Greater Pelvic Organ Prolapse Research Articles

Characterization of Pain Associated With Pelvic Organ Prolapse: Is Surgery the Answer?

Data on the incidence of pelvic organ prolapse (POP)-related pain, risk factors for its development, and treatment effects of surgery remain sparse. The aims of the study were to evaluate the incidence and characteristics of POP-related pain in patients presenting with POP and assess the outcome of pain after surgery. This was a retrospective study of patients presenting for initial evaluation of POP from May 2019 to May 2020. Using a standardized questionnaire, patients were asked "Do you have pain associated with your prolapse (not pressure or fullness)?" and to indicate pain severity and location(s). Patients who underwent surgery were asked postoperatively if their POP-related pain resolved. Patient and perioperative characteristics were obtained from the medical record and used to evaluate relationships between the presence and resolution of POP-related pain. Of the 795 patients who met inclusion criteria, 106 (13.3%) reported POP-related pain. The mean age of all patients was 59.9 years, 38.1% had stage 3 or greater POP, and 52.1% were sexually active. Women with POP-related pain reported a median severity of 5 of 10. The most common pain locations were the vagina (46.6%), lower abdomen (27.4%), and back (9.6%). Fifty-seven women with pain (53.8%) underwent surgery, and 40 (70.2%) reported postoperative pain resolution. Of those who did not have resolution, pain improved or remained stable in severity. No patients reported worsening pain after surgery. Pain is a symptom experienced by more than 1 in 8 women presenting with POP, with 70% reporting resolution of their pain postoperatively.

Effect of Pessary vs Surgery on Patient-Reported Improvement in Patients With Symptomatic Pelvic Organ Prolapse

Pelvic organ prolapse is a prevalent condition among women that negatively affects their quality of life. With increasing life expectancy, the global need for cost-effective care for women with pelvic organ prolapse will continue to increase. To investigate whether treatment with a pessary is noninferior to surgery among patients with symptomatic pelvic organ prolapse. The PEOPLE project was a noninferiority randomized clinical trial conducted in 21 participating hospitals in the Netherlands. A total of 1605 women with symptomatic stage 2 or greater pelvic organ prolapse were requested to participate between March 2015 through November 2019; 440 gave informed consent. Final 24-month follow-up ended at June 30, 2022. Two hundred eighteen participants were randomized to receive pessary treatment and 222 to surgery. The primary outcome was subjective patient-reported improvement at 24 months, measured with the Patient Global Impression of Improvement scale, a 7-point Likert scale ranging from very much better to very much worse. This scale was dichotomized as successful, defined as much better or very much better, vs nonsuccessful treatment. The noninferiority margin was set at 10 percentage points risk difference. Data of crossover between therapies and adverse events were captured. Among 440 patients who were randomized (mean [SD] age, 64.7 [9.29] years), 173 (79.3%) in the pessary group and 162 (73.3%) in the surgery group completed the trial at 24 months. In the population, analyzed as randomized, subjective improvement was reported by 132 of 173 (76.3%) in the pessary group vs 132 of 162 (81.5%) in the surgery group (risk difference, -6.1% [1-sided 95% CI, -12.7 to ∞]; P value for noninferiority, .16). The per-protocol analysis showed a similar result for subjective improvement with 52 of 74 (70.3%) in the pessary group vs 125 of 150 (83.3%) in the surgery group (risk difference, -13.1% [1-sided 95% CI, -23.0 to ∞]; P value for noninferiority, .69). Crossover from pessary to surgery occurred among 118 of 218 (54.1%) participants. The most common adverse event among pessary users was discomfort (42.7%) vs urinary tract infection (9%) following surgery. Among patients with symptomatic pelvic organ prolapse, an initial strategy of pessary therapy, compared with surgery, did not meet criteria for noninferiority with regard to patient-reported improvement at 24 months. Interpretation is limited by loss to follow-up and the large amount of participant crossover from pessary therapy to surgery. Netherlands Trial Register Identifier: NTR4883.

