Pelvic Floor Reconstructive Surgery Research Articles

The role of conventional pelvic floor reconstructive surgeries in obstructed defecation symptoms change: CARE and OPTIMAL trials sub-analysis of 2-year follow-up data.

The current study was aimed at addressing two questions: first, is any conventional vaginal prolapse repair effective in curing obstructed defecation symptoms, and second, is there evidence to suggest that a sacrocolpopexy will increase the risk of worsening or new-onset obstructed defecation symptoms? This is a sub-analysis of two major clinical trials performed by the Pelvic Floor Disorders Network: the Colpopexy and Urinary Reduction Efforts (CARE) trial and the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial. Two-year follow-up data were included. Demographics, pelvic organ prolapse quantification examination, and symptoms were compared between first, two surgical arms in the OPTIMAL study and second, CARE and OPTIMAL datasets using Chi-squared test for categorical variables and Student's t test or Mann-Whitney U test for continuous variables. A total of 353 subjects form the OPTIMAL study and 279 subjects from the CARE study met the inclusion criteria. Regardless of trial, obstructed defecation symptoms were present in more than half of the patients at the initial visit before the surgical intervention, and interestingly, about one third of the patients were symptomatic at the 24-month follow-up in all surgical groups. The conventional vaginal prolapse surgeries, with or without posterior vaginal wall repair, improved obstructed defecation symptoms by 50%, but about 35% of patients were suffering from at least one of the aspects of obstructed defecation at the 24-month follow-up. It is also important to note that about a quarter of the patients experienced persisting or worsening of their obstructed defecation symptoms in the absence of anatomical failure.

An update of a former FIGO Working Group Report on Management of Posterior Compartment Prolapse.

The FIGO Working Group (FWG) in Pelvic Floor Medicine and Reconstructive Surgery (2012-2015) established a consensus among international opinion leaders in evaluating current evidence and providing practice recommendations. To provide an update of the previous clinical opinion report on conservative and surgical treatment of posterior compartment prolapse. Search of evidence was performed using Pubmed, Embase, and Cochrane Library databases up to August 2018. Controlled trials on posterior colporrhaphy, site-specific defect, transanal, abdominal, laparoscopic, and mesh repair. Collective consensus on surgical outcomes was based on a decision-making process during meetings and multiple group consultations. Basic evaluation and conservative treatment precede surgical management. Surgical techniques are performed by vaginal, transperineal, transanal, abdominal, or laparoscopic approach. The transvaginal surgical route without mesh appears superior to the transanal route. No conclusions can be drawn based on clinical studies or randomized controlled trials of posterior colporrhaphy and laparoscopic rectopexy. Management of rectocele should include patients' history, quality of life questionnaires, and, in case of complex anorectal symptoms, imaging and functional studies. Evidence on the best type of posterior vaginal wall repair is still scarce. Randomized controlled trials are needed to determine the best approach to achieve safe, effective, and long-term anatomical and functional outcomes.

Three-Dimensional Transperineal Ultrasonography for Diagnosis of Female Occult Stress Urinary Incontinence.

BackgroundWe evaluated the utility of three-dimensional transperineal ultrasonography in detecting occult stress urinary incontinence in women undergoing anterior pelvic floor reconstruction surgery for severe cystocele.Material/MethodsWe enrolled 207 women with stage III–IV cystocele without urinary stress incontinence. One week before the operation, the patients underwent pelvic floor ultrasonography. We measured the vertical distance between the bladder neck and posterior margin of the pubic symphysis, the posterior vesicourethral angle, the urethral rotation angle, the formation of funnel shape, the hiatus area, and the length of the urethra and the funnel shape. Postoperatively, the patients were evaluated for symptoms of stress urinary incontinence and with the 20-minute pad test.ResultsThe posterior vesicourethral angle with Valsalva maneuver, the difference in the posterior vesicourethral angle between the resting state and with the Valsalva state, and the angle of the proximal urethra were larger in the incontinence-positive group than in the incontinence-negative group (P<0.05). Funnel shape urethra was longer in the incontinence-positive group than in the incontinence-negative group (P<0.05). The cutoff value was 137.5° for the posterior vesicourethral angle with Valsalva maneuver, 39.5° for the difference in the posterior vesicourethral angle, 44.5° for the angle of the proximal urethra, and 0.35 cm for the length of the funnel shape. Multivariate analysis revealed that the difference between the posterior vesicourethral angle in the resting state and with Valsalva, the angle of the proximal urethra, and the length of funnel shape were strongly correlated with occult stress urinary incontinence.ConclusionsUltrasonography is an effective method for identifying occult stress urinary incontinence.

