Open Sacrocolpopexy Research Articles

At the Scrub Sink: Permanent Versus Absorbable Sutures for Sacrocolpopexy Vaginal Mesh Fixation.

Thirty years ago, open sacrocolpopexy was the main route for the procedure, and at that time, most surgeons used permanent sutures to attach the mesh to the vagina. With the changes to laparoscopic and robotic-assisted routes, some urogynecologists started using delayed absorbable sutures while others continued using permanent sutures. The current data suggest no increased failures with delayed absorbable sutures. Given that the risk of suture exposure is almost eliminated with delayed absorbable sutures, it is reasonable to use delayed absorbable sutures in attaching the mesh to the vagina over permanent sutures. Regardless of the suture selection, the 10% long-term mesh exposure rate after sacrocolpopexy should prompt us to continue discussing and working on solutions to lower the mesh exposure rate and improve prolapse surgery outcomes for our patients.

Evaluation of Long-Term Sexual Satisfaction in Women Submitted to Laparoscopic Sacrocolpopexy: Retrospective Tertiary Center Study

Introduction: Traditional treatments for apical compartment prolapse and multicompartment prolapse, such as open sacrocolpopexy, have been associated with concerns regarding sexual function. In recent years, laparoscopic or robotically assisted sacrocolpopexy has emerged as an alternative with potential benefits, including enhanced visualization, symptom relief, and comparable anatomical results. However, the impact of laparoscopic sacrocolpopexy (LSP) on long-term sexual satisfaction in women remains an important area of investigation. This retrospective tertiary center study aimed to evaluate the long-term sexual satisfaction in women who underwent LSP for the treatment of POP. The objective was to assess postoperative sexual satisfaction among patients with a history of active sexual life before the surgery. Methods: A total of 30 patients who underwent laparoscopic sacrocolpopexy between August 2014 and December 2016 were included in the analysis. The patients’ sexual satisfaction was assessed using The New Sexual Satisfaction Scale, a validated questionnaire in the Portuguese language with a mean follow-up of 7 years. Baseline characteristics, surgical and function outcomes were also evaluated. Results: Among the participants, 70% remained sexually active after the surgery. The mean score on The New Sexual Satisfaction Scale was 75.1, indicating a moderate to very satisfied level of sexual satisfaction. Out of the patients who reported a change in their sexual satisfaction after surgery, 69.2% would still recommend the procedure to others. The mean rate of global satisfaction with the surgery was 6.97 out of 10, with 83.3% of the patients recommending the surgery to someone else. Conclusion: The study provides valuable insights into the impact of laparoscopic sacrocolpopexy on sexual well-being in women with POP. Despite potential changes in sexual function, the majority of patients remained sexually active and perceived the procedure as beneficial, expressing overall satisfaction and recommending it to others. The findings highlight the importance of considering sexual function in the management of POP and suggest that LSP can be an effective treatment option that preserves sexual activity. However, further studies with larger sample sizes and comprehensive assessments are warranted to better understand the complex relationship between pelvic organ prolapse surgery, sexual function, and patient outcomes.

Evaluating the Long-term Impact of Implementing Standardized Postoperative Opioid Prescribing Recommendations Following Pelvic Organ Prolapse Surgery.

Improving opioid stewardship is important, given the common use of opioids and resultant adverse events. Evidence-based prescribing recommendations for surgeons may help reduce opioid prescribing after specific procedures. The aim of this study was to assess longitudinal prescribing patterns for patients undergoing pelvic organ prolapse surgery in the 2 years before and after implementing evidence-based opioid prescribing recommendations. In December 2017, a 3-tiered opioid prescribing recommendation was created based on prospective data on postoperative opioid use after pelvic organ prolapse surgery. For this follow-up study, prescribing patterns, including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates, were retrospectively compared for patients undergoing prolapse surgery before (November 2015-November 2017; n = 238) and after (December 2017-December 2019; n = 361) recommendation implementation. Univariate analysis was performed using the Wilcoxon rank sum and χ2 tests. Cochran-Armitage trend tests and interrupted time-series analysis tested for significance in the change in OMEs prescribed before versus after recommendation implementation. After recommendation implementation, the quantity of postoperative opioids prescribed decreased from median 225 mg OME (interquartile range, 225, 300 mg OME) to 71.3 mg OME (interquartile range, 0, 112.5 mg OME; P < 0.0001). Decreases also occurred within each subgroup of prolapse surgery: native tissue vaginal repair ( P < 0.0001), robotic sacrocolpopexy ( P < 0.0001), open sacrocolpopexy ( P < 0.0001), and colpocleisis ( P < 0.003). The proportion of patients discharged following prolapse surgery without opioids increased (4.2% vs 36.6%; P < 0.0001), and the rate of opioid refills increased (2.1% vs 6.0%; P = 0.02). With 2 years of postimplementation follow-up, the use of procedure-specific, tiered opioid prescribing recommendations at our institution was associated with a significant, sustained reduction in opioids prescribed. This study further supports using evidence-based recommendations for opioid prescribing.