7419 Vaginally Assisted Laparoscopic Sacrocolpopexy

<h3>Study Objective</h3> The objective of this video is to demonstrate the surgical technique for attaching sacrocolpopexy mesh using a vaginal approach. We will highlight the steps of the procedure and discuss findings in the literature to support this approach. <h3>Design</h3> Surgical video recording of vaginal and laparoscopic procedures to demonstrate the steps of this technique for prolapse repair. <h3>Setting</h3> Operating Room <h3>Patients or Participants</h3> 69-year-old female with stage III anterior and apical pelvic organ prolapse who desired surgical management. <h3>Interventions</h3> Total vaginal hysterectomy, followed by mesh attachment via a vaginal approach for stage III pelvic organ prolapse. Laparoscopic sacrocolpopexy was then performed in the routine fashion. Excellent apical support was noted at completion of the procedure. <h3>Measurements and Main Results</h3> Vaginal mesh attachment after hysterectomy and prior to laparoscopic sacrocolpopexy has shorter mean operating room times with no significant difference in complication rates or anatomic outcomes. Mesh exposure is not significantly higher in those who have vaginal mesh attachment vs. laparoscopic mesh attachment. <h3>Conclusion</h3> Vaginally attached mesh prior to laparoscopic sacrocolpopexy is an efficient way to perform minimally invasive sacrocolpopexy in patients with stage 3 or greater pelvic organ prolapse, and with the appropriately selected patient, allows for same day discharge.

Intrapartum risk factors associated with pelvic organ prolapse at 6 months postpartum

Pregnancy and childbirth are known risk factors associated with the development of pelvic organ prolapse; specific intrapartum risk factors are not well characterized. This study aimed to determine intrapartum factors associated with increased risk of pelvic organ prolapse identified after delivery. A planned secondary analysis of a multicenter randomized clinical trial of delayed vs immediate pushing among nulliparous women at ≥37 weeks of gestation in labor with neuraxial analgesia was conducted at 6 academic and community hospitals in the United States. Intrapartum characteristics were identified, and Pelvic Organ Prolapse Quantification assessments at 6 weeks and 6 months after delivery were performed. The primary outcome was pelvic organ prolapse, defined as stage 2 or greater prolapse using the Pelvic Organ Prolapse Quantification assessment at 6 months. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, macrosomia, and maternal age. Among the 941 women participating in the pelvic floor follow-up, 793 women had Pelvic Organ Prolapse Quantification assessments at 6 weeks with 91 of 793 women (11.5%) demonstrating stage 2 or greater prolapse. Of the 728 women followed up at 6 months, stage 2 or greater prolapse was identified in 58 of 728 women (8.0%). Prostaglandin use for induction of labor was associated with an increased risk at 6 months (adjusted odds ratio, 2.15; 95% confidence interval, 1.18-3.91; P<.01). The length and type (spontaneous vs induced) of the first stage of labor were not significantly associated with stage 2 or greater prolapse. Moreover, increased length of the second stage of labor and duration of pushing were not associated with stage 2 or greater prolapse. After adjusting for confounding factors, cesarean delivery was protective of pelvic organ prolapse at 6 months (adjusted odds ratio, 0.12; 95% confidence interval, 0.02-0.90). The management of the first and second stages of labor, including time length, was not associated with stage 2 or greater prolapse at 6 months. The findings that prostaglandin exposure was associated with increased risk likely were not directly affecting the risk of prolapse but may be surrogates for other labor features that deserve exploration. Cesarean delivery was associated with protection from stage 2 or greater pelvic organ prolapse at 6 months, consistent with previous literature.

Vaginal microbiome and serum metabolite differences in late gestation commercial sows at risk for pelvic organ prolapse

Sow mortality attributable to pelvic organ prolapse (POP) has increased in the U.S. swine industry and continues to worsen. Two main objectives of this study were, (1) to develop a perineal scoring system that can be correlated with POP risk, and (2) identify POP risk-associated biological factors. To assess POP risk during late gestation, sows (n = 213) were scored using a newly developed perineal scoring (PS) system. Sows scored as PS1 (low), PS2 (moderate), or PS3 (high) based on POP risk. Subsequently, 1.5, 0.8, and 23.1% of sows scored PS1, PS2, or PS3, respectively, experienced POP. To identify biomarkers, serum and vaginal swabs were collected from late gestation sows differing in PS. Using GC–MS, 82 serum metabolite differences between PS1 and PS3 animals (P < 0.05) were identified. Vaginal swabs were utilized for 16S rRNA gene sequencing and differences in vaginal microbiomes between PS1 and PS3 animals were detected on a community level (P < 0.01) along with differences in abundances of 89 operational taxonomic units (P < 0.05). Collectively, these data demonstrate that sows with greater POP risk have differential serum metabolites and vaginal microflora. Additionally, an initial and novel characterization of the sow vaginal microbiome was determined.

Changes in β-Catenin Expression in the Anterior Vaginal Wall Tissues of Women With Pelvic Organ Prolapse: A Potential Pathophysiological Mechanism.

