Minimally Invasive Sacrocolpopexy Research Articles

Retrospective Cohort Study of Recovery From Sacrocolpopexy Versus Nonmesh Prolapse Repair.

Providing recovery expectations for prolapse surgery is an important part of patient counseling and aids in patient-centered decision making. The purpose of this study was to determine if postoperative recovery from minimally invasive sacrocolpopexy (MISCP) is noninferior to that of native tissue repair. Recovery at 2 and 6 weeks was quantified using the Postdischarge Surgical Recovery 13 scale, where higher scores indicate greater patient-perceived recovery. A 2:1 MISCP to native tissue repair ratio was used. The study population was created from 3 prior studies involving patients who underwent prolapse surgery between 2013 and 2021.Independent-samples t test was used for normally distributed data, Mann-Whitney U tests for nonnormally distributed data, and the χ2 test for population proportions. A parsimonious linear regression analysis was performed to determine if the surgical group independently predicted postdischarge surgical recovery at 2 and 6 weeks, after controlling for significant confounders identified during bivariate analysis. The study population included 476 patients: 352 underwent MISCP and 124 underwent native tissue repair.Postdischarge Surgical Recovery 13 scores for patients who underwent MISCP compared with native tissue repair were higher at 2 weeks (mean, 58.4 ± 18.2 vs 54.4 ± 18.7; P = 0.04) and at 6 weeks postoperatively (mean, 77.2 ± 15.6 vs 73.7 ± 18.7; P = 0.1). Our findings indicate that recovery after MISCP is noninferior to that of native tissue repair. This information is important for delivering patient-centered care during preoperative counseling.

Is there an association between 6-month genital hiatus size and 24-month composite prolapse recurrence following minimally invasive sacrocolpopexy?

Although an enlarged postoperative genital hiatus (GH) size has been identified as a predictor of recurrence following pelvic organ prolapse (POP) surgery, the protective role of concurrent level III support procedures to reduce the GH size at the time of minimally invasive sacrocolpopexy (MI-SCP) remains unclear. The objective of this study was to compare 24-month composite prolapse recurrence following MI-SCP between patients with a 6-month postoperative GH measurement of <3 cm versus ≥3 cm; and to explore the impact of concurrent level III support procedures on prolapse recurrence, bowel, and sexual function. This was a secondary analysis of two randomized controlled trials of women who underwent MI-SCP from 2014 to 2020. Our primary outcome was composite prolapse recurrence defined as retreatment with either pessary or surgery, and/or subjective bothersome vaginal bulge. A receiver operating characteristic (ROC) curve was generated to identify a 6-month GH cutoff point associated with 24-month composite recurrence. Of the 108 women who met the inclusion criteria, 13 (12%) had composite prolapse recurrence at 24 months: 12 patients (11.1%) reported a bothersome vaginal bulge, and 3 patients (2.8%) underwent retreatment with surgery. A ROC curve demonstrated that a 6-month postoperative GH size of 3 cm had 84.6% sensitivity to predict vaginal bulge and/or retreatment at 24 months (area under curve = 0.52). There was no difference in the composite prolapse recurrence between the groups; however, only patients with a 6-month GH >3 cm underwent retreatment. Twenty-four-month composite prolapse recurrence does not differ based on 6-month GH size; however, surgical failure may be more common in those with a GH size greater than 3 cm.

PROMIS pain intensity and interference after pelvic organ prolapse surgery.

Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires provide valid comparisons across disciplines. Pain measures can be used to track functional outcomes. Limited PROMIS pain data exist in gynecological surgery. We sought to use pain intensity and pain interference short forms to assess pain and recovery after pelvic organ prolapse surgery. The PROMIS pain intensity and pain interference questionnaires were given to patients undergoing uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF) or minimally invasive sacrocolpopexy (MISC) at baseline, 1 week, and 6 weeks postoperatively. Clinical minimally important change was defined as a difference of 2-6T-score points. Mean pain intensity and pain interference T-scores were compared at baseline, 1 week and 6 weeks with ANOVA. Multiple linear regression assessed 1-week scores adjusted for apical suspension type, advanced prolapse, concurrent hysterectomy, concurrent anterior or posterior repair, and concurrent sling. At 1 week, all apical suspension groups showed minimally important change in pain intensity and pain interference T-scores. Between groups at 1 week, pain interference was higher in USLS (66.3±6.6) and MISC (65.5±5.9) than in SSLF (59.2±9.8), p=0.01. Multiple linear regression showed an association of hysterectomy with increases in pain intensity and pain interference. USLS had a higher proportion of concurrent hysterectomy (100%) than SSLF (0%) and MISC (30.8%), p<0.01. No difference was found based on apical suspension type alone. No differences were found in PROMIS pain intensity and pain at 1week postoperatively after apical suspension procedures.