MP07-16 RACIAL DISPARITIES IN COMPLICATIONS AFTER SURGICAL TREATMENT OF PELVIC ORGAN PROLAPSE

You have accessJournal of UrologyCME1 Apr 2023MP07-16 RACIAL DISPARITIES IN COMPLICATIONS AFTER SURGICAL TREATMENT OF PELVIC ORGAN PROLAPSE Arshia Aalami Harandi, Anjali Kapur, and Jason Kim Arshia Aalami HarandiArshia Aalami Harandi More articles by this author , Anjali KapurAnjali Kapur More articles by this author , and Jason KimJason Kim More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic organ prolapse (POP) is a common condition with a 12.5% risk of surgical treatment by age 80. Prior studies have shown racial differences in outcomes of surgical treatment of POP in the US. Our study investigates whether there are racial disparities in adverse outcomes following surgical treatment of POP in the American College of Surgeons National Surgical Quality Improvement Program (NSPIQ) database. METHODS: Patients were collected from the NSPIQ database between 2011-2020 with current procedural terminology codes for minimally invasive and open sacrocolpopexy, vaginal vault suspension, anterior colporrhaphy, vaginal repair, enterocele/rectocele repair, and obliterative surgery. Reported complications were aggregated into composite Clavien-Dindo I-II and III-IV classifications. Multivariate logistic regression was utilized to calculate adjusted odds ratios (aOR) for complications. Age, BMI, past medical history, smoking history, surgical treatment, and ASA score were included as covariates in the regression model. RESULTS: Within Clavien Dindo III-IV complications, African Americans had a 35% increased risk (aOR: 1.35, p<.01), while Asians and Hispanics had a 42% (aOR: 0.58, p<.01) and 23% (aOR: 0.77, p<.01) decreased risk, respectively. Asian race was associated with a 19% decreased risk of Clavien-Dindo I-II complications (aOR: 0.81, p<.05) compared to White patients, with all other ethnicities bearing similar risk. Age >65 was associated with a 14% decreased risk of Clavien-Dindo I-II complications (aOR: 0.86, p<.01) and 15% decreased risk of Clavien-Dindo III-IV complications (aOR: 0.85, p<.01). Comorbidities of dyspnea, severe COPD, ascites, CHF, disseminated cancer, open wound/infection, steroids/immunosuppression, smoking history, and BMI >30 were significantly associated with higher odds of Clavien-Dindo III-IV complications (p<.05) (Table 1). CONCLUSIONS: African American women receiving surgical treatment for POP have increased risk of high-grade complications even when adjusted for age, past medical history, smoking status, and type of surgery. Further research is needed to elucidate implicit biases or disparities in healthcare that may contribute to adverse outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e91 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arshia Aalami Harandi More articles by this author Anjali Kapur More articles by this author Jason Kim More articles by this author Expand All Advertisement PDF downloadLoading ...

Evaluation of laparoscopic versus open sacrocolpopexy for vaginal vault prolapse – A study from a tertiary care center

Background: Post hysterectomy vault prolapse is a progressive herniation of the vaginal vault through the urogenital diaphragm and commonly leads to per vaginal bulge. Surgically, vault prolapse is corrected by sacrocolpopexy which can be done both as an open abdominal surgery and as a laparoscopic repair. Aims and Objectives: This study was performed to compare the therapeutic efficacies of laparoscopic and abdominal sacrocolpopexy. Materials and Methods: This study includes 50 cases of vault prolapsed who underwent hysterectomy previously, admitted in our institution and operated during January 2021–June 2022 for a period of 18 months with both open abdominal and laparoscopic sacrocolpopexy. We compared the basic characteristics, duration of surgery, post-operative stay, post-operative complications, and patient satisfaction between open and laparoscopic groups. Results: No significant difference was observed between the characteristics of the patients in the abdominal-approach group and the laparoscopic-approach group. The laparoscopic-approach group had a lower intraoperative estimated blood loss (187.8 vs. 90.3 mL, P&lt;0.001) and a shorter operative time (148.0 vs. 115.3 min, P&lt;0.001) than the abdominal-approach group. The complication rates of the two groups were not significantly different. Conclusion: Our Study is favorable for the use of laparoscopic approach over open abdominal surgery for treating cases of vault prolapse for sacrocolpopexy. The less invasive method leads to less blood loss and a shorter operative time than an open approach.