The purpose of this study was to investigate the expression of β-catenin in the lamina propria of the anterior vaginal wall of women with pelvic organ prolapse (POP) compared with the expression in the controls. Anterior vaginal wall tissues were obtained from women undergoing POP surgery for stage 3 or greater POP (POP group, n = 30; age, 58 ± 7.839 years), with a menopause rate of 70%, and from women without POP undergoing hysterectomy for benign indications (control group, n = 30; age, 54.7 ± 7.173 years), with a menopause rate of 50%. Hematoxylin and eosin staining and Masson trichrome staining were performed on anterior vaginal wall sections. β-Catenin, p-β-catenin, glycogen synthase kinase 3β (GSK3β), p-GSK3β, collagen I, collagen III, MMP2, MMP9, TIMP2, caspase 3, proliferating cell nuclear antigen, and cyclin D1 were evaluated using immunohistochemical analysis. Lamina propria tissues were obtained for Western blot analyses. Hematoxylin and eosin staining and Masson trichrome staining showed that the collagen fibers were more disorganized and fragmented in the POP group than in the control group. In the POP samples, β-catenin (mean density, POP vs control, 0.43 ± 0.13 vs 0.58 ± 0.16), p-GSK3β, collagen I, collagen III, proliferating cell nuclear antigen, and cyclin D1 were downregulated in the lamina propria, whereas in the control group, p-β-catenin, TIMP2, and caspase 3 were downregulated (P < 0.05 for all). GSK3β was not different between the 2 groups (P > 0.05). We demonstrated that decreased β-catenin may play an important role in the onset of POP by affecting collagen anabolism.

The role of transforming growth factor-ß (TGF-ß1) in postmenopausal women with pelvic organ prolapse: An immunohistochemical study.

ObjectiveAim of the study was to investigate the expression of transforming growth factor-β1 (TGF-β1), a key regulator of the extracellular matrix composition, in the uterosacral ligaments (USLs) of women with pelvic organ prolapse (POP) compared with controls. We hypothesized that the expression pattern of TGF-β1 differs between postmenopausal women with or without POP.MethodsUnder ethical approval, USL samples were obtained from postmenopausal women undergoing vaginal hysterectomy for stage two or greater pelvic organ prolapse (cases, n = 70) and from postmenopausal women without pelvic organ prolapse undergoing vaginal hysterectomy for benign indications (controls, n = 30). Immunohistochemical staining was performed from paraffin embedded tissue using anti-TGF-β1 antibodies. The expression of TGF-β1 was evaluated by the pathologist, who was blinded to all clinical data.ResultsThe expression of TGF-ß1 was similar in patients with symptomatic POP (89 % positive) and in controls (90 % positive) without any signs of prolapse (p = 0.091). Age-adjusted analysis did not significantly alter these results. Regarding POP-Q stages, TGF-ß1 was significantly more frequently expressed in severe prolapse cases compared to moderate/mild cases (POP-Q stage IV versus POP-Q stage II and III; p = 0.001). No significant association could be detected between TGF-ß1 expression and age, BMI and parity in cases with POP (p > 0.05). As published previously, advanced patients’ age as well as early menopausal age remained independent risk factors associated with POP in multiple logistic regression analysis (p = 0.001; p = 0.02).ConclusionAlthough our study detected POP-Q stage related alterations in USL composition and TGF-ß1 expression, there was no significant difference in the expression of TGF-β1 in cases with or without prolapse.

Long-term pelvic organ prolapse recurrence and mesh exposure following sacrocolpopexy.

Large, long-term studies are needed to compare pelvic organ prolapse (POP) recurrence and mesh exposure following all modes of sacrocolpopexy (open, robotic, and laparoscopic). We hypothesized that the prevalence of recurrent POP and mesh exposure does not differ between modes of sacrocolpopexy. This is a retrospective cohort study with a cross-sectional, prospective survey. Participants were surveyed regarding complications, retreatments, and symptoms following sacrocolpopexy. Baseline characteristics, POP recurrence, mesh exposure, and survey responses were compared. A total of 709 participants met the criteria. Median time from sacrocolpopexy to last follow-up for all participants was 0.5years (2days to 13.4years). 15.0% experienced recurrent stage 2 or greater POP or underwent retreatment (open 11.7% [95% CI 7.8-17.2%]; robotic 21.1% [95% CI 15.6-27.9%]; laparoscopic 13.8% [95% CI 10.6-17.9%]; p = 0.03). After adjusting for baseline differences there was no significant difference among groups (p = 0.30). 5.3% experienced mesh and/or suture exposure (mesh n = 19, suture n = 10, mesh and suture n = 8) with no significant difference among groups (open 7.7% [95% CI 4.6-12.5%]; robotic 3.6% [95% CI 1.7-7.6%]; laparoscopic 4.9% [95% CI 3.1-7.7%]; p = 0.20). Median time from sacrocolpopexy to survey completion was 6.5 (1.6-13.4) years. 9.2% reported evaluation or treatment for recurrent POP (open 6.3% [95% CI 2.1-16.8%]; robotic 12.5% [95% CI 6.9-21.5%]; laparoscopic 8.5% [5.1-13.8%]; p = 0.44). 6.9% reported evaluation or treatment for mesh exposure (open 6.0% [95% CI 2.1-16.2%]; robotic 3.9% [95% CI 1.3-10.7%]; laparoscopic 8.6% [5.2-13.9%]; p = 0.38). Objective and patient-reported long-term prevalence of POP recurrence and mesh exposure are low following all modes of sacrocolpopexy.

