Paravaginal Defect Research Articles

8988 Laparoscopic Combined Paravaginal Repair, Burch Colposuspension, and Sacral Colpopexy

<h3>Study Objective</h3> The objective of this video is to demonstrate an overview of indications, procedural steps, and high-yield anatomy for laparoscopic paravaginal defect repair, Burch colposuspension, and sacral colpopexy. <h3>Design</h3> Surgical video. <h3>Setting</h3> The setting is a community teaching hospital. <h3>Patients or Participants</h3> 54yo G1P1 with grade 3 cystocele, grade 2 rectocele, and uterine prolapse identified on physical exam in the outpatient setting after initially presenting with complaints of pelvic discomfort, vaginal pressure, and sensation of urinary retention. She failed conservative management with pessary and desired definitive management. <h3>Interventions</h3> Total laparoscopic hysterectomy was first performed in routine fashion. Then, laparoscopic paravaginal defect repair, Burch colposuspension, and sacral colpopexy were together performed for correction of pelvic organ prolapse. Burch colposuspension was performed prophylactically to treat potential postoperative stress urinary incontinence. The patient had a stable postoperative course. <h3>Measurements and Main Results</h3> QBL was 50mL. <h3>Conclusion</h3> The risk of requiring surgery for pelvic organ prolapse increases with age. A laparoscopic approach to pelvic organ prolapse correction offers advantages to both the patient and surgeon. Burch colposuspension is an effective additional procedure during pelvic organ prolapse surgery for prophylactic treatment of potential postoperative stress urinary incontinence.

A modified technique for paravaginal repair of cystocele with paravaginal defect: A retrospective study

We aimed to determine the efficacy and safety of a modified protocol for paravaginal repair of symptomatic paravaginal defects and cystocele. This study was an observational case series of 98 consecutive female patients, referred to our hospital between June 2014 and May 2018, with symptomatic grade II to IV paravaginal defects and cystocele. Our modified technique for paravaginal repair is based on the conventional protocol but incorporates reverse bridge repair and the cross-stitching of bilateral sutures. The curative effect of this new technique was evaluated subjectively and objectively during postoperative follow-up. All operations were successful. Patients were followed up for 12 to 48months, until June 2019; the mean follow-up period was 32.4months. Three months after surgery, the rate of success was 100% (98/98 cases); in each case, the top of the vagina lay above the level of the sciatic spine. The rate of success was 94.9% (93/98 cases) at 12months after surgery, 91.0% (61/71 cases) at 24months after surgery, and 76.2% (16/21 cases) at 48months after surgery. Four cases required a second surgery; three of these cases were treated with sacrocolpopexy, and one case was treated with sacrospinous ligament fixation. Our modified technique for paravaginal repair was safe and effective for anterior vaginal prolapse and cystocele, as confirmed by the results observed over a mean follow-up period of 32.4months.

Robot-Assisted Laparoscopic Paravaginal Repair and Sacrocolpopexy in Patients With Pelvic Organ Prolapse

To evaluate the surgical effects of robotic paravaginal repair and sacrocolpopexy in patients diagnosed with lateral cystocele due to paravaginal defect. Robotic paravaginal repair and sacrocolpopexy were performed contemporaneously in 43 patients with high-grade pelvic organ prolapse combined with a lateral or mixed cystocele. To objectively evaluate prolapse correction, the Pelvic Organ Prolapse Quantification (POP-Q) test was performed at the 12-month visit and the results compared to those of the preoperative period. Subjective satisfaction was scored using the Patient Global Impression of Improvement (PGI-I) questionnaire. POP-Q measurement results before and after surgery, an objective indicator of surgery, the Ba and C scores improved significantly from 2.1 ± 1.2 preoperatively to -2.0 ± 1.1 postoperatively (P <.01), and from 0.3 ± 1.3 preoperatively to -4.3 ± 1.1 postoperatively (P <.01), respectively. In PGI-I questionnaire, the numbers of patients who awarded scores of 1 and 2 (evidencing high-level symptom improvement) were 33 at 1 month (76.7%), 30 at 3 months (69.8%), and 28 (65.1%) at 12 months. When respondents awarding 3 points (a little improvement) were included, the numbers rose to 38 (88.4%) at 1 and 3 months and 35 (81.4%) at 12 months, indicating satisfaction with symptom improvement. There were no critical complications during and after surgery, but complications such as de novo stress urinary incontinence that lower patient satisfaction occurred in some cases. Robot-assisted paravaginal repair and sacrocolpopexy can be safely performed in patients with cystocele-predominant pelvic organ prolapse and good surgical results can be expected with excellent effects.