Enhanced recovery after surgery versus traditional care in total pelvic floor reconstruction surgery with transvaginal mesh.

To investigate the impact of enhanced recovery after surgery (ERAS) on perioperative outcomes after total pelvic floor reconstruction surgery with transvaginal mesh. A single-center, retrospective observational cohort study involved 177 patients who underwent total pelvic floor reconstruction surgery with transvaginal mesh between August 2015 and November 2017. Eighty-five patients treated according to a traditional protocol formed the control group and 92 patients treated using the ERAS pathway were assigned to the ERAS group. Registered outcomes included demographic characteristics, intraoperative and postoperative data (first assisted walking time, first intestinal exhaust time, length of stay, hospital costs), and complications. The first assisted walking time (40.6±1.48 vs 23.56±3.26hours, P<0.001) and the first intestinal exhaust time (27.65±11.63 vs 18.65±10.68hours, P<0.001) were earlier in the ERAS group. The implementation of the ERAS pathway was associated with shorter length of stay (121.35 vs 70.25hours, P<0.001) and lower hospital costs (46 838.65±2584.08 vs 42 793.57±2560.3 RMB, P<0.001). There was no difference in surgical outcomes or postoperative complications between the two groups. ERAS is safe, economical, and reliable after total pelvic floor reconstruction surgery and promotes perioperative recovery without increasing complication rates.

2234 Comparing Pain Levels and Blood Loss Following Pelvic Floor Reconstructive Surgery Between Vaginal Packing Soaked with Either Estrogen, Bupivacaine or Saline

Study Objective To determine if there is any difference in outcomes between estrogen, bupivacaine and saline-soaked vaginal packing, in patients following pelvic floor reconstructive surgery (PFRS). The primary outcome is post-operative pain, as rated by patients using a visual analog scale (VAS) 2 and 6 hours post-surgery and on the morning of post-operative day1 (POD#1). Secondary outcomes include: intra-operative estimated blood loss (EBL), change in hemoglobin, pain medication use, urinary retention, and length of stay (LOS) in hospital. Design Prospective cohort study. Setting Tertiary academic care center. Patients or Participants Patients undergoing PFRS for pelvic organ prolapse and/or stress urinary incontinence by four trained urogynecologists at an academic center. 142 patients have been enrolled. Interventions Women undergoing vaginal surgery received vaginal packing that was soaked with saline, 0.25% Bupivacaine or conjugated estrogen vaginal cream, according to physician preference. Measurements and Main Results The study population included 142 patients (saline: n=40; bupivacaine: n=47; estrogen: n=55). Results of ANOVA showed no significant differences between the three treatment methods for post-operative pain scores (at 2 hours and 6 hours post-surgery as well as morning of POD#1). The average VAS (2hours) was 2.24, 2.30 and 2.66 and among patients receiving saline, Bupivacaine and estrogen respectively (p=0.4656). There were no significant differences between any of the three treatment methods in VAS pain scores at 6 hours (p=0.2181), and POD#1 (p=0.2832). No significant difference was found with EBL between the three groups (p=0.8914). Conclusion This study did not find a difference between the use of saline, bupivacaine and estrogen cream with vaginal packing after pelvic floor reconstructive surgery on post-operative VAS pain scores, EBL, LOS or urinary retention. Saline soaked packing is an equivalent, but less expensive, alternative to estrogen or bupivacaine vaginal packing – and could replace estrogen-soaked packing in those who have contraindications to estrogen use.

Prolapse Repair Using Non-synthetic Material: What is the Current Standard?