MP07-08 MINIMALLY INVASIVE SACROCOLPOPEXY: TRENDS AND SAFETY OF SAME-DAY DISCHARGE

You have accessJournal of UrologyCME1 Apr 2023MP07-08 MINIMALLY INVASIVE SACROCOLPOPEXY: TRENDS AND SAFETY OF SAME-DAY DISCHARGE Tal Cohen, Arshia Aalami Harandi, and Jason Kim Tal CohenTal Cohen More articles by this author , Arshia Aalami HarandiArshia Aalami Harandi More articles by this author , and Jason KimJason Kim More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Laparoscopic or robotic sacrocolpopexy (SCP) has become a preferred approach in women with pelvic organ prolapse. This study aims to evaluate trends and outcomes of same day discharge (SDD) laparoscopic or robotic SCP using the American College of Surgeons National Surgical Quality Improvement Program (NSPIQ) database. METHODS: Patients were collected from the NSQIP database between 2012-2020 with the current procedural terminology code 57280. Patients with total hospital stay of 0 days were classified as SDD and compared to patients that were discharged on post-op day 1 or 2. The primary outcomes were 30-day complications and readmission rates. Demographic data and perioperative characteristics between the two groups were compared using the appropriate t-test, Chi-squared test, or Fisher’s exact test. RESULTS: A total of 17,723 SCP were included. There were 3,112 (17.6%) same day discharges. There was a significant association between SDD SCP and year of operation (p<.001), with 31.0% of SCP in 2020 discharged on the same day in contrast to 10% of SCP in 2012. SDD patients were younger (56.8 vs. 58.9 years, p<.001), and had lower prevalence of diabetes (8.2% vs. 9.9%, p<.01) and hypertension requiring medications (30.9% vs. 36.9%, p<.001). SDD SCP were more frequently performed by gynecologists than urologists (94.4% vs. 89.5%, p<.001) and had lower operative time (165.5 vs. 187.6 minutes, p<.001). There were fewer cases of readmissions following SDD (1.5% vs. 2.5%, p<.01). Post-operatively, SDD cases were associated with more superficial surgical site infections (1.5% vs. 0.8%, p<.001), but significantly fewer cases of class III-IV complications (0.7% vs. 1.2%, p<.05, Table 1). CONCLUSIONS: There has been a steady rise in SDD after minimally invasive SCP with no significant association of increased risk for serious complications. With further patient education on wound care, SDD after minimally invasive SCP may be a safe and less costly alternative in the surgical management of pelvic organ prolapse. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e87 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Tal Cohen More articles by this author Arshia Aalami Harandi More articles by this author Jason Kim More articles by this author Expand All Advertisement PDF downloadLoading ...