Abdominal and robotic sacrocolpopexy costs following implementation of enhanced recovery after surgery.

To compare perioperative costs and morbidity between open and robotic sacrocolpopexy after implementation of enhanced recovery after surgery (ERAS) pathway. The present retrospective cohort study of patients undergoing open or robotic sacrocolpopexy (January 1, 2014, through November 30, 2017) used an ERAS protocol with liposomal bupivacaine infiltration of laparotomy incisions. Primary outcomes were costs associated with index surgery and hospitalization, determined with Medicare cost-to-charge ratios and reimbursement rates and adjusted for variables expected to impact costs. Secondary outcomes included narcotic use, length of stay (LOS), and complications from index hospitalization to postoperative day 30. For the total of 231 patients (open cohort, 90; robotic cohort, 141), the adjusted mean cost of robotic surgery was $3239 higher compared with open sacrocolpopexy (95% confidence interval [CI] $1331-$5147; P < 0.001). Rates were not significantly different for intraoperative complications (robotic, 4.3% [6/141]; open, 5.6% [5/90]; P=0.754), 30-day postoperative complications (robotic, 11.4% [16/141]; open, 16.7% [15/90]; P=0.322), or readmissions (robotic, 5.7% [8/141]; open, 3.3% [3/90]; P=0.535). The percentage of patients dismissed on postoperative day 1 was greater in the robotic group (89.4% [126/141] vs. 48.9% [44/90], P < 0.001). Decreased LOS associated with ERAS provided significant cost savings with open sacrocolpopexy versus robotic sacrocolpopexy without adverse impacts on perioperative complications or readmissions.

Medium-term outcomes 2 years after laparoscopic sacrocolpopexy: a retrospective cohort study in Japan

This study was performed to investigate medium-term outcomes and reoperation rates after laparoscopic sacrocolpopexy (LSC). We examined 119 patients undergoing LSC for symptomatic pelvic organ prolapse (POP). The primary outcomes were subjective failure and anatomical failure at 2 years; a score ≥ 2 on question 3 of the PFDI-20 was considered to indicate subjective failure. POP-Q stage 2 or higher in any compartment was considered to indicate anatomical failure. Secondary outcomes were reoperations for POP recurrence, mesh-related complications, and stress urinary incontinence (SUI). The rates of subjective failure and anatomical failure were 4.2% (n = 5) and 9.2% (n = 11), respectively. Reoperations were needed in 13.4% (n = 16) of patients, including SUI with tape procedure in 7.5% (n = 9), POP recurrence in 4.2% (n = 5), and mesh-related complications in 1.6% (n = 2). The subjective failure rate at 2 years after LSC was acceptably low. Impact Statement What is already known on this subject? Laparoscopic sacrocolpopexy (LSC) has clinical efficacy equivalent to open sacrocolpopexy, and there is evidence that LSC involves less blood loss and shorter length of hospital stay. However, there is still insufficient evidence to assess medium-term outcomes after LSC in Japan. What the results of this study revealed? The findings of this study showed excellent medium-term rates of subjective failure (4.2%) and anatomical failure (8.4%) after LSC. We demonstrated that patients with persistent postoperative vaginal bulge (subjective failure) also had no improvement in postoperative urinary and colorectal symptoms. Our cohort had low rates of reoperation (13.4%) after LSC. The most common reoperations were for stress urinary incontinence (SUI) (7.5%), followed by pelvic organ prolapse (POP) recurrence (4.2%) and mesh-related complications (1.6%). What are the implications of these findings in clinical practice and/or further research? This study showed that LSC is a safe and effective treatment for POP. Comparative evaluation of anatomical outcomes and the patient’s condition is required to understand the extent to which LSC positively impacts a woman’s pelvic floor-related quality of life.