Due to recent concerns over the use of synthetic mesh in pelvic floor reconstructive surgery, there has been a renewed interest in the utilization of non-synthetic repairs for pelvic organ prolapse. The purpose of this review is to review the current literature regarding pelvic organ prolapse repairs performed without the utilization of synthetic mesh. Native tissue repairs provide a durable surgical option for pelvic organ prolapse. Based on recent findings of recently performed randomized clinical trials with long-term follow-up, transvaginal native tissue repair continues to play a role in the management of pelvic organ prolapse without the added risk associated with synthetic mesh. In 2019, the FDA called for manufacturers of synthetic mesh for transvaginal mesh to stop selling and distributing their products in the USA. Native tissue and non-synthetic pelvic organ prolapse repairs provide an efficacious alternative without the added risk inherent to the utilization of transvaginal mesh. A recent, multicenter, randomized clinical trial demonstrated no clear advantage to the utilization of synthetic mesh. Furthermore, transvaginal native tissue repairs have demonstrated good long-term efficacy, particularly when anatomic success is not the sole metric used to define surgical success.

Questionnaire survey on the application of polypropylene mesh and sling in pelvic floor reconstruction surgery in Chinese IUGA members

Objective: To investigate the similarities and differences between Chinese International Urogynecological Association (IUGA) members and international IUGA members on the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) with polypropylene (PP) mesh and sling. Methods: Questionnaires were sent to Chinese IUGA members by Email. The contents of the questionnaires included POP mesh, SUI slings, abdominal sacrocolpopexy (ASC), complications, patients' awareness of rights protection, litigation and database use.Chi-square test was used to compare the proportion of Chinese IUGA members and international IUGA members to the problem alternatives. Results: A total of 31 Chinese IUGA members (100%, 31/31) responded to the questionnaire. All Chinese IUGA members (100%, 31/31) recognized and used PP sling to treat SUI, 98% (917/936) of international IUGA members had used and continued to use PP sling. For ASC surgery, 81% (25/31) of Chinese IUGA members and 82% (768/936) of international IUGA members agreed with and implemented the operation (P=0.841), while 94% (29/31) of Chinese IUGA members and 72% (674/936) of international IUGA members had the same or increased surgical volume as before (P=0.019). For the treatment of POP by transvaginal implantation of PP mesh, Chinese IUGA members had significant differences with international IUGA members in terms of whether they had used (P=0.002), were using (P<0.001), reasons for not using mesh (P<0.001), and indications of mesh implantation (P<0.001). Totally 81% (25/31) of Chinese IUGA members used various databases for monitoring and follow-up, while only 62% (580/936) of international IUGA members used databases, but there was no statistical difference (P=0.092). Conclusion: There are great differences in the concept and clinical application of transvaginal PP mesh implantation for POP between Chinese IUGA members and international IUGA members.

Urinary tract infection prevention after midurethral slings in pelvic floor reconstructive surgery: A systematic review and meta-analysis.

Synthetic midurethral slings are the most common procedures currently performed for stress urinary incontinence in women. Infection is a frequent complication of urogynecologic surgery. We performed a systematic review and meta-analysis to identify interventions that successfully prevent infections, including urinary tract infection (UTI) and/or bacteriuria, compared with no intervention, in women undergoing midurethral sling surgery with or without concomitant pelvic reconstructive procedures for prolapse. The primary outcome was the development of any infection post-midurethral sling placement in women. MEDLINE, Embase, CINAHL and the Cochrane Library were searched for comparative studies from inception to July 2017, with no language restrictions. We used search terms related to midurethral sling, infections and infection-reduction interventions. Two independent reviewers abstracted data and assessed study quality. Pooled effect size estimates were calculated. We conducted meta-analysis of eligible studies. A protocol for this review has been registered and can be accessed online (http://hdl.handle.net/2429/64731). We identified seven eligible studies of infection risk-reducing interventions; all focused on UTIs. Only one study assessed preoperative antibiotics with midurethral sling alone and was halted early because of low UTI rates. All other studies (three randomized control trials and three observational studies) examined whether postoperative antibiotics decrease UTI/bacteriuria rates after midurethral sling with or without reconstructive procedures for pelvic organ prolapse and using bladder catheterization postoperatively. Due to considerable clinical heterogeneity, we only combined four studies for meta-analysis. Postoperative oral prophylactic nitrofurantoin showed no significant benefit in reducing UTI/bacteriuria in women post-midurethral sling with or without concomitant reconstructive pelvic surgery and the need for bladder catheterization, when compared with the reference group (pooled relative risk 0.73, 95% confidence interval [CI] 0.42-1.25). Based on the best available evidence, postoperative oral nitrofurantoin is not effective at reducing UTI/bacteriuria rates in catheterized women after midurethral sling with or without concomitant pelvic reconstructive surgery for prolapse. For midurethral sling alone, preoperative antibiotic prophylaxis may not be needed for UTI prevention.