MP19-17 SPECIALTY-SPECIFIC TRENDS IN THE SURGICAL MANAGEMENT OF APICAL PELVIC ORGAN PROLAPSE POST VAGINAL MESH

You have accessJournal of UrologyCME1 Apr 2023MP19-17 SPECIALTY-SPECIFIC TRENDS IN THE SURGICAL MANAGEMENT OF APICAL PELVIC ORGAN PROLAPSE POST VAGINAL MESH Rahul Dutta, Gopal Badlani, and Catherine Matthews Rahul DuttaRahul Dutta More articles by this author , Gopal BadlaniGopal Badlani More articles by this author , and Catherine MatthewsCatherine Matthews More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003244.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Since transvaginal mesh (VM) for apical pelvic organ prolapse (APOP) repair was labeled “high-risk” in 2016 and subsequently banned in 2019 by the US Food and Drug Administration, remaining surgical treatment options include abdominal mesh-augmented sacrocolpopexy (AS) via laparoscopic (LAS) and open (OAS) approaches and vaginal native tissue apical suspension (VN). Our aim was to determine trends in APOP procedures post VM and whether differences existed between urologists and gynecologists. METHODS: Between 2011-2020, the National Surgical Quality Improvement Program (NSQIP) database was queried for AS, VM, and VN performed by both urologists and gynecologists. Trends in surgical approach were analyzed. RESULTS: 26,477 cases of APOP repair (32% AS, 6% VM, 62% VN) were included, 9% by urologists. Urologists operated on older (65 vs 61 years) patients with higher ASA score (32% vs 25% ASA III) with a higher prevalence of diabetes, chronic obstructive pulmonary disease, and bleeding disorders (p<0.05). Mean BMI was 28 and did not vary by specialty. Urologists performed significantly higher proportion of AS (65% vs 29%) and VM (8% vs 6%) relative to VN (27% vs 65%) than gynecologists (p<0.0001). VM utilization has decreased over time for both urologists (p=0.0242) and gynecologists (p=0.0001); a trend towards increasing AS (p=0.1646) in urologists and VN (p=0.0913) in gynecologists has concurrently occurred. Both specialties have increasingly favored LAS over OAS (p<0.0001). Operating room times did not vary for AS (p=0.1719) and were slightly higher for urologists in VM (111 vs 106 min, p=0.0432) and VN (118 vs 111 min, p<0.0001). Concurrent mid-urethral mesh sling placement occurred in 29% of cases overall; this has remained unchanged over time for urologists (p=0.8348) and decreased (p=0.0003) for gynecologists. CONCLUSIONS: Significant differences in the surgical approach to apical prolapse repair procedures and concomitant mid-urethral mesh slings exist between specialties. Urologists tend to operate on more medically complex and older patients with APOP and continue to demonstrate a strong preference for mesh-augmented repairs compared to transvaginal native tissue repairs. Minimally-invasive sacrocolpopexy is being more frequently performed by both specialties treating APOP. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e272 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rahul Dutta More articles by this author Gopal Badlani More articles by this author Catherine Matthews More articles by this author Expand All Advertisement PDF downloadLoading ...

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy.

Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse. This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS. A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different. Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

"Every minute counts": association between operative time and post-operative complications for patients undergoing minimally invasive sacrocolpopexy.

Our aim was to assess whether operative time is independently associated with post-operative complications for minimally invasive sacrocolpopexy (MISCP). Using the National Surgical Quality Improvement Program (NSQIP) database, patients undergoing MISCP from 2015 to 2020 were identified by CPT code. The following data were extracted: demographics, concomitant procedures (hysterectomies, midurethral sling, and anterior or posterior repair), and post-operative complications. Complications were categorized into minor, major, and composite, modeled after the Clavien-Dindo classification. For analysis, covariates associated with operative time and composite complications were identified using a general linear model and Chi-squared or Fisher's exact test as appropriate. Then, adjusted spline regression was performed as a test of nonlinearity between operative time and composite complications. Adjusted relative risks of complications by 60-min increments were estimated using Poisson regression with robust error variance. A total of 13,239 patients who underwent MISCP were analyzed. Overall, mean operative time (SD) was 189.5 (78.3) min. Post-operative complication rates were 2.6% for minor, 4.7% for major, and 7.3% for composite complications. Age, smoking, and sling were the only covariates associated with both operative time and post-operative complications. Adjusted spline regression demonstrated linearity (p<0.0001). With each 60-min increase in operative time, adjusted relative risks (95% CI) were 1.14 for composite (1.09, 1.19), 1.16 for minor (1.10, 1.21), and 1.11 (1.03, 1.20) for major complications. Operative time is independently and linearly associated with post-operative complications for patients undergoing MISCP, even when adjusted for demographic variables and concomitant procedures.

Assessing the Impact of Vaginal Hysterectomy with Vaginal Mesh Attachment on Outcomes and Complications during Minimally Invasive Sacrocolpopexy