PD44-07 EVALUATING THE LONG-TERM IMPACT OF IMPLEMENTING STANDARDIZED POSTOPERATIVE OPIOID PRESCRIBING GUIDELINES FOLLOWING PELVIC ORGAN PROLAPSE SURGERY

You have accessJournal of UrologyCME1 May 2022PD44-07 EVALUATING THE LONG-TERM IMPACT OF IMPLEMENTING STANDARDIZED POSTOPERATIVE OPIOID PRESCRIBING GUIDELINES FOLLOWING PELVIC ORGAN PROLAPSE SURGERY Elizabeth J. Olive, Amy E. Glasgow, Elizabeth B. Habermann, John B. Gebhart, John A. Occhino, Emanuel C. Trabuco, and Brian J. Linder Elizabeth J. OliveElizabeth J. Olive More articles by this author , Amy E. GlasgowAmy E. Glasgow More articles by this author , Elizabeth B. HabermannElizabeth B. Habermann More articles by this author , John B. GebhartJohn B. Gebhart More articles by this author , John A. OcchinoJohn A. Occhino More articles by this author , Emanuel C. TrabucoEmanuel C. Trabuco More articles by this author , and Brian J. LinderBrian J. Linder More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002605.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess longitudinal prescribing patterns for patients undergoing surgery for pelvic organ prolapse in the 2-year timeframe before and after implementing an evidence based opioid prescribing recommendation and evaluate the impact of these recommendations on institutional practices. METHODS: Prospective data was previously used to create a 3-tiered recommendation for opioid prescribing following pelvic organ prolapse surgery at our institution based on narcotic use postoperatively. The guideline was implemented December 2017. Prescribing patterns including the quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid naïve patients undergoing prolapse surgery before (November 2015 through November 2017; N=238) and after (December 2017-December 2019; N=361) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and chi-squared tests. Cochran- Armitage trend tests and interrupted time series analysis were used to test for significance in the change in OMEs prescribed before vs after guideline implementation. RESULTS: The quantity of opioids prescribed at hospital discharge decreased from a median 225 OMEs (Interquartile range [IQR] 225, 300) before the guideline to 0 OMEs (IQR 0,75) after guideline implementation overall (p=xx) and also within each individual subgroup of prolapse surgery: native tissue vaginal (p<0.0001), robotic sacrocolpopexy (p<0.0001), open sacrocolpopexy (p<0.0001), and colpocleisis (p<0.003). The overall proportion of patients discharged following prolapse surgery without opioids significantly increased after guideline implementation (49.9% after vs 4.2% before; p<0.0001). Despite the significant decrease in opioid prescribing, rate of opioid refills was similar before (2.9%) versus after (6.5%) guideline implementation (p=0.06). CONCLUSIONS: With two years of postimplementation follow up, the use of procedure-specific, tiered opioid prescribing guidelines at our institution was associated with a significant reduction in opioids prescribed without adversely impacting refill rates. This study further supports the use of evidence-based guidelines for opioid prescribing. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e710 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elizabeth J. Olive More articles by this author Amy E. Glasgow More articles by this author Elizabeth B. Habermann More articles by this author John B. Gebhart More articles by this author John A. Occhino More articles by this author Emanuel C. Trabuco More articles by this author Brian J. Linder More articles by this author Expand All Advertisement PDF DownloadLoading ...

Surgical Management of Symptomatic Apical Pelvic Organ Prolapse: A Systematic Review and Meta-analysis.

To systematically review objective and subjective success and complications of apical suspensions for symptomatic uterine or vaginal vault pelvic organ prolapse (POP). MEDLINE, CENTRAL, ClinicalTrials.gov, and EMBASE (2002-2019) were searched using multiple terms for apical POP surgeries, including comparative studies in French and English. From 2,665 records, we included randomized controlled trials and comparative studies of interventions with or without hysterectomy, including abdominal apical reconstruction through open, laparoscopic, or robotic approaches and vaginal apical reconstructions. Repairs using transvaginal mesh, off-the-market products, procedures without apical suspension, and follow-up less than 6 months were excluded. Relative risk (RR) was used to estimate the effect of surgical procedure on each outcome. For each outcome and comparison, a meta-analysis was conducted to pool the RRs when possible. Meta-regression and bias tests were performed when appropriate. The GRADE (Grades for Recommendation, Assessment, Development and Evaluation) system for quality rating and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting were used. Sixty-two articles were included in the review (N=22,792) and 50 studies in the meta-analyses. There was heterogeneity in study quality, techniques used, and outcomes reported. Median follow-up was 1-5 years. Vaginal suspensions showed higher risk of overall and apical anatomic recurrence compared with sacrocolpopexy (RR 1.82, 95% CI 1.22-2.74 and RR 2.70, 95% CI 1.33-5.50) (moderate), whereas minimally invasive sacrocolpopexy showed less overall and posterior anatomic recurrence compared with open sacrocolpopexy (RR 0.59, 95% CI 0.47-0.75 and RR 0.59, 95% CI 0.44-0.80, respectively) (low). Different vaginal approaches, and hysterectomy and suspension compared with hysteropexy had similar anatomic success. Subjective POP recurrence, reintervention for POP recurrence and complications were similar between most procedures. Despite variations in anatomic outcomes, subjective outcomes and complications were similar for apical POP procedures at 1-5 years. Standardization of outcome reporting and comparative studies with longer follow-up are urgently needed. PROSPERO, CRD42019133869.

