Assisted Sacrocolpopexy.

The objective was to assess intraoperative and postoperative complication rates, along with perioperative and surgical outcomes, following single-port robotics-assisted sacrocolpopexy. This retrospective case series included 200 patients who underwent single-port robotics-assisted sacrocolpopexy to treat Pelvic Organ Prolapse Quantification (POPQ) stage 2-4 symptomatic prolapse between April 2020 and August 2023 by a single surgeon. Intraoperative and postoperative complications and perioperative outcomes were evaluated for all the patients, whereas surgical outcomes for 74 patients were assessed at 1-year follow-up. Surgical failure was defined as the presence of any of the following: the presence of vaginal bulging symptoms, any prolapse beyond the hymen, or retreatment for prolapse. During the study period, 200 single-port robotics-assisted sacrocolpopexies were performed. The median age and body mass index were 65.0 years and 24.6kg/m2 respectively. Most patients had POPQ stage 3 or 4 prolapse and underwent concomitant total hysterectomy. The median total operation time was 212.0min, and none of the patients required conversion to laparoscopy or laparotomy. The intraoperative cystotomy rate was 2.5%, and one patient had a blood transfusion owing to presacral vessel injury. Postoperative complications of mesh exposure and wound hernia were 0.5% and 2.0% respectively. At 1 year postoperatively, the rate of composite surgical failure was 9.5%, with a 5.4% anatomical recurrence rate. None of the patients experienced apical prolapse recurrence, and one received anterior colporrhaphy for anterior compartment prolapse recurrence. Single-port robotics-assisted sacrocolpopexy is safe and effective, with low complication rates and favorable perioperative and surgical outcomes.

Learning curves and perioperative outcomes of single-incision robotic sacrocolpopexy on two different da Vinci® surgical systems.

This study aimed to report a single surgeon's early experience and learning curves of single-incision robotic sacrocolpopexy on two different robotic surgical platforms, namely, the single-site approach on da Vinci Xi® and single-port approach on da Vinci SP® surgical systems. This retrospective study included 123 consecutive cases of robotic sacrocolpopexy performed between June 2017 and June 2021 for the patients with Pelvic Organ Prolapse Quantification stage 2-4 symptomatic prolapse. First consecutive 57 cases were performed under the da Vinci Xi® system applying the single-site manner, whereas the following 66 cases were done under the da Vinci SP® system. The primary outcome was intraoperative and perioperative complication rates, and the secondary outcome was learning curve of single-incision robotic sacrocolpopexy under the two different robotic surgical platforms. Learning curves based on the operation time were obtained through cumulative sum analysis. The mean age of each group was 65.6 ± 8.7years for single-site robotic sacrocolpopexy and 63.7 ± 7.6years for the single-port one (p = 0.202). More than 80% of patients for each group had advanced prolapse stages and underwent concomitant total hysterectomy. The overall baseline characteristics did not differ significantly between groups. The median operation time for each group were 201.0 and 201.5min, respectively. Both groups showed comparable perioperative outcomes in terms of operation time, intraoperative blood loss, and length of hospital stay. Intraoperative cystostomy rates were 1.8% and 3.0%, respectively, and revealed no statistical difference (p = 0.736). The learning curves were comparable, and the surgeon required less than 15 cases for both single-site and single-port robotic sacrocolpopexies to stabilize operation time. Comparable learning curves and favorable intraoperative and perioperative outcomes of single-incision robotic sacrocolpopexy using two different robotic surgical systems show that both are feasible options for robotic sacrocolpopexy.

Recurrence of Anterior Vaginal Prolapse After Robotic Sacrocolpopexy: Does Cervical Preservation Affect Outcome?