Pelvic Floor Muscle Training Versus Watchful Waiting and Pelvic Floor Disorders in Postpartum Women: A Systematic Review and Meta-analysis

Pelvic floor muscle training (PFMT) is often recommended to treat postpartum urinary incontinence (UI). However, the role of postpartum PFMT in pelvic organ prolapse (POP), sexual function, and anal incontinence (AI) remains unclear. We therefore aim to assess the efficacy of postpartum PFMT on these pelvic floor disorders. This study is a meta-analysis consisting of randomized controlled trials (RCTs). We searched databases including CENTRAL, MEDLINE, EMBASE, CINAHL, and PEDro. We also sought after grey literature including conference proceedings. We included RCTs comparing PFMT versus watchful waiting in women with stage II or less POP within 1 year postpartum. Two authors independently performed study screening, risk of bias assessments, and data extraction. Fifteen RCTs (3845 patients) were included. Women undergoing PFMT less likely report bothersome POP symptoms (risk ratio [RR], 0.48 [0.30-0.76]; very low-quality evidence). There is no significant difference in the number of women with stage II or greater POP (RR, 0.74 [0.45-1.24]; moderate-quality evidence). Fewer women receiving PFMT report the presence of sexual dysfunction (RR, 0.48 [0.30-0.77]; low-quality evidence). There is no significant difference in AI symptoms (RR, 1.11 [0.82-1.51]), but PFMT may be more beneficial for women with anal sphincter injuries (standardized mean differencein AI scores, -0.57 [-1.12 to -0.02]; low-quality evidence). Women receiving PFMT less likely report UI (RR, 0.44 [0.25-0.75]; moderate-quality evidence) with a more pronounced effect on stress UI (SUI). At present, it remains uncertain whether postpartum PFMT improves POP symptoms because of very low-quality evidence, and more high-quality RCTs are needed in this area. The POP staging will likely not change with postpartum PFMT. The PFMT may result in improved postpartum sexual function compared to watchful waiting, and may provide benefit for AI in women with anal sphincter injuries. Postpartum PFMT likely reduces the risk of UI, particularly stress urinary incontinence symptoms. There is currently little evidence about postpartum PFMT and long-term pelvic floor function.

How to reduce the operative time of laparoscopic sacrocolpopexy?

Objective:Laparoscopic sacrocolpopexy (LSC) has been reported to achieve lower recurrence rates, shorter recovery time, and less dyspareunia. However, as a pelvic organ prolapse (POP) surgery, LSC is problematic because it requires specific techniques and it takes a comparatively longer operative time. In this study, we present our surgical techniques of LSC and their effectiveness for shortening operative times and raising safety.Methods:Thirty-four women with stage 2 or greater POP who underwent LSC in our hospital between September 2014 and October 2015 were enrolled in this study. The notable points of our operative procedures are as follows: (1) fixing the sigmoid colon to the left lateral abdominal wall for a clearer visualization of the sacral promontory, (2) making a retroperitoneal tunnel (not opening the peritoneum) from the sacral promontory to the Douglas pouch, (3) dissection of the vaginal wall after transvaginal hydrodissection, (4) fixation of mesh to the vaginal wall by using absorbable tacks, and (5) limiting usage of posterior mesh for the patients with posterior vaginal wall descent.Results:The median operative time was 140 (range, 90–255) minutes, and blood loss was 50 (range, 10–1600) mL. The operative time decreased as the surgical techniques improved through experience. No major intra- or postoperative complications occurred. The mean follow-up period was 4 (range, 1 –14) months, and only one patient presented a recurrent grade 2 cystocele.Conclusion:Our unique procedures will help shorten operative times and reduce complications of LSC.