Mesenchymal stem cell-based bioengineered constructs: foreign body response, cross-talk with macrophages and impact of biomaterial design strategies for pelvic floor disorders.

An excessive foreign body response (FBR) has contributed to the adverse events associated with polypropylene mesh usage for augmenting pelvic organ prolapse surgery. Consequently, current biomaterial research considers the critical role of the FBR and now focuses on developing better biocompatible biomaterials rather than using inert implants to improve the clinical outcomes of their use. Tissue engineering approaches using mesenchymal stem cells (MSCs) have improved outcomes over traditional implants in other biological systems through their interaction with macrophages, the main cellular player in the FBR. The unique angiogenic, immunomodulatory and regenerative properties of MSCs have a direct impact on the FBR following biomaterial implantation. In this review, we focus on key aspects of the FBR to tissue-engineered MSC-based implants for supporting pelvic organs and beyond. We also discuss the immunomodulatory effects of the recently discovered endometrial MSCs on the macrophage response to new biomaterials designed for use in pelvic floor reconstructive surgery. We conclude with a focus on considerations in biomaterial design that take into account the FBR and will likely influence the development of the next generation of biomaterials for gynaecological applications.

Clinical efficacy of pelvic floor reconstruction with autologous tissue in treatment of pelvic organ prolapse

One hundred and twenty nine patients with pelvic organ prolapse (stage Ⅲ to Ⅳ according to POP-Q staging) diagnosed in our hospital from January 2010 to December 2016 were enrolled, among whom 66 cases underwent vaginal hysterectomy plus vaginal anterior and posterior wall repair (TO group), 63 cases underwent vaginal hysterectomy plus pelvic floor reconstruction with autologous tissue (AT group). Clinical parameters, perioperative and postoperative complications were analyzed. There was no statistically significant difference in intraoperative blood loss, indwelling urethral catheter time, length of hospital stay, and anal exhaust time between group AT and group TO (P>0.05). The average operation time of group AT was significantly longer than that of group TO (P 0.05), while the BND at 12 months after operation in group TO was increased compared to 3 months after operation (P<0.05). There were significant differences in scores of PFIQ-7 and PISQ-12 before surgery and 12 month after surgery in both groups (P<0.05). There was no statistically significant difference between the two groups in the incidence of postoperative recurrence and pressure incontinence (P<0.05). It is suggested that the stability of pelvic floor anatomical structure after pelvic floor reconstruction with autologous tissue is better than that of the traditional surgery, especially for patients with severe pelvic organ prolapse. Key words: Uterine prolapse; Urinary incontinence, stress; Rrepair of vaginal anterior and posterior wall; Pelvic floor reconstruction surgery with autologous tissue

Mid-term efficacy of laparoscopic sacral colpopexy of combined transabdominal-transvaginal approach in the treatment of stage Ⅳ pelvic organ prolapse