Anterior vaginal prolapse (AVP) is the most common site of recurrence after sacrocolpopexy (SCP). Supracervical hysterectomy helps to prevent mesh exposure, but it is unclear if cervical preservation (CP) affects adequate reduction of AVP. Our primary objective was to determine the difference in AVP recurrence rates in patients who have undergone SCP with or without CP. Secondary outcomes were composite failure and complications rates. This was a retrospective cohort analysis of women who underwent robotic SCP between 2012 and 2019 at Kaiser Permanente Southern California. The first cohort included women with CP (prior or concomitant supracervical hysterectomy). The second included women without CP (prior or concomitant total hysterectomy). Primary outcome was defined as recurrent AVP beyond the hymen. Patients without 12-month follow-up were included in demographic and surgical data analysis only. The charts of 373 patients with CP and 175 without CP were reviewed. Women with CP were more likely to undergo concomitant anterior repair at the time of SCP (14% vs 6%, P < 0.01); however, rates of AVP recurrence were not significantly different between groups (5% vs 3%, P = 0.26). Median follow-up time was 26 months (interquartile range, 14-38 months). Composite failure was similar between groups (17% vs 11%, P = 0.12). Women with CP were more likely to experience asymptomatic apical failure (6% vs 1%, P = 0.03). Cervical preservation at the time of SCP is associated with an increased need for concomitant anterior repair but is not associated with higher rates of AVP recurrence or composite failure.

Use of Novel Configuration with Suture Kit Device for Robotic-assisted Minimally Invasive Sacrocolpopexy

<h3>Study Objective</h3> To assess safety and efficacy of performing robotic-assisted laparoscopic sacrocolpopexy (RA-SCP) using a four-arm robotic configuration and suture kit system. <h3>Design</h3> Retrospective case series. <h3>Setting</h3> Tertiary care referral center. <h3>Patients or Participants</h3> Patients undergoing RA-SCP with or without concomitant hysterectomy. <h3>Interventions</h3> All procedures were performed using four-arm robotic configuration and the Stitch Kit® polytetrafluoroethylene (PTFE) (Origami Surgical) suture kit device. The configuration included four 8 mm ports: one camera port and three working ports. No bedside assistant port was used. The Stitch Kit® PTFE, a canister with 6 polytetrafluoroethylene sutures and a separate compartment for used needles, was inserted into the abdominal cavity through a 8 mm umbilical skin incision prior to robotic docking. After suturing, each needle was replaced in the canister. The canister was closed and removed through the umbilical port site at the end of the case. No fascial closure of port sites was required. <h3>Measurements and Main Results</h3> 422 patients underwent RA-SCP for pelvic organ prolapse from 2018-2021. Mean age was 60 ± 10 years and mean BMI was 27 ± 6 kg/m². Most patients had stage III prolapse (73%) and underwent concomitant total hysterectomy (70%). 99% (n=416) of cases were completed robotically; of the 1% (n=6) not completed robotically, 5 had sacrospinous ligament suspensions due to presence of prior eroded foreign body material or extensive adhesions and 1 was aborted due to colorectal mass. The Stitch Kit® canister was successfully inserted and removed in all cases completed robotically with correct needle counts. 337 (80%) of participants followed up at 3 months. No umbilical or port site hernias were reported. <h3>Conclusion</h3> Our case series illustrates that RA-SCP can be performed safely using a four-arm robotic configuration with a suture kit device. This setup eliminates the need for any incisions greater than 8 mm and an assistant port. These modifications allow for surgical efficiency without compromising patient outcomes.

Mesh exposure following minimally invasive sacrocolpopexy: a narrative review.

Sacrocolpopexy is considered mainstay treatment for apical or vaginal vault prolapse and is currently most often performed via a minimally invasive approach. Although mesh-related complications after this procedure are uncommon, mesh exposure can have an important impact on the patient's quality of life. Our objective is to perform a literature review on this complication post laparoscopic or robotic sacrocolpopexy. Web of Science and MEDLINE databases were searched for relevant articlespublished between 2005 and 2021. We retrieved 272 articles of which 83 ultimately were withheld. Minimally invasive sacrocolpopexy (MISC) implies a low risk of mesh exposure, which is currently estimated at 3.5%. Literature however is marked by substantial methodological heterogeneity. Controversy remains in the debate over prevention of mesh exposure after MISC. Performing a concomitant total hysterectomy is associated with an increased risk compared to subtotal hysterectomy or hysteropexy. Treatment of mesh exposure is challenging as guidelines are lacking. Although supported by few prospective data, patients with asymptomatic mesh exposure are managed conservatively. Surgical intervention, preferentially performed by an experienced pelvic surgeon, is indicated in symptomatic patients. Mesh exposure is often undiagnosed and remains untreated. There is a gap in evidence exploring risk factors for mesh-related complications and efficient measures for reducing them. Choosing the best treatment option is still difficult. Management should be individualized and optimized at the time of diagnosis. Lack of acknowledgement and experience can result in increased morbidity.