To compare mesh complications and failure rates after 1 year in laparoscopic minimally invasive sacrocolpopexy (MISC) with ultralightweight mesh attached vaginally during total vaginal hysterectomy (TVH), laparoscopically if posthysterectomy (PH), or laparoscopically during supracervical hysterectomy. Single-center retrospective cohort study. Tertiary referral center. Women with symptomatic pelvic organ prolapse who elected for MISC. Laparoscopic MISC with ultralightweight mesh attached vaginally during TVH, laparoscopically if PH, or laparoscopically during supracervical hysterectomy. Composite failure was defined as recurrent prolapse symptoms, prolapse past the hymen, or retreatment for prolapse. Between 2010 and 2017, 650 patients met the inclusion criteria with 278 PH, 82 supracervical hysterectomy, and 290 vaginal hysterectomy patients. Median follow-up was similar for all groups (382 days vs 379 vs 345; p=.31). The majority in all groups were white (66.6%), nonsmokers (74.8%), postmenopausal (82.5%), and did not use estrogen (70.3%). Mesh complications did not differ among groups (1.6% PH, 2.5% supracervical hysterectomy, 2.2% vaginal hysterectomy; p >.99). There was no difference in anatomic failure (5% PH, 1.2% supracervical hysterectomy, 2.1% vaginal hysterectomy; p=.07), reoperation for prolapse (1.4% vs 1.2% vs 0.7%; p=.57), or composite failure (9.0% vs 3.7% vs 4.8%; p=.07). TVH with vaginal mesh attachment of ultralightweight mesh had similar adverse events, mesh exposure rates, and failure rates to those of laparoscopic PH sacrocolpopexy or supracervical hysterectomy with laparoscopic mesh attachment.

Is Same-Day Discharge Following Minimally Invasive Sacrocolpopexy Safe and Feasible? A National Contemporary Database Analysis.

The aim of this study was to investigate trends and outcomes of ambulatory minimally invasive sacrocolpopexy (MISC) using data from a contemporary multicenter nationwide cohort. We used the American College of Surgeons National Surgical Quality Improvement Program database to identify women who underwent nonemergent MISC (laparoscopic and robotic) from 2012 to 2018. Exclusion criteria were age <18 or ≥90 years, rectal prolapse, postoperative discharge day ≥3, and concomitant hysterectomy, transvaginal mesh repair, colpocleisis, and/or colorectal surgery. Baseline demographics and 30-day outcomes were compared between patients who underwent same-day discharge (SDD; discharge on postoperative day [POD] 0) and those discharged on POD 1-2 using Kruskal-Wallis, Fisher exact, and Pearson χ2 tests. A 2-sided Cochran-Armitage trend test assessed SDD over time, and person-years methodology was used to assess readmission rates. Multivariable logistic regression and Cox proportional hazards modeling evaluated associations between SDD and postoperative outcomes. We hypothesized that SDD increased over the study time frame and is not associated with adverse outcomes. Of 2,928 women, 362 (12.4%) were SDD, and 2,566 (87.6%) were discharged POD 1-2. The proportion of SDD nearly quadrupled over time (5.6% [2012], 20.6% [2018]; P < 0.001). The SDD group was younger (mean age, 61.9 vs 63.6; P = 0.04), with lower proportion of American Society of Anesthesiologists class III or higher (21.8% vs 27.5%; P = 0.02) and hypertension (37.3% vs.46.5%; P < 0.001), shorter total operation time (median, 142 vs 172 minutes; P < 0.001), and fewer concomitant slings (21.5% vs 33.0%; P < 0.001). Outcomes were similar for SDD: 30-day overall complications (3.0% vs 4.4%; P = 0.23), readmissions (1.1% vs 2.0%; P = 0.28), and reoperations (1.1% vs 0.9%; P = 0.55) and persisted with multivariable analysis. Ambulatory MISC significantly increased during the study period and appears safe and feasible in select patients.

Trends in Same-Day Discharge Rate After Minimally Invasive Sacrocolpopexy and Propensity Score-Matched Analysis of Postoperative Complication Rates Using the National Surgical Quality Improvement Program Database.