Preperitoneal laparoscopic lateral repair in pelvic organ prolapse - a novel approach.

The aim of this study is to present a novel approach for a paravaginal defect treatment. This extraperitoneal approach can be performed in patients with comorbidities and on obese patients. The main advantages are: not requiring the pneumoperitoneum and the Trendelenburg position and the avoidance of peritoneal adhesions. This study presents the results in 27 patients with cystocele caused by a lateral defect pelvic organ prolapse quantification (POP Q) stage II or higher. The procedure was performed with a modified Richardson and Burch technique using a preperitoneal approach. Three follow-up examinations were conducted two, six weeks, and six months after the operation. A quality of life assessment was conducted before and after surgery using the short form of the PFIQ-7. All patients had a POP Q II cystocele and 59% had concomitant stress urinary incontinence. In all patients cystocele was reduce to asymptomatic POP Q stage I or 0. Mean operation time was approximately 80 minutes. In six months post-operation follow up, one case of recurrence was noted. The patients' quality of life revealed a statistical improvement from an average of 6.8 points before, to an average of 0.7 points after the operation (p < 0.05) in the PFIQ-7. Preperitoneal laparoscopic lateral repair is a relatively fast procedure and it is also feasible for obese women and for patients with a cardiopulmonary risk. Neither the Trendelenburg position nor the pneumoperitoneum are required. Postoperatively, the patients witnessed a reduction of the cystocele and complaints connected with their previous condition.

Transperineal Repair of Enterocele within Perineal Hernia Secondary to Le Fort Colpocleisis

An 80-year-old female patient with advanced pelvic organ prolapse underwent vaginal hysterectomy with unilateral sacrospinous fixation and anterior/posterior correction through repair of the paravaginal defect and perineorrhaphy. Within less than a year after the first procedure, the patient presented with stage 4 uterovaginal prolapse, and a Le Fort colpocleisis with perineorrhaphy was performed.

Trans-obturator cystocele repair of level 2 paravaginal defect.

It is reported that almost one in five women will need some form of pelvic organ prolapse surgery in their lifetime, with anterior wall repair accounting for nearly half of these. Cystoceles occur secondary to defect(s) in one or more of the vaginal wall support mechanisms, including its lateral paravaginal attachments. Paravaginal defects are very common in women presenting with cystocele, thus highlighting the importance of paravaginal defect repair for optimal cystocele correction in the majority of cases. Although there are several paravaginal defect repair procedures, some entail complex techniques, whereas others rely on the use of transvaginal mesh, which is currently not permitted in many countries. In this video article we present a novel trans-obturator native tissue paravaginal defect repair for the management of cystocele. This procedure has the advantages of avoiding complex transabdominal paravaginal defect repair, the controversial use of transvaginal mesh, or a single-point fixation to an arcus tendineus fasciae pelvis that might be difficult to identify. We believe that the trans-obturator cystocele repair procedure offers several advantages over existing paravaginal defect repair alternatives.