Laparoscopic Versus Abdominal Sacrocolpopexy: A Randomized, Controlled Trial

Few randomized, controlled trials have compared standard abdominal sacrocolpopexy and the laparoscopic approach. We tested the hypothesis that laparoscopic sacrocolpopexy could compete with abdominal sacrocolpopexy for pelvic organ prolapse repair. This randomized, controlled trial was done to compare laparoscopic sacrocolpopexy and abdominal sacrocolpopexy for pelvic organ prolapse repair in women referred to our tertiary Department of Urology for symptomatic stage 2 or greater pelvic organ prolapse. The primary outcome was quantitative evaluation by the POP-Q (Pelvic Organ Prolapse Quantification) system. Cure was defined as prolapse stage 1 or less, point C/D -5 or less at the apex and at least 7 cm total vaginal length. Secondary outcomes were the complication rate, operative time, intraoperative blood loss, hospital stay and PGI-I (Patient Global Impression of Improvement) scores. The Kaplan-Meier estimator with the log-rank test was used to estimate pelvic organ prolapse recurrence-free survival rates. A total of 200 patients were eligible for study. We compared 60 and 61 patients treated with abdominal and laparoscopic sacrocolpopexy, respectively. At a mean followup of 41.7 months the cure rate was of 100% for both approaches. Kaplan-Meier curves showed that overall pelvic organ prolapse recurrence-free survival was longer following the open approach. Patients treated with laparoscopic sacrocolpopexy showed significantly earlier recurrence (p = 0.030), mostly in the first 12 months after surgery. When evaluating the different compartments, a statistically significant difference was observed between the laparoscopic and abdominal approaches for anterior compartment descensus (11 vs 1, p = 0.004). Statistical results had high internal validity but may not be applicable to other populations or settings. Laparoscopic sacrocolpopexy provides outcomes as good as those of abdominal sacrocolpopexy for anatomical correction but not for anterior pelvic organ prolapse.

Vaginal prolapse repair with or without a midurethral sling in women with genital prolapse and occult stress urinary incontinence: a randomized trial

We compared pelvic organ prolapse (POP) repair with and without midurethral sling (MUS) in women with occult stress urinary incontinence (SUI). This was a randomized trial conducted by a consortium of 13 teaching hospitals assessing a parallel cohort of continent women with symptomatic stage II or greater POP. Women with occult SUI were randomly assigned to vaginal prolapse repair with or without MUS. Women without occult SUI received POP surgery. Main outcomes were the absence of SUI at the 12-month follow-up based on the Urogenital Distress Inventory and the need for additional treatment for SUI. We evaluated 231 women, of whom 91 randomized as follows: 43 to POP surgery with and 47 without MUS. A greater number of women in the MUS group reported absence of SUI [86% vs. 48%; relative risk (RR) 1.79; 95% confidence interval (CI) 1.29-2.48]. No women in the MUS group received additional treatment for postoperative SUI; six (13%) in the control group had a secondary MUS. Women with occult SUI reported more urinary symptoms after POP surgery and more often underwent treatment for postoperative SUI than women without occult SUI. Women with occult SUI had a higher risk of reporting SUI after POP surgery compared with women without occult SUI. Adding a MUS to POP surgery reduced the risk of postoperative SUI and the need for its treatment in women with occult SUI. Of women with occult SUI undergoing POP-only surgery, 13% needed additional MUS. We found no differences in global impression of improvement and quality of life.