The primary aim of this study was to review trends in the same-day discharge (SDD) rate after minimally invasive sacrocolpopexy (MISCP). The secondary aim was to compare the composite 30-day postoperative complication rates between propensity score-matched SDD and admitted cohorts. This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2019. Patients who underwent MISCP were identified by Current Procedural Terminology codes. Concurrent hysterectomy, anterior or posterior repairs, rectopexy, and midurethral sling were also identified. Multivariable logistic regression and propensity score matching were performed. A total of 12,762 MISCP patients were captured: 3,968 underwent MISCP only, 4,065 underwent MISCP with total laparoscopic hysterectomy, 734 underwent MISCP with laparoscopically assisted vaginal hysterectomy, and 3,995 underwent MISCP with laparoscopic supracervical hysterectomy. Overall, the SDD rate was 16.3%, with an increase from 12.3% in 2015 to 23.1% in 2019. Multivariable logistic regression showed that admitted patients were more likely to be older, to be of Black race, have an American Society of Anesthesiologists classification of 3 or 4, have hypertension requiring medication, have longer operative time, and have undergone concurrent anterior or posterior repair, rectopexy, or sling. After propensity score matching, the composite postoperative complication rates were similar between the 2 cohorts (5.7% vs 6.4%, P = 0.818). However, superficial surgical site infection was more likely in the SDD cohort (adjusted odds ratio, 2.3; P < 0.001) and blood transfusion in the admitted cohort (adjusted odds ratio, 11.9; P = 0.0.34). The rate of SDD after MISCP seems to be increasing. Composite postoperative complication rates are similar between SDD and admitted cohorts.

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.

Complications After Vaginal Vault Suspension Versus Minimally Invasive Sacrocolpopexy in Women With Elevated Body Mass Index: A Retrospective Cohort Study Using Data From the National Surgical Quality Improvement Program Database.

Overweight and obese women represent a growing share of pelvic floor reconstruction surgeons' practices. Determining perioperative risk specific to this population is essential to inform decision making regarding operative approach in this population. The aim of the study was to compare surgical complications among overweight and obese women undergoing apical compartment prolapse surgery by either minimally invasive abdominal or vaginal approach. The American College of Surgeons National Surgical Quality Improvement Database was used to identify overweight and obese patients (body mass index ≥ 25) undergoing either minimally invasive sacrocolpopexy (MISC) or vaginal vault suspension (VVS) in the form of a sacrospinous vault fixation or uterosacral ligament fixation for pelvic organ prolapse from 2012 to 2019. Odds ratios for surgical complications, readmission, and reoperation were estimated using multivariable logistic regression. Of 8,990 eligible patients, 5,851 underwent a VVS and 3,139 patients underwent MISC. There was a greater odds of any complication in the first 30 days following VVS (n = 608 [10.4%]) compared with MISC (n = 247 [7.9%]; odds ratio, 1.27; 95% confidence interval, 1.08-1.48) on multivariable analysis. Urinary tract infections (UTIs) were the most common complication and were more likely following VVS (112 (3.6%) versus 350 (6.0%), P < 0.001). When UTIs were excluded, there was no difference in complications between approaches (1.00; 95% CI, 0.82-1.22). There were no statistically significant odds of readmission, reoperation, or serious complications between approaches. Vaginal vault suspension may be associated with a higher odds of any complication compared with MISC in overweight and obese women, but the rate of serious complications, readmission, and reoperation are low, and approaches were comparable when considering complications other than UTI.

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.

Perioperative outcomes of reconstructive surgery for apical prolapse in the very elderly: a national contemporary analysis.

It is predicted that the number of women aged 80years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly. The National Surgical Quality Improvement Program database was used to identify women age ≥ 80years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications. A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p < 0.05). ASC had higher rates of blood transfusion, thromboembolism and reintubation. Life-threatening complications, readmission, pneumonia, stroke and 30-day mortality were lowest in the vaginal group. ASC (aOR 2.27), age > 85years (aOR 1.98), operative time > 3h (aOR 2.02), baseline dyspnea (aOR 2.17), "other race" (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications. ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.

Bowel preparation prior to minimally invasive sacrocolpopexy: a randomized controlled trial.

The objective was to determine if a bowel preparation prior to minimally invasive sacrocolpopexy (MIS) influences post-operative constipation symptoms. We hypothesized that women who underwent a bowel preparation would have an improvement in post-operative defecatory function. In this randomized controlled trial, women undergoing MIS received a pre-operative bowel preparation or no bowel preparation. Our primary outcome was post-operative constipation measured by the Patient Assessment of Constipation Symptoms (PAC-SYM) 2weeks post-operatively. Secondary outcomes included surgeon's perception of case difficulty. Both intention-to-treat (ITT) and per-protocol analyses (PPA) were performed. Analyses were carried out using t test, Fisher's exact test, the Wilcoxon test and the Chi-squared test. Of 105 enrolled women, 95 completed follow-up (43 preparation and 52 no preparation). Baseline characteristics and rates of complications were similar. No differences were noted on ITT. The post-operative abdominal PAC-SYM subscale was closer to baseline for women who received a bowel preparation on PPA (change in score 0.74 vs 1.08, p= 0.045). Women who underwent a preparation were less likely to report strain (6.0% vs 26.7%, p= 0.009) or type 1 Bristol stool on their first post-operative bowel movement (4.3% vs 17.5%, p= 0.047). Surgeons were more likely to rate the complexity of the case as "more difficult than average" (54.4% vs 40.1%, p= 0.027) in those without a bowel preparation. Although there was no difference in ITT analysis, women who underwent a bowel preparation prior to MIS demonstrated benefit to post-operative defecatory function with a corresponding improvement in surgeon's perception of case complexity.