Prospective Evaluation of Laparoscopic Sacrocolpopexy with Concomitant Laparoscopic-Assisted Total Vaginal Hysterectomy

(1) Background: Sacrocolpopexy (SCP) with subtotal hysterectomy (SH) is a standard procedure for the treatment of utero-vaginal prolapse. Several disadvantages are associated with the remaining cervix; therefor, SCP with total hysterectomy (TH) may be preferred. According to some publications, SCP with concomitant TH is associated with higher rates of mesh extrusion. Our hypothesis is that mesh extrusion at the apex can be avoided through prevention of thermal injury and through vaginal cuff suturing when performing the laparoscopic sacrocolpopexy combined with a laparoscopic-assisted vaginal total hysterectomy (LAVH). (2) Methods: This prospective cohort study was performed from 2016 until January 2019 including women with a utero-vaginal prolapse undergoing laparoscopic SCP with LAVH. The SCP was performed utilizing a non-absorbable polypropylene macroporous mesh (EndoGYNious®). The primary outcome was the mesh extrusion rate after SCP with concomitant LAVH. The secondary outcome was the objective and functional outcome. (3) There were 50 women included in this prospective cohort. At follow up of 6–12 weeks postoperatively, no mesh extrusion was detected and objectified. Overall, all women showed excellent anatomical and functional outcome. The median time from surgery was 42 months. (4) Laparoscopic SCP with concomitant LAVH showed no increased risk of mesh extrusion and good objective and functional outcomes.

Supracervical Hysterectomy Is Protective against Mesh Complications after Minimally Invasive Abdominal Sacrocolpopexy: A Population-Based Cohort Study of 12,189 Patients.

Although minimally invasive (robotic or laparoscopic) abdominal sacrocolpopexy (MISC) has become the new gold standard for durable pelvic organ prolapse repair after the vaginal mesh controversy, current literature is limited. Our objective was to study reoperation for mesh complications after MISC. All women undergoing MISC in California from January 2012 to December 2018 were identified from Office of Statewide Health Planning and Development data sets using appropriate ICD-9/10 (International Classification of Diseases 9th/10th Revision) and CPT® (Current Procedural Terminology) codes. Univariate and multivariable analyses were performed to assess associations between patient demographics, surgical details and our primary outcomes: rates of reoperation for a mesh complication. Of 12,189 women undergoing MISC 8,398 (68.9%) had concomitant hysterectomy. Total hysterectomy (TH) and supracervical hysterectomy (SCH) were performed in 5,027 (41.2%) and 3,371 (27.6%) cases, respectively. Reoperation rates for mesh complications were lower after SCH vs TH (overall: 0.7%, mean followup time 1,111 days vs 3.1%, mean followup time 1,095 days, p <0.001; subcohort with at least 4 years of followup: 2.1% vs 8.9%, p <0.001). Additionally, mesh complication rates were higher even if TH was performed remotely, as compared to concomitant SCH (5.2% vs 0.7%, p <0.001). The increased risk for reoperation due to mesh complications after TH was preserved on multivariable analysis (OR 4.20, 95% CI 2.72‒6.50, p <0.001). Concomitant TH at time of MISC is associated with a significantly higher rate of mesh complication as compared to SCH. The increased risk of a mesh complication associated with TH is present even if the TH was performed prior to the MISC.

Minimally Invasive Sacrocolpopexy Mesh Exposure Rates with and without Concomitant Total Hysterectomy