Objective: To evaluate the clinical effect after laparoscopic sacral colpopexy (LSC) of combined transabdominal-transvaginal approach on stage Ⅳ pelvic organs prolapse (POP). Methods: The clinical data of 65 patients undergoing LSC of combined transabdominal-transvaginal approach from January 1st, 2010 to July 30th, 2017 due to POP stage Ⅳ in First Affiliated Hospital of Guangzhou Medical University were retrospectively analyzed. Objective outcome was assessed by comparing preoperative and postoperative pelvic organ prolapse quantification (POP-Q) systems. Subjective effects were assessed by comparing pelvic floor distress inventory-short form 20 (PFDI-20), pelvic floor impact questionnaire short form (PFIQ-7), pelvic organ prolapse/urinary incontinence sexual questionnaire-12 (PISQ-12) and patient global impression of improvement (PGI-I). Results: All 65 patients were successfully performed without any intraoperative complications. Fifty-three patients were followed in the clinic department and 12 were followed up by telephone. The follow-up duration was 6.1-80.3 months and the median follow-up duration was 24.5 months. The bleeding loss was 20-250 ml. Postoperative urethral catheter residence day was (2.5±1.1) days, length of postoperative stay was (6.2±1.7) days. The postoperative POP-Q scores were compared with preoperative scores which had significantly improved except pb (all P<0.01). The objective cure rates of vaginal anterior wall, apical and posterior wall prolapse stage Ⅳ were 90% (47/52), 100% (23/23) and 95% (20/21).About PGI-I, except for 1 patient who chose "improvement" , the other 64 patients (98%, 64/65) all chose "significant improvement" . Furthermore, preoperative and postoperative PFDI-20, PFIQ-7, and PISQ-12 scores were all statistically significant (all P<0.01). Subjective efficacy was significant. Three cases (5%, 3/65) of postoperative fever occurred. Two cases (4%, 2/53) had mesh exposure. Six patients (11%, 6/53) had recurrence of postoperative prolapse. Five cases had recurrence of vaginal anterior wall prolapse and no reoperation was performed; 1 case was recurrence of posterior vaginal wall prolapse who diagnosed as vaginal posterior wall prolapse stage Ⅲ; no recurrence of apical prolapse. The rate of reoperation (including exposed-mesh removal and pelvic floor reconstruction surgery) was 5% (3/65). Conclusions: The LSC of combined transabdominal-transvaginal approach has a high subjective efficacy rate. The objective cure rate in the case of apical prolapse stage Ⅳ is one hundred percent.The LSC of combined transabdominal-transvaginal approach has low mesh exposure, low postoperative infection and the reoperation rate, which is one of optional pelvic floor reconstruction surgery. However, there is still a risk of recurrence in patients with POP stage Ⅳ with severe bladder bulging.

LBL deposition of chitosan and silk fibroin on nanofibers for improving physical and biological performance of patches.

Pelvic floor dysfunction diseases (PFD) become more prevalent with the increase of elderly population, and complications of pelvic floor reconstructive surgery (e.g. infection and exposure of mesh) have been troubling to patients and gynecologists. In this study, the nanofibrous mats were prepared by alternately depositing chitosan (CS) and silk fibroin (SF) on Nylon6 (N6) nanofibrous mats via layer-by-layer (LBL) technique. The as-prepared mats were characterized. The results showed that CS and SF molecules were successfully assembled on the nanofibers. Additionally, after LBL modification, the hydrophilicity of the nanofibrous mats was reduced and the mechanical properties were improved. Furthermore, the antibacterial activity of the LBL-structured mats reached >95% inhibiting Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus). The in vitro cell co-culture experiments indicated that LBL-structured mats had smaller toxic effects and more excellent biocompatibility to L929 fibroblasts, especially the mats with 15 bilayers coated films. Hence, the LBL-structured mats are promising materials for pelvic floor reconstruction to reduce postoperative pelvic complication rates.

Current Treatments for Female Pelvic Floor Dysfunctions.

As global population aging, the issue of pelvic floor dysfunctions becomes increasingly. Millions of women were affected every year. The treatment of pelvic floor dysfunction has evolved in the past decade. This review aims to provide the current information on the treatment for female pelvic floor dysfunction, including pelvic organ prolapse (POP), urinary, fecal incontinence (FI), and myofascial pelvic pain among women. We used PubMed, Embase, and Web of Science to search for studies that were related to pelvic floor dysfunction regarding the POP, urinary, FI, and treatments. The development of laparoscopic surgery and synthetic and biological materials for pelvic floor reconstructive surgery were summarized. The surgical outcomes and complications of different pelvic floor reconstructive surgeries were compared. New devices for FI and the potential modified pelvic floor reconstructive surgery were also discussed here. Female pelvic medicine will continue to evolve for better treatment in the future. The pelvic floor reconstructive surgery tends to be minimally invasive approach with synthetic graft use.