Comparison between pelvic floor ultrasound and physical examination in the evaluation of cystocele

The main aim of this study was to explore the agreement between physical examination and ultrasound findings in the assessment of cystocele. It was a prospective observational study of women with primary cystocele. It enrolled 54 patients who underwent an interview, physical examination and 2D/3D transperineal ultrasound. The study included two observers: one who conducted the interview and carried out the examination, and another who performed the transperineal ultrasound. There was a concordance of 51.8% between examination and ultrasound concerning cystocele grading. In paravaginal defects, the concordance was 46.3%. In 42.6% of the patients, the ultrasound yielded better results for diagnosing paravaginal defect than the physical examination. Ultrasound revealed that levator ani muscle avulsion was present in 60.4% of patients and hiatal ballooning in 69.8%. In conclusion, the main utility of transperineal ultrasound is the evaluation of levator ani muscle integrity and urogenital hiatus through the axial plane in 3D.

The new etiology and surgical therapy of stress urinary incontinence in women

To determine the subjective and objective cure rate of a urethral stabilization procedure (USP) for stress urinary incontinence (SUI) in women; to describe this new surgical intervention; to record its potential complications; to establish the SUI etiology. The author conducted a prospective case series study in ambulatory settings and under local anesthesia. Thirty-four consecutive women with uncomplicated SUI subjected to USP, which was performed by reconstructing site-specific defects within the urethral stabilizing mechanism (USM) and using no surgical slings, meshes or absorbable sutures. The paravaginal defect(s) was repaired by transvaginal approach. The endopelvic fascia was sharply separated from the ventral perineal membrane (VPM) just above the anterior urethral meatus. The vestibular bulbs sharply dissected from VPM and advance upwards. The VPM defect(s) reconstructed and vestibular bulbs placed back to the original location. The access to the peri- and the para-urethral region was created by making a lateral vertical incision, aside from the lateral urethral meatus and defects were repaired. The suburethral transverse incision was made beneath the urethral meatus and the stratum-by-stratum surgical dissection conducted until the lateral vaginourethral ligament is visualized bilaterally. The defect(s) within the vaginourethral ligaments was surgically reconstructed, and the vaginal wall repaired. The primary outcome measured subjective and objective cure rates, and the secondary outcome measured the occurrence of potential complications. The five-year postoperative follow-up was conducted. Two out of thirty-four patients dropped-out from the study. The USP performed without difficulties, and no severe complication observed. One-subject developed superficial wound separation (3.1 %) and one-subject (3.1 %) developed urinary urge incontinence at the 5-postoperative-year. At 60-month follow-up subjective and objective cure rates were a 92 % and an 88 % respectively. The urethral stabilization procedure yields a high degree of subjective and objective cure rates without severe complications and is a well-tolerated operation by women. The urethral stabilization procedure is a simple, easy to implement, and reproducible method for uncomplicated stress urinary incontinence in women. Site-specific defects within the urethral stabilizing mechanism constitute the etiology of the stress urinary incontinence in women.

Short-term Outcomes of Laparoscopic Repair of Paravaginal Defects

Short-term Outcomes of Laparoscopic Repair of Paravaginal Defects

Prospective evaluation of paravaginal defect repair with and without apical suspension: a 6-month postoperative follow-up with MRI, clinical examination, and questionnaires.

Paravaginal defect (PVD) has been suggested as one of the main contributors to the development of prolapse in the anterior vaginal wall (AVW). We aimed to evaluate the descent of pelvic organs, presence of vaginal H configuration, and pubococcygeus (PC) muscle defect by pelvic magnetic resonance imaging (MRI), together with subjective symptoms of prolapse, before and 6months after PVD repair. We also aimed to evaluate risk factors of recurrence. Fifty women with PVD diagnosed by gynecological examination and scheduled for vaginal PVD repair were planned for enrollment. Preoperatively and 6months postoperatively, subjective symptoms were evaluated using the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) together with MRI of the pelvis to evaluate defects in the PC muscle, vaginal shape, and pelvic organ descent. Forty-six women completed the study. Twenty had PVD repair alone, whereas 26 also had concomitant surgery performed. Prolapse grade, subjective symptoms, sexual problems, and quality of life (QoL) were significantly improved at follow-up. Missing vaginal H configuration was observed in 21 women before operation and was correlated with PC muscle defect. Recurrence rate was 39%, and significantly more women with recurrence had PC muscle defects and missing H configuration. Vaginal PVD repair alone or combined with concomitant surgery significantly reduces objective prolapse and subjective symptoms. We could not demonstrate MRI findings of missing H configuration to be a sign of PVD but, rather, a sign of defect in the PC muscle. Risk of recurrence is significantly higher in women with major PC muscle defects and missing H configuration.