Study Objective Determine the risk difference of mesh exposure rates at 1-year following minimally invasive sacrocolpopexy (MISC) with and without concomitant total hysterectomy utilizing lightweight Y-mesh. Design Retrospective cohort, 2016-2019. Setting Single academic institution. Patients or Participants Women who underwent MISC and had 1-year in-office follow-up. Excluded if history of prior mesh augmented prolapse repair or supracervical hysterectomy. Interventions Women who underwent MISC with or without concomitant total hysterectomy were compared. Measurements and Main Results Cohort included 259 women, mean age was 63.6±9.2 years, BMI 27.1 kg/m2, 89% were post-menopausal, 46% sexually active, 18% had a history of prior FPMRS surgery. MISC + total hysterectomy (n=126) v. MISC alone (n=133). The overall rate of mesh exposure was 3/259 (1.2%, 95% CI, 0.2% - 3.4%). All mesh exposures were in the total hysterectomy group, two with absorbable suture, one with permanent suture for graft attachment. The risk difference of mesh exposure was 2.4% (95% CI, -0.5% - 6.9%) for those who underwent MISC + total hysterectomy v. MISC alone and was not significantly different from zero. The NSQIP 30-day complication rate was higher in the total hysterectomy group 14.3% v. 2.3% (p <0.01), however, this difference is attributed to the increased rate of urinary tract infections (total hysterectomy group n=14, post-hysterectomy group n=0). There were no mortalities and 30-day readmission rates did not differ between groups 1.5% v. 1.6% (p = 1.0). Rate of recurrent prolapse, defined as ≥ Stage 2 on clinical examination, was not statistically different between groups, MISC+ total hysterectomy 12.7 % v. MISC alone 21.8 % (p=0.06). There was one reoperation for prolapse, which was in the MISC alone group (isolated posterior repair). Conclusion The rate of mesh exposure one year after MISC with lightweight Y-mesh is low at 1.2%, with no statistically significant difference between those who underwent MISC with or without concomitant total hysterectomy. Determine the risk difference of mesh exposure rates at 1-year following minimally invasive sacrocolpopexy (MISC) with and without concomitant total hysterectomy utilizing lightweight Y-mesh. Retrospective cohort, 2016-2019. Single academic institution. Women who underwent MISC and had 1-year in-office follow-up. Excluded if history of prior mesh augmented prolapse repair or supracervical hysterectomy. Women who underwent MISC with or without concomitant total hysterectomy were compared. Cohort included 259 women, mean age was 63.6±9.2 years, BMI 27.1 kg/m2, 89% were post-menopausal, 46% sexually active, 18% had a history of prior FPMRS surgery. MISC + total hysterectomy (n=126) v. MISC alone (n=133). The overall rate of mesh exposure was 3/259 (1.2%, 95% CI, 0.2% - 3.4%). All mesh exposures were in the total hysterectomy group, two with absorbable suture, one with permanent suture for graft attachment. The risk difference of mesh exposure was 2.4% (95% CI, -0.5% - 6.9%) for those who underwent MISC + total hysterectomy v. MISC alone and was not significantly different from zero. The NSQIP 30-day complication rate was higher in the total hysterectomy group 14.3% v. 2.3% (p <0.01), however, this difference is attributed to the increased rate of urinary tract infections (total hysterectomy group n=14, post-hysterectomy group n=0). There were no mortalities and 30-day readmission rates did not differ between groups 1.5% v. 1.6% (p = 1.0). Rate of recurrent prolapse, defined as ≥ Stage 2 on clinical examination, was not statistically different between groups, MISC+ total hysterectomy 12.7 % v. MISC alone 21.8 % (p=0.06). There was one reoperation for prolapse, which was in the MISC alone group (isolated posterior repair). The rate of mesh exposure one year after MISC with lightweight Y-mesh is low at 1.2%, with no statistically significant difference between those who underwent MISC with or without concomitant total hysterectomy.

Robotic or laparoscopic sacrocolpopexy with concomitant total hysterectomy for pelvic organ prolapse compared to abdominal approach

Objective To evaluate the feasibility of robotic or laparoscopic sacrocolpopexy with concomitant total hysterectomy (RLSC) for patients with pelvic organ prolapse (POP) and to assess the perioperative results compared to abdominal sacrocolpopexy (ASC). Methods We analyzed retrospectively 249 POP patients who underwent total hysterectomy followed by sacrocolpopexy. We compared the operative results and symptoms after surgery between RLSC group (n=51; 12 robotic and 39 laparoscopic surgery) and ASC group (n=198). Results The RLSC cohort showed shorter surgical time (164.4 vs. 201.4 minutes, P=0.001) and smaller blood loss (100 vs. 200 mL, P<0.0001; postoperative hemoglobin decrease, 1.5 vs. 1.8 g/dL, P=0.001). Patients’ postoperative satisfaction of RLSC and ASC was 92.2% and 96%, respectively. Each one patient of both the groups underwent surgery again. Although the distribution of each postoperative symptom did not differ between the two groups, the RLSC group had a smaller number of patients who had complaints at least once compared to the ASC group (25% vs. 43.4%, P=0.020). Conclusion The sacrocolpopexy with concomitant total hysterectomy was feasible for POP without complication. Additionally, robotic or laparoscopic surgery can be considered as a minimally invasive surgical approach for POP. Key Words: Hysterectomy; Laparoscopy; Robotics; Pelvic organ prolapse