Is robotic-assisted sacrocolpo(hystero)pexy safe and effective in women over 65 years of age?

The objective was to evaluate the safety and efficacy of robotic-assisted sacrocolpo(hystero)pexy in elderly patients with symptomatic apical pelvic organ prolapse and to compare the outcomes of open abdominal and robotic-assisted sacrocolpo(hystero)pexy in geriatric patients. Elderly patients (≥65years of age) who underwent open abdominal or robotic-assisted sacrocolpo(hystero)pexy for treatment of symptomatic grade 3 and 4 apical pelvic organ prolapse between November 2015 and May 2019 were evaluated retrospectively. The success rates of the procedures, the surgical outcomes, and the perioperative adverse events of both groups were compared. Perioperative adverse events were categorized according to the Clavien-Dindo classification. Forty-four patients underwent open abdominal sacrocolpo(hystero)pexy and 30 patients underwent robotic-assisted sacrocolpo(hystero)pexy. The mean age in the open abdominal sacrocolpo(hystero)pexy group was 68.4 ± 3.4years and in the robotic-assisted sacrocolpo(hystero)pexy group it was 69.7 ± 4.1years. The success rates in the open abdominal sacrocolpo(hystero)pexy and robotic-assisted sacrocolpo(hystero)pexy groups were 59% and 57% at median follow-up time of 28months and 24months respectively. Although the mean dosage of the analgesic (10.1mg/24h) and the mean length of hospital stay (2.1days) were significantly lower and shorter for the robotic-assisted sacrocolpopexy group, the mean duration of operation was considerably longer (141.2min). The rate of grade 2 or higher complications for open abdominal sacrocolpopexy was 16% (7 out of 44) and for robotic-assisted sacrocolpopexy it was 17% (5 out of 30). Anatomical outcomes and adverse events are similar in elderly patients undergoing open sacrocolpo(hystero)pexy and robotic-assisted sacrocolpo(hystero)pexy.

Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women

To compare success and complication rates of apical suspension procedures for the surgical management of symptomatic uterine or vaginal vault prolapse. Women with symptomatic uterine or vaginal vault prolapse seeking surgical correction. Interventions included abdominal apical reconstructive repairs (sacrocolpopexy, sacrohysteropexy, or uterosacral hysteropexy) via open, laparoscopic, or robotic approaches; vaginal apical reconstructive repairs (vault suspensions or hysteropexy, sacrospinous, uterosacral, iliococcygeus, McCall's, or Manchester types); and vaginal obliterative procedures (with or without uterus in situ). Individual procedures or broad categories of procedures were compared: (1) vaginal versus abdominal routes for reconstruction, (2) abdominal procedures for reconstruction, (3) vaginal procedures for reconstruction, (4) hysterectomy and suspension versus hysteropexy for reconstruction, and (5) reconstructive versus obliterative options. The Urogynaecology Committee selected outcomes of interest: objective failure (obtained via validated pelvic organ prolapse [POP] quantification systems and defined as overall objective failure as well as failure rate by compartment); subjective failure (recurrence of bulge symptoms determined subjectively, with or without use of a validated questionnaire); reoperation for POP recurrence; complications of postoperative lower urinary tract symptoms (de novo or postoperative stress urinary incontinence; reoperation for persistent, recurrent, or de novo stress urinary incontinence; urge urinary incontinence; and voiding dysfunction); perioperatively recognized urinary tract injury (bladder or ureter); other complications (mesh exposure, defined as mesh being visible and exposed in the vagina, and non-sexual pelvic pain); and sexual function (de novo dyspareunia and sexual function score according to a validated questionnaire). This guideline will benefit patients seeking surgical correction of apical POP by improving counselling on surgical treatment options and possible outcomes. It will also benefit surgical providers by improving their knowledge of various surgical approaches. Data presented could be used to develop frameworks and tools for shared decision-making. We searched Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase from 2002 to 2019. The search included multiple terms for apical POP surgical procedures, approaches, and complications. We excluded POP repairs using transvaginal mesh and studies that compared procedures without apical suspension. We included randomized controlled trials and prospective or retrospective comparative studies. We limited language of publication to English and French and accessibility to full text. A systematic review and meta-analysis was performed. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Gynaecologists, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with POP. All statements refer to correction of apical vaginal prolapse in the short and medium term (up to 5 years), except when otherwise specified.