MULTILEVEL SURGICAL CORRECTION OF POSTGISTERECTOMIC GENITAL HERNIA

The article presents a new surgical method for correcting posthisterectomic genital hernia, accompanied by bilateral paravaginal defects. Despite the use of many surgical techniques and high-tech materials for the prevention and treatment of posthisterectomic genital hernia, the prevalence rate of this pathology fails to decline, but on the contrary, for many reasons, it tends to grow, which calls for the development of new surgical methods of the treatment. The proposed surgical program of multilevel correction of posthisterectomic genital hernia with bilateral paravaginal defects, providing multifocal fixation of anatomical structures with polypropylene implants, will improve clinical results and their duration, as well as the fall of the prevalence rate of relapses of the disease.

Improvement of overactive bladder symptoms: Is correction of the paravaginal defect in anterior vaginal wall prolapse necessary?

To explore the relationship between overactive bladder (OAB) symptoms and paravaginal defects (PVDs), and to identify the necessity of PVD repair by transvaginal mesh (TVM) for the treatment of OAB symptoms. A retrospective clinical study of 30 women with advanced cystocele with limited apical and posterior vaginal wall prolapse was conducted to identify any changes in OAB symptoms following a single Perigee procedure. Prolapse was assessed using the pelvic organ prolapse quantification (POP-Q) system, and paravaginal defects were identified by sonography. Complete urodynamic examination was performed prior to and one year after operation. All patients completed the overactive bladder questionnaire pre- and postoperatively for a quantitative assessment of OAB symptoms. All patients showed a significant improvement at points Aa and Ba in the POP-Q system. The results of the administered questionnaire revealed statistically significant improvement postoperatively. The difference of OAB symptoms between the group with PVDs and that with central defects was not statistically significant (p=0.67). Moreover, no statistically significant improvement of OAB symptoms in the group with repaired PVDs was observed postoperatively (p=0.42). Statistical improvements of symptoms exist after Aa and Ba points recovery as evaluated by POP-Q system regardless of PVD existence identified by sonography. Repairing PVD did not show significantly improve the severity of OAB symptoms in objective urodynamic data or subjective questionnaire data. The superiority of TVM in PVD repair to manage OAB symptoms seems not manifest.

Short-term complications associated with the use of transvaginal mesh in pelvic floor reconstructive surgery: Results from a multi-institutional prospectively maintained dataset.

Vaginal reconstructive surgery can be performed with or without mesh. We sought to determine comparative rates of perioperative complications of native tissue versus vaginal mesh repairs for pelvic organ prolapse. Using the National Surgical Quality Improvement Program (NSQIP) database, we concatenated surgical data from vaginal procedures for prolapse repair, including anterior and posterior colporrhaphy, paravaginal defect repair, enterocele repair, and vaginal colpopexy using Current Procedural Terminology (CPT) coding. We stratified this data by the modifier associated with mesh usage at the time of the procedure. We then compared 30-day perioperative outcomes, postoperative complications (bleeding, infection, etc), and readmission rates between women with and without mesh-based repairs. We identified 10 657 vaginal reconstructive procedures without mesh and 959 mesh-based repairs from 2009 through 2013. Patients undergoing mesh repair were more likely to experience at least one complication than native tissue repair (9.28% vs 6.15%, P < 0.001), with the overall complication rate also being higher in the mesh group (11.37% vs 9.39%, P = 0.03). Procedures with mesh had a higher rate of perioperative bleeding requiring transfusion than native tissue repair (2.3% vs 0.49%, P < 0.001), and organ surgical site infection (SSI) (0.52% vs 0.17%, P = 0.02). There were no significant differences in rates of readmission, superficial, or deep SSIs, pneumonia, urinary tract infection, sepsis, or renal failure. The use of vaginal mesh for pelvic organ prolapse repair appears to result in a higher rate of perioperative complications than native tissue repair. Patients undergoing these procedures should be counselled preoperatively concerning these risks.