MP52-14 EXPRESSIONS OF VAGINAL PHOSPHODIESTERASE 5 AND NITRIC OXIDE SYNTHASE IN FEMALE SEXUAL DYSFUNCTION

You have accessJournal of UrologySexual Function/Dysfunction/Andrology: Basic Research I1 Apr 2015MP52-14 EXPRESSIONS OF VAGINAL PHOSPHODIESTERASE 5 AND NITRIC OXIDE SYNTHASE IN FEMALE SEXUAL DYSFUNCTION Kang Jun Cho, Jang Hwan Kim, Jong Bo Choi, Seung-June Oh, Kyu-Sung Lee, Myung-Soo Choo, Young Ho Kim, and Joon Chul Kim Kang Jun ChoKang Jun Cho More articles by this author , Jang Hwan KimJang Hwan Kim More articles by this author , Jong Bo ChoiJong Bo Choi More articles by this author , Seung-June OhSeung-June Oh More articles by this author , Kyu-Sung LeeKyu-Sung Lee More articles by this author , Myung-Soo ChooMyung-Soo Choo More articles by this author , Young Ho KimYoung Ho Kim More articles by this author , and Joon Chul KimJoon Chul Kim More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1731AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Phosphodiesterase 5 (PDE5) and endothelial nitric oxide synthase (eNOS) are important enzymes related to sexual function and are found in the vaginal tissue. We investigated the change in expression of vaginal PDE5 and eNOS in women with sexual dysfunction to identify the pathophysiology of female sexual dysfunction (FSD). METHODS We obtained specimens of vaginal tissue from women aged ≥40 years who were undergoing surgery for stress urinary incontinence and had sexual activity ≥2 times every month for the last 6 months. Those with menopause or histories of vaginal surgery, total hysterectomy, oophorectomy, stage 2 or greater pelvic organ prolapse, diabetes mellitus, depression, and other diseases could influence sexual function were excluded. Patients completed the Female Sexual Function Index (FSFI) questionnaire for the evaluation of female sexual function. The FSD group was defined as patients with an FSFI <18 and arousal domain scores <3. Patients with an FSFI ≥26 and individual domain scores ≥4 were used as a control group. Expressions of PDE5 and eNOS were compared between the FSD and control groups by immunofluorescence staining and Western blotting. RESULTS In total, 16 women were evaluated. The mean total FSFI was 30.8 ± 2.8 in the FSD group (n = 8) and 14.8 ± 2.4 in the control group (n = 8). Immunofluorescence staining showed that PDE5 and eNOS were localized in the vaginal epithelium. In Western blot analysis, immunoreactive bands indicating expression of eNOS were decreased in the FSD group than in the control group, although this was not statistically significant. Immunoreactive bands indicating expression of PDE5 were significantly decreased in the FSD group than in the control group (P = 0.030). CONCLUSIONS eNOS and PDE5 in the vagina have a role in the pathophysiology of FSD. The expression of PDE5 in the vagina was decreased in women with sexual dysfunction. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e632 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kang Jun Cho More articles by this author Jang Hwan Kim More articles by this author Jong Bo Choi More articles by this author Seung-June Oh More articles by this author Kyu-Sung Lee More articles by this author Myung-Soo Choo More articles by this author Young Ho Kim More articles by this author Joon Chul Kim More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Transvaginal prolapse repair with or without the addition of a midurethral sling in women with genital prolapse and stress urinary incontinence: a randomised trial.

To compare transvaginal prolapse repair combined with midurethral sling (MUS) versus prolapse repair only. Multi-centre randomised trial. Fourteen teaching hospitals in the Netherlands. Women with symptomatic stage two or greater pelvic organ prolapse (POP), and subjective or objective stress urinary incontinence (SUI) without prolapse reduction. Women were randomly assigned to undergo vaginal prolapse repair with or without MUS. Analysis was according to intention to treat. The primary outcome at 12 months' follow-up was the absence of urinary incontinence (UI) assessed with the Urogenital Distress Inventory and treatment for SUI or overactive bladder. Secondary outcomes included complications. One hundred and thirty-four women were analysed at 12 months' follow-up (63 in MUS and 71 in control group). More women in the MUS group reported the absence of UI and SUI; respectively 62% versus 30% UI (relative risk [RR] 2.09; 95% confidence interval [CI] 1.39-3.15) and 78% versus 39% SUI (RR 1.97; 95% CI 1.44-2.71). Fewer women underwent treatment for postoperative SUI in the MUS group (10% versus 37%; RR 0.26; 95% CI 0.11-0.59). In the control group, 12 women (17%) underwent MUS after prolapse surgery versus none in the MUS group. Severe complications were more common in the MUS group, but the difference was not statistically significant (16% versus 6%; RR 2.82; 95% CI 0.93-8.54). Women with prolapse and co-existing SUI are less likely to have SUI after transvaginal prolapse repair with MUS compared with prolapse repair only. However, only 17% of the women undergoing POP surgery needed additional MUS. A well-informed decision balancing risks and benefits of both strategies should be tailored to individual women.

Transforming growth factor β1 and extracellular matrix protease expression in the uterosacral ligaments of patients with and without pelvic organ prolapse.

This study was undertaken to evaluate the expression of transforming growth factor β1 (TGF-β1) and matrix metalloproteinase 9 (MMP-9), key regulators of the extracellular matrix composition, in the uterosacral ligaments (USLs) of women with pelvic organ prolapse (POP) compared with controls. Under an institutional review board approval, USL samples were obtained from women undergoing vaginal hysterectomy for stage 2 or greater POP (cases, n = 21) and from women without POP undergoing vaginal hysterectomy for benign indications (controls, n = 19). Hematoxylin and eosin and trichrome staining were performed on the USL sections, and the distribution of smooth muscle and fibrous tissue were quantified. Immunohistochemical staining was performed using anti-TGF-β1 and anti-MMP-9 antibodies. The expressions of TGF-β1 and MMP-9 were evaluated by the pathologist, who was blinded to all clinical data. Transforming growth factor β1 expression positively correlated with MMP-9 expression (R = 0.4, P = 0.01). The expressions of TGF-β1 and MMP-9 were similar in subjects with POP versus controls. There was a significant increase in fibrous tissue (P = 0.008) and a corresponding decrease in smooth muscle (P = 0.03), associated with increasing age. The TGF-β1 expression, but not MMP-9 expression, also significantly increased with age (P = 0.02). Although our study uncovered age-related alterations in USL composition and TGF-β1 expression, there was no difference in the expression of TGF-β1 or MMP-9 in the subjects with POP versus controls.