Conversion rate of laparoscopic or robotic to open sacrocolpopexy: are there associated factors and complications?

To evaluate the conversion rate of laparoscopic or robotic to open sacrocolpopexy and to identify associated factors in a large population-based database. We used Health Care Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) databases 2005-2014. We extracted data on apical suspension and synthetic mesh with laparoscopy or robot in adult women using International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM) codes. We evaluated the rate of conversion and used logistic regression to study the association with risk factors. We identified 3295 women with laparoscopic or robotic sacrocolpopexies. There were 2777 robotic procedures with 37 conversion (1.33%) and 518 laparoscopic procedures with 37 conversions (7.14%), with an overall conversion rate of 2.2%. Median age was 62years [interquartile range (IQR) = 55-69]. Concomitant hysterectomy was significantly more frequent in the robotic than laparascopic group (41.7% versus 13.9%, p < 0.01) and was not associated with conversion. Factors associated with lower conversion included a robotic approach (adjusted odd ratio (aOR) 0.32 [95% CI 0.19-0.54]) and private insurance (aOR 0.53 [95% CI 0.32-0.86]). Factors associated with higher conversion were obesity (aOR 3.27 [95% CI 1.72-6.19]) and lysis of adhesions (aOR 3.32 [95% CI 1.89-5.85]). Accidental organ puncture was significantly associated with conversion (14.9% versus 3.8%; p < 0.01). In this American database, the rate of conversion of laparoscopic or robotic to open sacrocolpopexy was low. The majority (84%) of minimally invasive sacrocolpopexies used a robotic approach, which was associated with a lower risk of conversion. Obesity and lysis of adhesions were associated with a higher risk of conversion.

Depth and Location of Sacral Suture Placement During Cadaveric Simulation of Open Sacrocolpopexy

OBJECTIVESTo evaluate the location and depth of placement of sacral sutures in a cadaveric sacrocolpopexy model. MATERIALS AND METHODSFollowing a 1-hour instructional session, trainees performed an open sacrocolpopexy on unembalmed cadavers under guidance by a Female Pelvic Medicine & Reconstructive Surgery board-certified surgeon. At completion of the session, the presacral tissues were dissected and the location and depth of each sacral suture was identified. RESULTSA total of 19 sutures were placed by 9 trainees into 8 cadavers. The majority of sutures (14/19, 74%) were placed between L5 and S1. Three sutures (16%) were placed at L5 and 2 (11%) were placed at the S1 vertebral body. The mean depth of the anterior longitudinal ligament (ALL) was 1.4 mm. When assessing depth of suture placement, 13 of 19 (68%) were placed into the ALL without penetrating the disc space. Two sutures (11%) were placed in the tissues superficial to the ALL and 4 (22%) were placed deep to the ALL into the periosteum or disc. CONCLUSIONThis study of cadaveric simulation of open sacrocolpopexy finds that location of sacral suture placement is most commonly at the level of the L5-S1 disc space and that placement of sutures into the underlying disc occurs about 1 in 5 times.

Lower urinary tract function improves after laparoscopic sacrocolpopexy for elderly patients with pelvic organ prolapse.