23: Laparoscopic paravaginal defect repair using delayed absorbable barbed suture

23: Laparoscopic paravaginal defect repair using delayed absorbable barbed suture

Structural Failure Sites in Anterior Vaginal Wall Prolapse: Identification of a Collinear Triad

(Abstracted from Obstet Gynecol 2016;128:853–862) The most common form of pelvic organ prolapse and the most frequent site of operative failure is cystocele formation (anterior vaginal wall prolapse). Potential fascial and muscular failure factors (anatomic sites of injury) identified as causal factors contributing to cystocele formation include 2 vaginal failure sites (apical support and paravaginal defects), 2 vaginal wall factors (vaginal width and length), and 2 levator ani factors (hiatus size and levator ani defects).

Structural Failure Sites in Anterior Vaginal Wall Prolapse: Identification of a Collinear Triad.

To test the null hypothesis that six factors representing potential fascial and muscular failure sites contribute equally to the presence and size of a cystocele: two vaginal attachment factors (apical support and paravaginal defects), two vaginal wall factors (vaginal length and width), and two levator ani factors (hiatus size and levator ani defects). Thirty women with anterior-predominant prolapse (women in a case group) and 30 women in a control group underwent three-dimensional stress magnetic resonance imaging. The location of the anterior vaginal wall at maximal Valsalva was identified with the modified Pelvic Inclination Coordinate System and the six factors measured. Analysis included repeated-measure analysis of variance, logistic regression, and stepwise linear regression. We identified a collinear triad consisting of apical location, paravaginal location, and hiatus size that were not only the strongest predictors of cystocele size, but were also highly correlated with one another (r=0.84-0.89, P<.001) for the presence and size of the prolapse. Together they explain up to 83% of the variation in cystocele size. Among the less significant vaginal factors, vaginal length explained 19% of the variation in cystocele size, but no significant difference in vaginal width existed. Women in the case group were more likely to have abnormalities in collinear triad factors (up to 80%) than vaginal wall factors (up to 23.3%). Combining the strongest collinear triad with the vaginal factors, the model explained 92.5% of the variation in cystocele size. Apical location, paravaginal location, and hiatus size are highly correlated and are strong predictors of cystocele presence and size.

Paravaginal defect: anatomy, clinical findings, and imaging.

The paravaginal defect has been a topic of active discussion concerning what it is, how to diagnose it, its role in anterior vaginal wall prolapse, and if and how to repair it. The aim of this article was to review the existing literature on paravaginal defect and discuss its role in the anterior vaginal wall support system, with an emphasis on anatomy and imaging. Articles related to paravaginal defects were identified through a PubMed search ending 1 July 2015. Support of the anterior vaginal wall is a complex system involving levator ani muscle, arcus tendineus fascia pelvis (ATFP), pubocervical fascia, and uterosacral/cardinal ligaments. Studies conclude that physical examination is inconsistent in detecting paravaginal defects. Ultrasound (US) and magnetic resonance imaging (MRI) have been used to describe patterns in the appearance of the vagina and bladder when a paravaginal defect is suspected. Different terms have been used (e.g., sagging of bladder base, loss of tenting), which all represent changes in pelvic floor support but that could be due to both paravaginal and levator ani defects. Paravaginal support plays a role in supporting the anterior vaginal wall, but we still do not know the degree to which it contributes to the development of prolapse. Both MRI and US are useful in the diagnosis of paravaginal defects, but further studies are needed to evaluate their use.

Paravaginal defect: A new classification of fascial and muscle tears in the paravaginal region.