58: Mind the gap – Changes in levator dimensions following sacrocolpopexy

Prior studies demonstrated that genital hiatus (GH) decreases following surgical correction of the vaginal apex. We hypothesized that the underlying levator hiatus (LH) and levator area (LA) would decrease following apical suspension in women with preoperative prolapse (POP) beyond the hymen. Our objective was to compare LH and LA on transvaginal 3D ultrasound (US) and the GH, as measured by POP-Q exam, before surgery and at 14 weeks following sacrocolpopexy without posterior repair or perineorrhaphy. This was a prospective cohort study of women undergoing minimally-invasive sacrocolpopexy +/- hysterectomy without posterior repair or perineorrhaphy for stage II or greater POP beyond the hymen. At baseline and 14-weeks after surgery, patients underwent POPQ exam and US performed at rest. US was performed using multi-frequency 360° rotational probe with a 3D automatic acquisition system (Type 20R3 BK Medical, Herlev, Denmark). Data from each study were de-identified and analyzed by two urogynecologists, blinded to image sequence. The LH was measured from the junction of the superior pubic rami to the posterior margin of the external anal sphincter in the axial plane with urethra, puborectalis muscle, and anal canal visible simultaneously. Based on prior studies of POPQ GH change, we calculated that 32 women were needed to find a 1cm change in GH with 80% power and an alpha of 0.05. Measurements and scores were compared in SPSS Version 25 using paired t-tests for continuous variables. Correlations of non-parametric data are reported as Spearman’s rho. 43 patients were enrolled in the study; 35 completed all preoperative and postoperative ultrasounds and are included in the analysis. Patients had a mean age ± SD of 55 ± 11. Most were white (89%), parous (94%), postmenopausal (66%), sexually active (63%) and had stage III POP (86%). The majority (89%) had concomitant total hysterectomy, and 60% had a midurethral sling. At baseline, mean PFDI scores were 98±50 and mean POPDI subscale scores were 42±22. Median (IQR) POP stage decreased after surgery from 3 (3-3) to 0 (0-1) (p<0.001) and mean PFDI scores decreased to 55±42 (p=0.002). At baseline, mean GH was 3.5 ± 0.7cm and mean perineal body (PB) was 2.4 ± 0.6. While the GH decreased by 0.5cm following surgery, PB was unchanged (Table 1). LH increased by 1mm at 14 weeks postoperatively while LA remained unchanged (Table 1). At 14 weeks, the change in LH was not correlated with the change in GH (ρ= -0.2, p=0.2) or POP stage (ρ= -0.2, p=0.9) as measured on POPQ exam. Repositioning the apex with sacrocolpopexy significantly reduces GH size on clinical exam; however, restoration of the apex does not impact the size of the underlying levator hiatus or levator area suggesting that size of the levator gap does not impact sacrocolpopexy outcomes.

Identifying Preoperative Factors Associated with Nonresponders in Women Undergoing Comprehensive Surgical Treatment for Endometriosis

Study ObjectiveTo examine whether existing quality of health outcome measures can be used to predict or have an association with nonresponse surgery for endometriosis. DesignRetrospective cohort study. SettingsSingle endometriosis referral center. PatientsWomen (n = 198) undergoing surgery for endometriosis. InterventionsValidated health questionnaires and visual analogue scales. Measurements and Main ResultsPatients were given validated health questionnaires, including Endometriosis Health Profile 30, Gastrointestinal Quality of Life Index, EuroQol-5, Hospital Anxiety and Depression Scale, preoperatively and at 12 months after full surgical excision of endometriosis. Visual analogue scales were also used that measured dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain. Surgical management was dependent on severity of disease. Superficial disease was treated by laparoscopic peritoneal excision or laser ablation. Deep infiltrating disease involving the bowel was excised completely together with laparoscopic bowel surgery (shave, disc, or segmental resection) with/without concomitant total hysterectomy and bilateral salpingo-oophorectomy. Nonresponders were defined as women who failed to demonstrate an improvement in pain scores 12 months postoperatively. We examined preoperative and postoperative questionnaires, visual analogue scores, and other variables such as age at onset of symptoms, type of surgery, and the presence of postoperative complications comparing responder and nonresponder women to identify the factors associated with nonresponse. Of 102 women treated for superficial endometriosis, 25 (24.51%) were nonresponders. No factors were associated with nonresponse at 12 months. Of 96 women treated for severe endometriosis involving the bowel, 10 (10.41%) were nonresponders. Nonresponders had significantly less preoperative pain (p = .031) and feeling of control (p = .015) than responders. There was no association between nonresponders and women who underwent a hysterectomy with bilateral salpingo-oophorectomy or those with complications. Radical bowel surgery (resection) was associated with nonresponders. ConclusionMinimal preoperative factors are associated with nonresponse for women having surgery for endometriosis. The severity of pain experienced by women with endometriosis may be used to predict their response to surgery.

