Pelvic Organ Prolapse Procedures Research Articles

Perioperative opioid prescriptions associated with stress incontinence and pelvic organ prolapse surgery

There is an opioid epidemic in the United States with a contributing factor of opioids being prescribed for postoperative pain after surgery. Among women who underwent stress urinary incontinence and pelvic organ prolapse surgeries, our primary objective was to determine the proportion of women who filled perioperative opioid prescriptions and to compare factors associated with these opioid prescriptions. We also sought to assess the risk of prolonged opioid use through 1 year after stress urinary incontinence and pelvic organ prolapse surgeries. Using a population-based cohort of commercially insured individuals in the 2005-2015 IBM MarketScan databases, we identified opioid-naive women ≥18 years who underwent stress urinary incontinence and/or pelvic organ prolapse procedures based on Current Procedural Terminology codes. We defined the perioperative period as the window beginning 30 days before surgery extending until 7 days after surgery. Any filled opioid prescription in this window was considered a perioperative prescription. For our primary outcome, we reported the proportion of opioid-naive women who filled a perioperative opioid prescription and reported the median quantity dispensed in the perioperative period. We also assessed demographic and perioperative factors associated with perioperative opioid prescription fills. Previous studies have defined prolonged use as the proportion of women who fill an opioid prescription between 90 and 180 days after surgery. We report this estimate as well as continuous opioid use, defined as the proportion of women with ongoing monthly opioid prescriptions filled through 1 year after stress urinary incontinence and/or pelvic organ prolapse surgery. Among the 217,460 opioid-naive women who underwent urogynecologic surgery, 61,025 (28.1%) had pelvic organ prolapse and stress urinary incontinence surgeries, 85,575 (39.4%) had stress urinary incontinence surgery without pelvic organ prolapse surgery, and 70,860 (32.6%) had pelvic organ prolapse surgery without stress urinary incontinence surgery. Overall, 167,354 (77.0%) filled a perioperative opioid prescription, and the median quantity was 30 pills (interquartile range, 20-30). In a multivariate regression model, younger age, pelvic organ prolapse surgery with or without stress urinary incontinence surgery, abdominal route, hysterectomy, and mesh use remained significantly associated with opioid prescriptions filled. Among those with a filled perioperative opioid prescription, the risk of prolonged use defined as an opioid prescription filled between 90 and 180 days was 7.5% (95% confidence interval, 7.3-7.6). However, the risk of prolonged use defined as continuous use with at least 1 monthly opioid prescription filled after surgery was significantly lower: 1.2% (1.13-1.24), 0.32% (0.29-0.35), 0.06% (0.05-0.08), and 0.04% (0.02-0.05) at 60, 90, 180, and 360 days after surgery, respectively. Among privately insured, opioid-naive women undergoing stress urinary incontinence and/or pelvic organ prolapse surgery, 77% of women filled an opioid prescription with a median of 30 opioid pills prescribed. For prolonged use, 7.5% (95% confidence interval, 7.3-7.6) filled an opioid prescription within 90 to 180 days after surgery, but the rates of continuously filled opioid prescriptions were significantly lower at 0.06% (95% confidence interval, 0.05-0.08) at 180 days and 0.04% (95% confidence interval, 0.02-0.05) at 1 year after surgery.

National Analysis of Perioperative Morbidity of Vaginal Versus Laparoscopic Hysterectomy at the Time of Uterosacral Ligament Suspension

The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension. Retrospective propensity-score matched cohort study. American College of Surgeons National Surgical Quality Improvement Program database. We included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. We compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort. The study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3-2.8; p <.01) and a higher serious complication rate (5.6% vs 3.1%, OR 1.8, 1.1-3.1; p = .02), which excluded urinary tract infection and superficial surgical site infection. The propensity score analysis was performed, and patients were matched in a 1:1 ratio between the TVH-USLS group and the TLH-USLS group. In the matched cohort, patients who underwent TVH-USLS had a higher composite complication rate than those who underwent TLH-USLS (10.3% vs 6.4%, OR 1.7, 95% confidence interval [CI], 1.1-2.7; p = .04), whereas the rate of serious complications did not differ between the groups (4.3% vs 3.1%, OR 1.4, 95% CI, 0.7-2.8; p = .4). On multivariate logistic regression, TVH-USLS remained an independent predictor of composite complications (adjusted OR 1.6, 95% CI, 1.0-2.6; p = .04) but not serious complications (adjusted OR 1.4, 95% CI, 0.7-2.8; p = .3). In this large national cohort, TVH-USLS was associated with a higher composite complication rate than TLH-USLS, largely secondary to an increased rate of urinary tract infection. After matching, the groups had similar rates of serious complications. These data suggest that TLH-USLS should be viewed as a safe alternative to TVH-USLS.