Pelvic organ prolapse (POP) is relatively common in the elderly population. Laparoscopic sacrocolpopexy (LSC) has been reported by several studies to be a less invasive treatment option as compared to open sacrocolpopexy. However, almost all prior reports focused on the complications or surgical obstacles. The present study was designed to examine POP patients of all ages and assess lower urinary tract function before and after LSC. This retrospective study examined the results of LSC performed in POP patients. Urodynamic studies were performed pre- and postoperatively in 50 patients, with the subjects divided into two groups containing those less than and those older than 65 years of age. We performed a pressure flow study. We examined bladder functions by evaluating bladder capacity, detrusor pressure at maximum flow (PdetQmax), maximum flow rate (Qmax), normal desire to void, strong desire to void, voided volume, and postvoid residual volume (PVR). Statistical analysis was performed using Wilcoxon signed rank test. Values of P < .05 were considered significant. With regard to the pressure-flow study parameters, there was a significant increase in the normal desire to void and bladder capacity only in the ≥65 age group. After the operation, there was a significant increase in the mean postoperative Qmax and voided volume, while there was a significant decrease in the PdetQmax and PVR as compared to the preoperative values only in the ≥65 age group. Results show that in elderly patients with POP, LSC might be a valid option with regard to potentially regaining urinary tract function.

Updates in Minimally Invasive Approaches to Apical Pelvic Organ Prolapse Repair

The purpose of this article is to review and comment on the recent medical evidence regarding minimally invasive procedures for apical pelvic organ prolapse repair. Sacrocolpopexy remains the “gold standard” repair for apical prolapse for those who desire to maintain sexual function, and minimally invasive approaches offer equal efficacy with lower risk than open sacrocolpopexy. Similar to the impact on hysterectomy rates, the introduction of robotic technology has converted a large number of open abdominal sacrocolpopexy procedures to a minimally invasive approach in the USA. Newer surgical approaches such as nerve-sparing techniques of dissection at the sacral promontory, use of the iliopectineal ligaments, and natural orifice vaginal sacrocolpopexy offer potential improvements for apical repair. Whether using traditional laparoscopy or robotic assistance, prolapse recurrence is consistently noted in at least 10% of patients. Recent evidence has confirmed that ancillary factors including pre-operative prolapse stage, retention of the cervix and/or uterus, type of mesh implant, and genital hiatus size all adversely affect surgical efficacy. Minimally invasive apical repair procedures seem well suited to early recovery after surgery protocols. While overall complication rates are low, small bowel injury is higher with any abdominal approach and aggressive evaluation of women not meeting routine post-operative goals is advised. Minimally invasive sacrocolpopexy has achieved similar outcomes to the traditional abdominal route and should be considered the new “gold standard” in apical prolapse repair. Alterations in surgical techniques can reduce the risk of constipation.

Пушкарь. Робот-ассистированная реконструкция тазового дна: обзор литературы и собственный опыт

Pelvic organ prolapse (POP) is the most common urogynecological disease in women of middle and older age groups. This disease causes numerous urogenital symptoms and significantly reduces the quality of life of patients. Surgical correction of POP is the optimal method f treatment for this category of patients, however, the choice of surgery and access remains controversial. In recent decades, thanks to the development of robotic technologies, the use of robot-assisted sacrocolpopexy (RAS) has become increasingly popular. Numerous studies have shown the equivalence of results compared with the "gold standard" repair of prolapse - open sacrocolpopexy. This article presents a review of the current literature and our own experience of RAS.

Open sacrocolpopexy and vaginal apical repair: retrospective comparison of success and serious complications.

We compared treatment success and adverse events between women undergoing open abdominal sacrocolpopexy (ASC) vs vaginal repair (VAR) using data from women enrolled in one of three multicenter trials. We hypothesized that ASC would result in better outcomes than VAR. Participants underwent apical repair of stage 2-4 prolapse. Vaginal repair included uterosacral, sacrospinous, and iliococcygeal suspensions; sacrocolpopexies were via laparotomy. Success was defined as no bothersome bulge symptoms, no prolapse beyond the hymen, and no retreatment up to 24months. Adverse events were collected at multiple time points. Outcomes were analyzed using longitudinal mixed-effects models to obtain valid outcome estimates at specific visit times, accounting for data missing at random. Comparisons were controlled for center, age, body mass index (BMI), initial Pelvic Organ Prolapse Quantification (POP-Q) stage, baseline scores, prior prolapse repair, and concurrent repairs. Of women who met inclusion criteria (1022 of 1159 eligibile), 701 underwent vaginal repair. The ASC group (n = 321) was older, more likely white, had prior prolapse repairs, and stage 4 prolapse (all p < 0.05). While POP-Q measurements and symptoms improved in both groups, treatment success was higher in the ASC group [odds ratio (OR) 6.00, 95% confidence interval (CI) 3.45-10.44). The groups did not differ significantly in most questionnaire responses at 12months and overall improvement in bowel and bladder function. By 24months, fewer patients had undergone retreatment (2% ASC vs 5% VAR); serious adverse events did not differ significantly through 6weeks (13% vs 5%, OR 2.0, 95% CI 0.9-4.7), and 12months (26% vs 13%, OR 1.6, 95% CI 0.9-2.9), respectively. Open sacrocolpopexy resulted in more successful prolapse treatment at 2years.