Risk factors for vaginal mesh exposure after mesh-augmented anterior repair: a retrospective cohort study.

The aim of this study is to identify risk factors for vaginal mesh exposure after mesh-augmented repair of anterior prolapse. We performed a retrospective cohort study of all patients who had mesh-augmented anterior repair by 1 surgeon between January 2007 and February 2012. Data were extracted from medical records. The primary outcome was the rate of anterior or apical vaginal mesh exposure. Both univariate and multivariate analyses were performed. A total of 201 subjects were included. The mean (SD) follow-up was 14.3 (12.4) months. All cases were done using a type 1 macroporous monofilament polypropylene mesh. The overall mesh exposure rate was 8.5% (17/201). Univariate analysis showed a statistically significant positive association between exposure rates and the following risk factors: lower body mass index (BMI) (P = 0.016), menopause in combination with the use of hormone replacement therapy (P = 0.023), midline sagittal vaginal incision (compared with distal transverse incision) (P = 0.026), concurrent total hysterectomy (P < 0.001), surgery time (P = 0.002), and worse apical prolapse at baseline (P = 0.007). After multivariate analysis using logistic regression, only BMI (P < 0.001) and concomitant total hysterectomy (odds ratio, 48; P < 0.001) remained relevant. The exposure rate was 23.5% (16/68) when concomitant hysterectomy was performed compared with 0.8% (1/133) when no hysterectomy was done. Exposure rates stratified by BMI class were 12.9% (8/62) for BMI less than 25 kg/m, 9.5% (8/84) for BMI of 25 to 29.9 kg/m, 3.1% (1/32) for BMI of 30 to 34.9 kg/m, and 0% (0/23) for BMI greater than or equal to 35 kg/m. Concomitant total hysterectomy is an independent risk factor for mesh exposure after mesh-augmented anterior repair, whereas BMI may negatively correlate with exposure rates.

A review on the role of laparoscopic sacrocervicopexy.

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

Reconstructive laparoscopic prolapse surgery to avoid mesh erosions.

Introduction: The objective of the study is to examine the efficacy of the purely laparoscopic reconstructive management of cystocele and rectocele with mesh, to avoid the risk of erosion by the graft material, a well known complication in vaginal mesh surgery. Material and methods: We performed a prospective, single-case, non-randomized study in 325 patients who received laparoscopic reconstructive management of pelvic organe prolaps with mesh. The study was conducted between January 2004 and December 2012 in a private clinic in India. The most common prolapse symptoms were reducible vaginal lump, urinary stress incontinence, constipation and flatus incontinence, sexual dysfunction and dypareunia. The degree e of the prolaps was staged according to POPQ system. The approach was purely laparoscopic and involved the use of polypropylene (Prolene) or polyurethane with activated regenerated cellulose coating (Parietex) mesh. Results: The mean age was 55 (30–80) years and the most of the patients were multiparous (272/325). The patients received a plastic correction of the rectocele only (138 cases), a cystocele and rectocele (187 cases) with mesh. 132 patients had a concomitant total hysterectomy; in 2 cases a laparoscopic supracervical hysterectomy was performed and 190 patients had a laparoscopic colposuspension. The mean operation time was 82.2 (60–210) minutes. The mean follow up was 3.4 (3–5) years. Urinary retention developed in 1 case, which required a new laparoscopical intervention. Bladder injury, observed in the same case was in one session closed with absorbable suture. There were four recurrences of the rectocele, receiving a posterior vaginal colporrhaphy. Erosions of the mesh were not reported or documented. Conclusion: The pure laparoscopic reconstructive management of the cystocele and rectocele with mesh seems to be a safe and effective surgical procedure potentially avoiding the risk of mesh erosions.