Clinical effect of improved mesh in the treatment of severe pelvic organ prolapse

Objective To discuss the clinical effect of improved pelvic floor mesh implantation in the treatment of severe pelvic organ prolapse. Methods From January 2016 to April 2018, eighty-four patients with severe pelvic organ prolapse admitted to Harbin First Hospital were randomly divided into observation group and control group with 42 cases in each group.The control group was treated with traditional pelvic floor reconstruction, which used two meshes to reconstruct front and back of pelvic cavity.42 cases of the observation group were treated with improved mesh-augmented vaginal reconstructive surgery, which used only one mesh to reconstruct total pelvic reconstruction by changing the location of puncture.The therapeutic effects of the two surgical methods were compared, including general condition of the whole body, perioperative period, operative period and follow-up. Results The amount of blood loss in the observation group were significantly lower than that in the control group((65.32±20.39) ml vs.(86.52±30.23) ml), and the difference was statistically significant (t=4.56, P 0.05). Conclusion The improved mesh-augmented vaginal reconstructive surgery is an effective minimally invasive surgery, which has small trauma and fewer complications, faster recovery after surgery, can save medical costs, and has broad prospects for clinical application. Key words: Pelvic floor reconstruction surgery; Severe pelvic organ prolapse; Improved mesh-augmented surgery; Treatment outcome

Early Catheter Removal After Pelvic Floor Reconstructive Surgery: A Randomized Trial

(Abstracted from Int Urogynecol J 2018;29:1203–1212) Traditionally, postoperative voiding function is evaluated by performing a retrograde or a spontaneous fill voiding trial on postoperative day 1. The impact of a day-of-surgery voiding trial on postoperative urinary retention in women undergoing major pelvic reconstructive surgery has not yet been examined.

The Effect of Medical Consultation on Patients' Concerns Regarding Vaginal Mesh Use in Pelvic Reconstructive Surgery.

This study sought to determine patients' background knowledge and attitudes towards the use of mesh in pelvic floor reconstructive surgery (PFRS) and the effect of medical consultation on their knowledge and attitudes about mesh use. New urogynecology patients seen for pelvic organ prolapse and/or stress urinary incontinence were asked to complete pre-consultation questionnaires involving 12 questions on demographics and knowledge, attitudes, and concerns about the use of vaginal mesh. If PFRS was discussed, a post-consultation questionnaire was administered. A total of 202 new patients were surveyed. Of these patients, 73.8% had heard of vaginal mesh, and most of this information came from a media source followed by their health care provider. A total of 102 of 202 patients completed both the pre- and post-consultation questionnaire. Before medical consultation, patients' "level of concern" on a Likert scale (1 = not at all concerned, 10 = very concerned) was 5.98 ± 3.04. After consultation, the level of concern decreased significantly to 4.25 ± 2.68 (P = 0.00005). Before consultation, 33.3% of patients stated that they would be willing to proceed with surgery using mesh; however, after receiving standardized information on vaginal mesh risks and complications on the basis of the most current information available, 62.8% stated that they would be willing to proceed with mesh if required (P = 0.00001). Almost 75% of patients presenting for urogynecologic consultation had heard of vaginal mesh use, and 55.7% cited the media as their source of information. Medical consultation significantly reduced the patients' level of concern regarding the use of mesh in PFRS and significantly increased the proportion of patients willing to have mesh placed if appropriate.

Role of robotic surgery on pelvic floor reconstruction

Over the past two decades, minimally invasive surgery (MIS) abdominal surgery has increasingly been used to treat pelvic organ prolapse. Besides the several advantages associated with minimal invasiveness, this approach bridged the gap between the benefits of vaginal surgery and the surgical success rates of open abdominal procedures. The most commonly performed procedure for suspension of the vaginal apex for postoperative vaginal prolapse by robotic-assisted laparoscopy is the sacrocolpopexy. Conventional laparoscopic application of this procedure was first reported in 1994 by Nezhat et al. and had not gained widespread adoption due to lengthy learning curve associated with laparoscopic suturing. Since FDA approval of the da Vinci® robot for gynecologic surgery in 2005, minimally invasive abdominal surgery for pelvic organ prolapse has become increasingly popular, as robotic-assisted laparoscopic sacrocolpopexy is an option for those surgeons without experience or training in the conventional route. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the "gold standard" technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. In fact, repair of pelvic organ prolapse can be performed robotically, and sometimes surgeons can feel suturing and dissection during the procedures less challenging with the assistance of the robot. However, even if robotic surgery may confer many benefits over conventional laparoscopy, these advantages should continue to be weighed against the cost of the technology. To date, as long-term outcomes, evidence about robotic sacrocolpopexy for a repair of pelvic organ prolapse are not conclusive, and much more investigations are needed to evaluate subjective and objective outcomes, perioperative and postoperative adverse events, and costs associated with these procedures. It is plausible to think that the main advantage is that robotics may lead to a widespread adoption of minimally invasive techniques in the field of pelvic floor reconstructive surgery. The following review will address the development and current state of robotic assistance in treating pelvic floor reconstruction discussing available data about the techniques of robotic prolapse repair as well as morbidity, costs and clinical outcomes.