Analysis of minimally invasive sacrocolpopexy with 24-hour hospital stay for the treatment of pelvic organ prolapse

ObjectivesThe objective of this study is to analyze the impact (in terms of safety and saving of hospital costs) of the implementation of a new protocol for the correction of pelvic organ prolapse (POP) by minimally invasive sacrocolpopexy (MISC) with 24-h hospital stay. Material and methodsProspective observational study of the first 78 MISC procedures performed consecutively. 46 procedures (59%) were performed with 24-h hospital stay, and 32 (41%) required more than 24 h. The postoperative complications were determined for each group: visits to the Emergency Department, reoperations, and the average cost per procedure regarding hospital stay and ER visits. The cost model was established according to the data of the Analytical Accounting System of the Jiménez Díaz Foundation Hospital and of the Official State Gazette of Madrid. ResultsThere were no differences regarding intraoperative or postoperative complications between both groups. The number of visits to the Emergency Department, reinterventions or hospital re-admissions was lower in the 24-h hospital stay group, without reaching statistical significance. The implementation of the MISC protocol with 24-h hospital stay represented a saving of 607.91€ per procedure in hospital costs. ConclusionsCorrection of the POP with MISC with a 24-h hospital discharge policy was feasible and safe in at least 59% of the patients, with similar complications, visits to the Emergency Department or hospital readmission rates.

Perioperative Outcomes of Minimally Invasive Sacrocolpopexy Based on Route of Concurrent Hysterectomy: A Secondary Analysis of the National Surgical Quality Improvement Program Database

The objective of this study was to describe perioperative outcomes of minimally invasive sacrocolpopexy (MISCP) based on 4 different routes of concurrent hysterectomy: vaginal (VH), laparoscopic-assisted (LAVH), laparoscopic supracervical (LSCH), and total laparoscopic (TLH). This was a retrospective cohort study. A secondary analysis of the 2006-2015 National Surgical Quality Improvement Program (NSQIP) database was performed analyzing women who underwent concurrent hysterectomy with MISCP based on Current Procedural Terminology (CPT) codes. We excluded open abdominal hysterectomies. We compared outcomes between VH, LAVH, LSCH, and TLH including operative time, length of hospital stay, a composite outcome of 30-day postoperative adverse events, readmission, or reoperation. A logistic regression model was used to correct for pre-identified potential confounding variables. A minimum detectable effect analysis was planned. Hospitals participating in the NSQIP program. Women who underwent hysterectomy with MISCP. Not applicable. A total of 524 women underwent hysterectomy with MISCP including VH in 31 (5.9%), LAVH in 40 (7.6%), LSCH in 322 (61.5%), and TLH in 131 (25%). The VH group had a higher incidence of ≥4 concurrent CPT codes (71% vs 27% in other groups, p = .03). Operative times differed significantly between groups (p < .01): TLH had the shortest operating time (171.43 ± 83.77 minutes). There were no significant differences in length of hospital stay, rate of reoperation, 30-day readmission, or the composite outcome (p = .8). Route of hysterectomy was not associated with increased composite outcome on adjustment for confounders (adjusted odds ratio [OR] 1.1, 95% CI 0.3-3.99, p = .88). A minimum detectable effect analysis indicated that this study population had 80% power to detect an OR of 5.07 or greater between the different routes of hysterectomy during concomitant MISCP for the composite 30-day outcome. Regardless of route of concurrent hysterectomy, MISCP is associated with low rates of 30-day complications, reoperation, and readmission.