Abdominal Sacrocolpopexy Utilizing Gore-Tex in Genital Prolapse

In Brief Objective: To examine the efficacy and safety of abdominal sacrocolpopexy (ASC) for the treatment of genital prolapse and review unresolved issues, specifically the erosion rate with Gore-Tex in a concomitant total hysterectomy, and how best to attach the mesh to the prolapsed vagina. The rate of vaginal erosion of the most commonly used synthetic meshes is also reviewed. Methods: A 15-year prospective observational study was done on all patients undergoing ASC. The lead author performed all surgeries. Data collected included pelvic floor grading, urodynamic studies when indicated, concomitant surgical procedures, length of stay, and complications. The mesh used was expanded polytetrafluoroethylene and was attached in nearly all cases (96%) to the anterior and posterior vaginal wall. Follow-up was done by annual questionnaire or office visits. Results: A total of 168 patients with at least grade 2 prolapse underwent ASC. Eighty percent had long-term follow-up (mean, 43 months; range, 7–154) and the rest were followed less than 6 months (range, 1–6). Five intraoperative complications occurred (3%), yet no blood transfusions were needed. Postoperative complications developed in 29 patients (17%) with ileus or small-bowel obstruction in 18 (11%). Average hospital stay for uncomplicated and complicated cases was 3 days and 7.7 days, respectively. Graft erosion occurred in 4 patients (2.4%), with 3 of these having concomitant total hysterectomies (adjusted odds ratio = 21.9, 95% confidence interval = 2.57–462.8). Recurrent prolapse occurred in 3 patients (1.8%). In 2 of these patients, the failures happened after removal of the eroded mesh. Conclusions: The rate of intestinal complications in the present study (11%) is higher than comparable reports using a variety of meshes (4%-8%). The erosion rate of 2.4% in the present study is similar to other series. An ASC will restore upper vaginal support if the graft is applied to all prolapsed sites. Concomitant total hysterectomy appears to be a strong independent risk factor for vaginal erosion among women undergoing ASC with Gore-Tex mesh. A large series of abdominal sacral colpopexies using Gore-Tex is presented. There is discussion regarding mesh application, concomitant hysterectomy and mesh erosion. Unresolved issues are reviewed.

Abdominal sacrocolpopexy: a comprehensive review.

To summarize published data about abdominal sacrocolpopexy and to highlight areas about which data are lacking. We conducted a literature search on MEDLINE using Ovid and PubMed, from January,1966 to January, 2004, using search terms "sacropexy," "sacrocolpopexy," "sacral colpopexy," "colpopexy," "sacropexy," "colposacropexy," "abdominal sacrocolpopexy" "pelvic organ prolapse and surgery," and "vaginal vault prolapse or surgery" and included articles with English-language abstracts. We examined reference lists of published articles to identify other articles not found on the electronic search. We examined all studies identified in our search that provided any outcome data on sacrocolpopexy. Because of the substantial heterogeneity of outcome measures and follow-up intervals in case studies, we did not apply meta-analytic techniques to the data. Follow-up duration for most studies ranged from 6 months to 3 years. The success rate, when defined as lack of apical prolapse postoperatively, ranged from 78-100% and when defined as no postoperative prolapse, from 58-100%. The median reoperation rates for pelvic organ prolapse and for stress urinary incontinence in the studies that reported these outcomes were 4.4% (range 0-18.2%) and 4.9% (range 1.2% to 30.9%), respectively. The overall rate of mesh erosion was 3.4% (70 of 2,178). Some reports found more mesh erosions when concomitant total hysterectomy was done, whereas other reports did not. There were no data to either support or refute the contentions that concomitant culdoplasty or paravaginal repair decreased the risk of failure. Most authors recommended burying the graft under the peritoneum to attempt to decrease the risk of bowel obstruction; despite this, the median rate (when reported) of small bowel obstruction requiring surgery was 1.1% (range 0.6% to 8.6%). Few studies rigorously assessed pelvic symptoms, bowel function, or sexual function. Sacrocolpopexy is a reliable procedure that effectively and consistently resolves vaginal vault prolapse. Patients should be counseled about the low, but present risk, of reoperation for prolapse, stress incontinence, and complications. Prospective trials are needed to understand the effect of sacrocolpopexy on functional outcomes.