Can surgical reconstruction of vaginal and ligamentous laxity cure overactive bladder symptoms in women with pelvic organ prolapse?

To examine the extent and intensity of the coexistence of overactive bladder (OAB) symptoms in women with pelvic organ prolapse (POP) and to evaluate the likelihood of OAB symptom improvement after surgical POP reconstruction over a period of 2 years. The effectiveness of the transvaginal, single-incision 'Elevate' technique for anatomical cure of anterior/apical and posterior/apical vaginal prolapse has been previously reported in a prospective, multicentre study. This technique uses mesh arms attached to the sacrospinous ligaments to recreate apical ligamentous support. Using the same sample population as that used in the multicentre study (n = 281), we conducted the present sub-analysis focusing on estimating the extent of comorbidity between POP and OAB symptoms, as well as the effects of subsequent pelvic floor reconstruction on OAB symptoms over a long period. Assessments of POP and OAB symptom severity before and after surgery at 6, 12 and 24 months were obtained using the Pelvic Floor Distress Inventory (PFDI) questionnaire. Preoperatively, 70% of all POP patients reported moderate to severe OAB symptoms, with almost half (49.5%) noting severe OAB bother ('quite a bit bothersome') for one or more of the classic OAB symptom domains on the PFDI: 'daytime urinary frequency'; 'urinary urgency'; 'urinary urgency incontinence'; and/or 'nocturia'. In fact, across all four OAB symptom domains evaluated, there were significantly more severe symptoms ('quite a bit bothersome') than moderate ('moderately bothersome') or mild ('somewhat bothersome'): 26-31%, 13-21%, and 17-19% of patients, respectively. In patients with symptomatic POP >stage 2, there was no relationship between further degree of prolapse and presence of severity of OAB symptoms; however, patients with POP stage 2 had significantly more complaints regarding the items 'daytime urinary frequency' and 'urinary urgency incontinence' compared with those with stage 3-4 POP. Pelvic floor reconstructive surgery resulted in significant improvement in all OAB symptoms, which seemed to be stable over time. The cure rate of moderate-to-severe OAB complaints ranged between 60% and 80%, which was a durable improvement noted throughout 24 months. Results showed that POP was to a high degree accompanied by moderate-to-severe OAB complaints. Significant long-lasting improvements in bothersome OAB symptoms occurred after adequate surgical reconstruction of anterior/apical and posterior/apical vaginal support.

Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway

Enhanced recovery after surgery protocols were developed for colorectal surgery to hasten postoperative recovery. Variations of the protocol are being adopted for gynecological procedures despite limited population and procedure-specific outcome data. Our objective was to evaluate whether implementation of an enhanced recovery after surgery pathway would facilitate reduced length of admission in a urogynecology population. In this retrospective analysis of patients undergoing pelvic floor reconstructive surgery by 7 female pelvic medicine and reconstructive surgeons, we compared same-day discharge, length of admission and postoperative complications before and after implementation of an enhanced recovery after surgery pathway at a tertiary care hospital. Groups were compared using χ2 and Student t tests. Candidate variables that could have an impact on patient outcomes with P < .2 were included in multivariable logistic regression models. Satisfaction with surgical experience was assessed using a phone-administered questionnaire the day after discharge. Mean age and body mass index of 258 women (137 before enhanced recovery after surgery and 121 enhanced recovery after surgery) were 65.5 ± 11.3 years and 28.2 ± 5.0 kg/m2. The most common diagnosis was pelvic organ prolapse (n= 242, 93.8%) including stage III pelvic organ prolapse (n= 61, 65.1%). Apical suspension procedures included 58 transvaginal (25.1%), 112 laparoscopic/robotic (48.8%), and 61 obliterative (26.4%). Hysterectomy was performed in 57.4% of women. Demographic and surgical procedures were similar in both groups. Compared with before enhanced recovery after surgery, the enhanced recovery after surgery group had a higher proportion of same-day discharge (25.9% vs 91.7%, P < .001) and a 13.8 hour shorter duration of stay (25.9 ± 13.5 vs 12.1 ± 11.2 hours, P <.001). Operative and postsurgical recovery room times were similar (2.6 ± 0.8 vs 2.6 ± 0.9 hours, P=.955; 3.7 ± 2.1 vs 3.6 ± 2.2 hours, P= .879). Women in the enhanced recovery after surgery group were more likely to be discharged using a urethral catheter (57.9% enhanced recovery after surgery vs 25.4% before enhanced recovery after surgery, P= .005). There were no group differences in total 30 day postoperative complications overall and for the following categories: urinary tract infections, emergency room visits, unanticipated office visits, and return to the operating room. However, enhanced recovery after surgery patients had higher 30 day hospital readmission rates (n= 8, 6.7% vs n= 2, 1.5%, P= .048). Patients before enhanced recovery after surgery were readmitted for myocardial infarction and chest pain. Enhanced recovery after surgery patients were admitted for weakness, chest pain, hyponatremia, wound complications, nausea/ileus, and ureteral obstruction. Three enhanced recovery after surgery patients returned to the operating room for ureteral obstruction (n= 1), incisional hernia (n= 1), and vaginal cuff bleeding (n= 1). Enhanced recovery after surgery patients also had more postoperative nursing phone notes (2.6 ± 1.7 vs 2.1 ± 1.4, P= .030). On multivariable logistic regressions adjusting for age and operative time, same-day discharge was more likely in the enhanced recovery after surgery group (odds ratio, 32.73, 95% confidence interval [15.23-70.12]), while the odds of postoperative complications and emergency room visits were no different. After adjusting for age, operative time, and type of prolapse surgery, readmission was more likely in the enhanced recovery after surgery group (odds ratio, 32.5, 95% confidence interval [1.1-28.1]). In the enhanced recovery after surgery group, patient satisfaction (n= 77 of 121) was reported as very good or excellent by 86.7% for pain control, 89.6% for surgery preparedness, and 93.5% for overall surgical experience; 89.6% did not recall any postoperative nausea during recovery. Enhanced recovery after surgery implementation in a urogynecology population resulted in a greater proportion of same-day discharge and high patient satisfaction but with slightly increased hospital readmissions within 30 days.

Perioperative hemorrhagic complications in pelvic floor reconstructive surgery.

We sought to assess the incidence, symptoms, and risk factors of perioperative hemorrhagic complications in patients undergoing pelvic floor reconstructive surgery. This is a retrospective study on 694 consecutive patients who underwent pelvic floor reconstructive surgery with or without using mesh in our hospital over a 3-year period. We identified 694 pelvic floor reconstructive procedures from 2014 to 2016, including complete/incomplete colpocleisis (176, 25.4%), sacral colpopexy/hysteropexy with mesh (140, 20.1%), colporrhaphy (77, 11.1%) or vaginal mesh repair (99, 43.1%). Two patients who received only sacrospinous ligament suspension were excluded. There were 68 (9.8%) and 3 (0.1%) patients whose blood loss reached 200 and 500ml respectively. Procedures involving mesh and vaginal hysterectomy (VH) caused more intraoperative blood loss. Postoperative hemoglobin drop was least in colpocleisis (p < 0.05). All 6 of the patients (0.9%) who developed postoperative pelvic hematoma underwent concomitant VH, and 5 of them received mesh. Hemorrhagic complications during or after pelvic floor reconstructive surgery are rare. Mesh use and concomitant VH are two major surgical risk factors for hemorrhagic complications in pelvic floor reconstructive surgery.