Análisis del tratamiento del prolapso de órganos pélvicos mediante colposacropexia mínimamente invasiva con 24 horas de ingreso

ObjectivesThe objective of this study is to analyze the impact (in terms of safety and saving of hospital costs) of the implementation of a new protocol for the correction of pelvic organ prolapse (POP) by minimally invasive sacrocolpopexy (MISC) with 24-hour hospital stay. Material and methodsProspective observational study of the first 78 MISC procedures performed consecutively. 46 procedures (59%) were performed with 24-hour hospital stay, and 32 (41%) required more than 24hours. The postoperative complications were determined for each group: visits to the Emergency Department, reoperations, and the average cost per procedure regarding hospital stay and ER visits. The cost model was established according to the data of the Analytical Accounting System of the Jiménez Díaz Foundation Hospital and of the Official State Gazette of Madrid. ResultsThere were no differences regarding intraoperative or postoperative complications between both groups. The number of visits to the Emergency Department, reinterventions or hospital re-admissions was lower in the 24-hour hospital stay group, without reaching statistical significance. The implementation of the MISC protocol with 24-hour hospital stay represented a saving of 607.91€ per procedure in hospital costs. ConclusionsCorrection of the POP with MISC with a 24-hour hospital discharge policy was feasible and safe in at least 59% of the patients, with similar complications, visits to the Emergency Department or hospital readmission rates.

Computed-tomography image segmentation and 3D-reconstruction of the female pelvis for the preoperative planning of sacrocolpopexy: preliminary data.

Minimally-invasive sacrocolpopexy is the gold standard procedure for advanced apical prolapse. Nonetheless, sacrocolpopexy has potential serious complications leading many surgeons to avoid this excellent surgical procedure. To overcome these limitations, preoperative planning with 3D models of the female pelvis is proposed. The aim of the study is to evaluate the feasibility of pelvic anatomy reconstruction with the ITK-SNAP software and highlight its potential benefits in this intervention. Thirty patient-specific 3D models of the female pelvis were created using ITK-SNAP and the EndoCAS Segmentation Pipeline extension for image segmentation: contrast-enhanced computed tomography (CE-CT) data sets of women who underwent examinations for reasons other than prolapse were used. The distances of pelvic structures from the sacral promontory were standardised and measured, and correlations among these distances were evaluated with Spearman's correlation coefficient. Pelvic anatomy reconstruction was feasible for all CE-CT data sets. A statistically significant correlation was found between the distances of the cava bifurcation and common iliac vessels from the sacral promontory. An area for proximal mesh attachment was defined: it is free from the passage of iliac vessels in 97.5% of cases. A significant statistical correlation was found between the distances of the midpoint of the bispinous diameter and the uterine cervix from the sacral promontory; a process of linear regression showed that the latter measure can be estimated by multiplying the first one by 0.86. Pre-surgical 3D reconstructions of the female pelvis using ITK-SNAP could help achieve widespread use of sacrocolpopexy: further comparative studies are needed to evaluate the outcomes with and without their use.

Complications after minimally invasive sacrocolpopexy with and without concomitant incontinence surgery: A National Surgical Quality Improvement Program (NSQIP) database study.

To compare surgical complications for patients having minimally invasive sacrocolpopexy (MISCP) with concomitant incontinence procedure, to those having MISCP alone. Patients undergoing MISCP with and without a concomitant incontinence procedure between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. The main outcome of interest was a composite of surgical site infection, bleeding requiring blood transfusion, return to the operating room within 30 days, and surgical stay >48 h. Log-binomial regression was used to identify independent risk factors for the outcome and to generate adjusted effect measures for variables of interest. Seven thousand ninety-seven women met the inclusion criteria, of which 2433 (34%) underwent a concomitant incontinence procedure. Patients having incontinence procedures were slightly older (59 ± 11 vs 58 ± 12, P < 0.0001) and had longer total operating time (225 IQR 170-267 vs 184 IQR 120-232 min, P < 0.0001). Pre-operative steroid use, wound class III/IV (vs I/II), and longer operative time were independent predictors of the composite outcome. After adjusting for baseline patient characteristics and co-morbidities, no association was observed between concomitant incontinence procedure and the composite outcome (adjusted RR 0.87, 95%CI 0.65-1.18) but there was an increased likelihood of urinary tract infection (adjusted RR 2.47 95%CI 1.89-3.27). Despite being associated with a longer operative time, performing an incontinence procedure at the time of MSCIP was not associated with an increased risk of clinically important surgical complications other than urinary tract infection.