Review of 250 Consecutive Cases of Vaginal Mesh Surgery for Genital Organ Prolapse

Objective: The aim of the study was to assess the success and complications of vaginal mesh surgery performed in 250 successive cases. Design: This study had a retrospective design. Materials andMethods: An analysis was performed of vaginal mesh surgery for complaints of stage II or greater pelvic organ prolapse (POP) from September 2008 to November 2010. A composite score that included subjective criteria of absence of a bothersome bulge, and objective criteria based upon Pelvic Organ Prolapse–Quantification (POP-Q) stage <II and no re-interventions was used to assess treatment success. Results: Transvaginal mesh surgery was performed in 250 subjects (age: 64.40±11.26 years, body mass index [BMI]: 28.96±5.38 kg/m2) for POP. Ten (4.0%) anterior mesh surgeries, 69 (27.6%) posterior mesh surgeries, and 171(68.4%) total mesh surgeries were performed in subjects with stage II or greater degrees of prolapse. Stage II prolapse was noted in 61 (24.4%) subjects, 154 (61.6%) had stage III, and 35 (14.0%) had stage IV prolapse. The mean follow-up was 13 months, and 222 (88.8%) patients were seen at least 12 months post-surgery. The composite success score was 89.2%. Pure anatomic success based upon POP-Q<stage II was 94.1%. Mean operative time was 119.71±41.58 minutes. Mean intraoperative blood loss was 109.28±110.89 mL. There were 12 (5.4%) cases of mesh exposure in the vagina. There were no visceral injuries or mesh erosions. The incidence of de novo dyspareunia was 15.8%. Conclusions: Transvaginal mesh surgery for POP is safe and effective, with few postoperative morbidities when performed by an experienced pelvic floor surgeon. (J GYNECOL SURG 30:134)

Functional Status and Postoperative Morbidity in Older Women with Prolapse

We determined the relationship of preoperative functional status to postoperative morbidity after pelvic organ prolapse surgery in women older than 60 years. We performed a retrospective cohort study of 223 women older than 60 years who underwent surgery for stage II or greater pelvic organ prolapse. Our exposure was preoperative functional status, defined as American Society of Anesthesiologists (ASA) physical status class. We compared postoperative outcomes (length of stay in a medical facility, and number and severity of postoperative complications) in women with low functional status (ASA class III) to those in women with high functional status (ASA classes I and II). We determined the association of preoperative functional status with postoperative outcomes on multivariate analysis. Women in ASA class III were significantly likely to be older (mean ± SD age 72.7 ± 7.3 vs 68.3 ± 6.5 years) and of nonwhite ethnicity (36.1% vs 20.1%), have a higher body mass index (mean 29.5 ± 5.6 vs 26.1 ± 3.8 kg/m(2)) and worse functional comorbidity score (median 3 vs 2), and have undergone obliterative surgery (33.3% vs 9.1%) than women in ASA classes I and II (each p <0.05). Low preoperative functional status was independently associated with increased length of stay in a medical facility (2.13 days, 95% CI 0.57, 3.70, p <0.01) and postoperative complications (OR 2.17, 95% CI 1.03, 4.56), after adjusting for age, body mass index, nonwhite ethnicity, number of comorbidities, surgeon and type of surgery. As defined by ASA class, preoperative functional status is significantly associated with postoperative length of stay and complications. Preoperative functional status is useful for predicting postoperative outcomes in older women who undergo pelvic organ prolapse surgery.

Robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse: initial report and technique

The objective of our study is to describe the peri-operative and early postoperative surgical outcomes following robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse. This was a retrospective cohort study of ten women with symptomatic Stage 2 or greater pelvic organ prolapse and concomitant rectal prolapse who desired combined robotic surgery, at a single institution. The mean age of the subjects was 55.3±19.2years (range 19-86) and the mean body mass index was 25.8±5.7kg/m(2). Preoperatively, the women had Stage 2 or greater pelvic organ prolapse and the average length of rectal prolapse was 2.1±1.9cm. There were no conversions to conventional laparoscopy or laparotomy. The mean operating room time was 307±45min with an estimated blood loss of 144±68ml. The average length of stay was 2.4±0.8days. Preliminary data suggest that robotic sacrocolpoperineopexy with ventral rectopexy is a feasible procedure with minimal operative morbidity for the combined treatment of rectal and pelvic organ prolapse. Longer follow-up is needed to ensure favorable long-term subjective and objective outcomes.