The use of synthetic mesh for vaginal prolapse in the UK: a review of cases submitted to the British Society of Urogynaecology database

The use of mesh for vaginal prolapse gained popularity during the 1990s. More recently, concerns have been raised regarding the safety of mesh procedures. Mesh can be inserted vaginally, laparoscopically or via an open abdominal route, but there are few data comparing the outcomes. Most previous published data relate to small numbers of procedures. This was a review of data submitted to the British Society of Urogynaecology (BSUG) database of all cases reporting the use of mesh placed vaginally or abdominally (open or laparoscopic) between January 2006 and December 2016. The primary outcome was based on the reported patient global impression of improvement (PGI-I). A total of 6,709 cases of mesh prolapse repair were entered during the study period. Women in the laparoscopic group had a lower BMI and were younger. Significantly more patients in the open group (96.4%) described themselves as very much better or much better compared with the laparoscopic group (91%) and the vaginal mesh group (90.7%; p < 0.001). Only 0.5% of patients reported that they were worse or very much worse. This dataset suggests that the effectiveness of mesh repair might be good regardless of the route of insertion. The improvement in PGI-I seems to be greatest with open sacrocolpopexy.

Laparoscopic sacrocolpopexy compared with open abdominal sacrocolpopexy for vault prolapse repair: a randomised controlled trial

Introduction and hypothesisThe objective was to evaluate the functional outcome after laparoscopic sacrocolpopexy versus open sacrocolpopexy in women with vault prolapse.MethodsA multicentre randomised controlled trial was carried out at four teaching and two university hospitals in the Netherlands in women with symptomatic vault prolapse requiring surgical treatment. Participants were randomised for laparoscopic or open sacrocolpopexy. Primary outcome was disease-specific quality of life measured using the Urinary Distress Inventory (UDI) questionnaire at 12 months’ follow-up. Secondary outcomes included anatomical outcome and perioperative data. We needed 74 participants to show a difference of 10 points on the prolapse domain of the UDI 12 months after surgery (power of 80%, α error 0.05).ResultsBetween 2007 and 2012, a total of 74 women were randomised. Follow-up after 12 months showed no significant differences in domain scores of the UDI between the two groups. After 12 months, both groups reported a UDI score of 0.0 (IQR: 0–0) for the domain “genital prolapse”, which was the primary outcome. There were no significant differences between the two groups (p = 0.93). The number of severe complications was 4 in the laparoscopic group versus 7 in the open abdominal group (RR 0.57; 95% CI 0.50–2.27). There was less blood loss and a shorter hospital stay after laparoscopy; 2 (IQR 2–3) versus 4 (IQR 3–5) days, which was statistically different. There was no significant difference in anatomical outcome at 12 months.ConclusionOur trial provides evidence to support a laparoscopic approach when performing sacrocolpopexy, as there was less blood loss and hospital stay was shorter, whereas functional and anatomical outcome were not statistically different.

Robotic sacrocolpopexy for posthysterectomy vaginal vault prolapse: a case series of 31 patients by a single surgeon with a long term follow-up.

The aim of this paper was to evaluate the feasibility, short-term complications of robotic surgery and clinical outcomes in terms of long-term complications, pain relief and recurrence rate, for the treatment of vaginal vault prolapse (VVP). Prospective analysis of robotic-assisted laparoscopic sacrocolpopexy (RALS) performed between October 2011 and February 2015, in patients with advanced post-hysterectomy VVP and significant apical defects as defined by Baden- Walker Score ≥3. Thirty-one consecutive of RALS were performed, with a mean follow-up of 27 months (range 2-48). Average total operative time was 185 minutes (range: 170-235). Estimated blood loss was 50 ml (range: 30-150). One case of cystotomy was reported, repaired with a 2.0 point. No others intra-operative complications occurred. Successful outcome was reported in 94% (29/31) of VVP repairs. This series demonstrates optimal outcomes at long-term follow-up. RALS may provide the same long-term durability of open sacrocolpopexy with the benefit of a minimally invasive approach.