The lateral support of the vaginal wall depends on the integrity of the paravaginal section of the visceral pelvic fascia, levator ani, and their connection. Various defects of the muscle and fascia can result in identical clinical findings-ie, the descent of the lateral vaginal sulcus. In this study, we created a realistic scheme for classifying paravaginal defects, based on the complex relationship of the pelvic fascia with the levator ani. Surgical observations, cadaver examinations, and a complex magnetic resonance imaging (MRI)-based 3-dimensional (3D) model were used to analyze the spatial relationships of normal and defective anatomy of the female pelvic floor. Descent of the lateral vaginal sulcus can result from a defect in the paravaginal visceral pelvic fascia, levator ani, or both. The fascial defect can be partial or complete, and the muscle defect can vary in location. A detailed illustrated classification is presented. We present a new model of the pathology that underlies a common clinical finding.

Tecidos nativos na correção de defeitos de compartimento – casuística de 5 anos

Resumo Introducao/objetivos Atualmente, o uso de proteses na cirurgia de prolapso dos orgaos pelvicos tem aumentado em detrimento das correcoes baseadas em tecidos nativos, essencialmente pela elevada taxa de falencia atribuida a estes. Os objetivos do estudo foram analisar os resultados obtidos no tratamento cirurgico dos defeitos anterior e posterior da vagina com tecidos nativos e avaliar a taxa de sucesso. Metodos Estudo retrospetivo das 418 cirurgias vaginais para correcao de defeitos dos compartimentos anterior e posterior com recurso a tecidos nativos, realizadas no departamento de uroginecologia, de janeiro 2008 a dezembro 2012. Resultados Na nossa amostra a idade media era de 64 anos, com 90% das doentes em menopausa; 48,1% das mulheres foram histerectomizadas, 78,2% foram submetidas a colporrafia anterior e 72,7% a colporrafia posterior. A correcao do defeito paravaginal anterior realizou‐se em 32,5% das cirurgias e a do posterior em 25,4%. O enterocelo foi corrigido em 68,1% dos casos. A taxa de complicacoes intra e pos‐operatorias foi de 5%. Das 347 doentes avaliadas na consulta pos‐operatoria, foi dada alta a 91,6%. Sete foram posteriormente readmitidas (2,2%). Mantiveram‐se em vigilância 29 mulheres, maioritariamente por prolapso recidivante, que agravou apos um ano de seguimento. Foram reintervencionadas no total 18 mulheres, das quais 13 por recidiva (3,7%). Assim, a taxa de sucesso anatomica foi de 80%. Se forem adicionados os casos assintomaticos, em que nao se obteve cura anatomica, eleva‐se essa taxa para 94%. Discussao/conclusao A taxa de sucesso da correcao de defeitos de compartimento do nosso departamento esta de acordo com a descrita na literatura, com taxas de complicacoes e reintervencoes inferiores.

Standardized modified colposuspension--mid-term results of prospective studies in one centre.

Burch colposuspension is still estimated as a 'gold standard' by the Cochrane Collaboration Group in the treatment of operative stress urinary incontinence (SUI) Some urogynecologists agree with this statement, some argue that Burch colposuspension should no longer be used. The aim of this study was to evaluate mid-term effects and patient's satisfaction with standardized modified colposuspension performed in one centre. Modified colposuspension was performed after standardization by 2 trained gynaecologists in 354 women. Data collected from 227 women were added to the final analysis of mid-term results. Average time from the operation to mid-term visit was 19 months (range 9-36 months). At mid-term visit, 86.3% of patients were cured. There was no case of post-void urine residual over 100 ml. Pain near the operated region was reported by 1 woman from agricultural region. No one reported negative impact of modified colposuspension on sexual activity or dyspareunia. Modified colposuspension according to the E. Petri technique seems to be an operation that is safe and well-tolerated by women with preoperative stress urinary incontinence and paravaginal defect without urodynamic signs of ISD in mid-term observation.