Non-Oral Poster 32

OBJECTIVES: To determine the efficacy of abdominal sacral hysteropexy (ASH) with respect to subjective patient impression of improvement, anatomical cure and symptom change compared to abdominal sacral colpopexy with concomitant total abdominal hysterectomy (ASC/TAH). MATERIALS AND METHODS: We performed a retrospective cohort study of 29 patients who underwent abdominal sacral hysteropexy (n = 20) or abdominal sacral colpopexy with concomitant total abdominal hysterectomy (n = 9) for Stage 2 or greater pelvic organ prolapse. All patients were assessed preoperatively and at 1 year with history, examination (pelvic organ prolapse quantification system (POPQ)) and questionnaires (PFDI-20, PFIQ-7). At 1 year patients also completed a Global Impression of improvement question. The primary outcome measure was impression of improvement, and secondary outcome measures were anatomical cure, change in symptoms and complication rates including mesh erosion. Anatomical cure was defined separately for the apical, anterior and posterior compartments as follows; apical cure as point C/D + (TVL −2) ≤0, anterior/posterior cure as point Aa/Ba or Ap/Bp >-2. Symptom change was assessed using change in symptom subscales of the PFDI-20 and PFIQ-7. RESULTS: There were no significant differences in baseline characteristics between groups. Median age was 50 years (range 37–71) with 48% of patients being menopausal. 9 patients had had previous vaginal or incontinence surgery. 23 patients had polypropylene and 6 had porcine dermis as the suspensory graft. Mean follow up was 12 months (range 10–15 months). All patients, irrespective of surgery, indicated improvement being “much better” or “very much better”. One patient in the ASH group had anterior wall recurrence. There were no failures in the ASC/TAH group. There were no significant inter-group differences in symptom subscales. Mean operating time for ASH and ASC/TAH was 200 min and 230 min respectively (P = 0.13). Estimated blood loss was not significantly different (189ml (ASH) vs 333 ml (ASC/TAH), P = 0.1). Hospital stay did not differ significantly between the groups. Operative and post-operative complications were rare. 3 mesh erosions occurred, all in the ASC/TAH group, at a mean of 5.3 months (range 3–8 months). CONCLUSION: There were no differences in patient impression of improvement, anatomical cure or symptom change between groups. Given the small numbers, this pilot study was not powered to detect significant differences in the outcome measures. We are undertaking a prospective, multicentre study in order to provide definitive data.

Pelvic Organ Prolapse in Defecatory Disorders

To compare the prevalence of pelvic organ prolapse in subjects with defecatory disorders with that in control subjects. In 55 subjects with fecal incontinence, 42 subjects with obstructed defecation, and 45 healthy subjects without defecatory symptoms, a urogynecologist assessed pelvic organ prolapse by the pelvic organ prolapse quantification system, and a gastroenterologist evaluated perineal descent during simulated evacuation. A multiple logistic regression model evaluated whether obstetric-gynecological variables, including pelvic organ prolapse, could discriminate among controls, subjects with fecal incontinence, and subjects with obstructed defecation. Fifty-five percent of controls, 42% of those with obstructed defecation, and 29% of those with fecal incontinence had stage II or greater prolapse by clinical examination. Eleven percent of controls, 7% of those with obstructed defecation, and 47% of subjects with fecal incontinence had a forceps delivery. Eighteen percent of controls, 31% of those with obstructed defecation, and 64% of those with fecal incontinence had a hysterectomy. Even after controlling for a higher prevalence of obstetric risk factors and hysterectomy, fecal incontinence was associated with a lower risk of stage II or greater pelvic organ prolapse (odds ratio for fecal incontinence in > or = stage II pelvic organ prolapse relative to stage 0 pelvic organ prolapse = 0.1, 95% confidence interval 0.01-0.53). In contrast, pelvic organ prolapse severity was not associated with control versus obstructed defecation status. Seven percent of controls, 18% of subjects with obstructed defecation, and 7% of those with fecal incontinence had increased perineal descent during simulated evacuation. Excessive perineal descent was associated (P < .01) with pelvic organ prolapse. Despite a higher prevalence of risk factors for pelvic floor injury, pelvic organ prolapse severity was lower in those with fecal incontinence than in subjects without bowel symptoms. However, a subset of subjects with defecatory disorders, predominantly obstructed defecation, have excessive perineal descent, which is associated with pelvic organ prolapse.