Exploration of the efficacy of myofascial release and trigger point therapy for women with pelvic organ prolapse

Purpose: Pelvic organ prolapse (POP) is a common condition amongst women with up to 41% prevalence. Symptoms include pelvic pain, vaginal bulging, difficulty defaecating and urinary incontinence. The traditional biomechanical understanding of POP is that it is caused by weak pelvic tissues and therefore treatments aim to support and strengthen pelvic structures. Pelvic floor exercises may reduce POP symptoms for up to 30% of women but are typically only effective at alleviating urinary incontinence. Approximately one in ten women with POP are referred for surgery following the failure of non-surgical options. Surgery is not without risk and reoperation rates are high, with further surgery a significant risk of long-term morbidity. Following concerns about the safety of surgical procedures for POP and limited effectiveness of non-surgical approaches, the authors challenge the current biomechanical explanation of POP. In this study a biotensegrity hypothesis is proposed, whereby POP is caused by tension, not weakness. A new treatment approach was developed applying Myofascial Release (MFR) and Trigger Point (TrP) techniques to the pelvic floor to alleviate tension. The study presents preliminary clinical and patient-reported outcomes following this new treatment approach.

Laparoscopic Long Mesh Surgery with Augmented Round Ligaments: A Novel Uterine Preservation Procedure For Apical Pelvic Organ Prolapse

We aim to assess the surgical outcomes of our novel hysteropexy procedure, laparoscopic long mesh surgery (LLMS) with augmented round ligaments. Twenty-five consecutive women with stage II or greater main uterine prolapse defined by the POP quantification staging system were referred for LLMS. Long mesh is a synthetic T-shaped mesh, with the body fixed at the uterine cervix and the two arms fixed along the bilateral round ligaments. The clinical evaluations performed before and 6 months after surgery included pelvic examinations, urodynamic studies, and questionnaires for urinary and sexual symptoms. After a follow-up time of 12 to 24 months, the anatomical reduction rate was 92% (23/25) for the apical compartment. The average operative time was 65.4 ± 28.8 minutes. No major complications were recognized during LLMS. The lower urinary tract symptoms and scores on the questionnaires improved significantly after the surgery, except urgency urinary incontinence and nocturia. Neither voiding nor storage dysfunction was observed after the operations. All of the domains and total Female Sexual Function Index (FSFI) scores of the 15 sexually active women did not differ significantly after LLMS. The results of our study suggest that LLMS is an effective, safe, and time-saving hysteropexy surgery for the treatment of apical prolapse.

Comparative Retrospective Study of Tension-Free Vaginal Mesh Surgery, Native Tissue Repair, and Laparoscopic Sacrocolpopexy for Pelvic Organ Prolapse Repair.

Methods We identified that 308 women who had undergone surgical repair of POP were followed up for at least 6 months. Recurrence rates of POP after tension-free vaginal mesh (TVM) surgery (n = 243), native tissue repair (NTR) (vaginal hysterectomy with colpopexy, anterior and posterior colpoplasty, or circumferential suturing of the levator ani muscles and apical repair by transvaginal sacrospinous ligament fixation (SSLF)) (NTR; n = 31), and laparoscopic sacrocolpopexy after subtotal hysterectomy (LSC; n = 34) were compared. Presence of mesh erosion was also recorded. Results Patients who underwent LSC were significantly younger (65.32 ± 3.23 years) than those who underwent TVM surgery (69.61 ± 8.31 years). After TVM surgery, the rate of recurrence (over POP-Q stage II) was 6.17% (15/243) and was highest in patients with advanced POP. The recurrence rate in patients who underwent NTR procedure was 3.23% (1/34) and that in patients who underwent LSC was 11.76% (4/11). There was no statistically significant difference in the recurrence rate between the three types of surgery. There were 13 cases (5.35%) of mesh erosion after TVM surgery and none after LSC surgery. The risk of mesh erosion was correlated with having had total TVM surgery but not with patient age or POP stage. Repeat procedures were performed in 5 women (2.14%) who underwent TVM surgery and 1 (2.94%) who underwent LSC. No patient underwent repeat surgery after NTR. There was no statistically significant difference in the reoperation rate between the three types of surgery. Conclusion Our study suggested that TVM surgery, NTR, and LSC have comparable outcomes as for the postoperative recurrence rate and mesh erosion. However, the outcomes of each technique need to be carefully evaluated over a long period of time.

MP30-08 IS STRESS INCONTINENCE AND PELVIC ORGAN PROLAPSE SURGERY ASSOCIATED WITH THE DEVELOPMENT OF AUTOIMMUNE RHEUMATIC DISEASE? THE RESULTS OF A POPULATION-BASED COHORT STUDY

INTRODUCTION AND OBJECTIVE:Regulatory warnings for mesh-based stress urinary incontinence (SUI) and pelvic organ prolapse (POP) procedures have led to an unsupported claim that mesh directly stimul...

19: Modified Manchester-Fothergill procedure for pelvic organ prolapse in a patient with spina bifida

19: Modified Manchester-Fothergill procedure for pelvic organ prolapse in a patient with spina bifida

A randomized controlled trial of permanent vs absorbable suture for uterosacral ligament suspension

Uterosacral ligament suspension (USLS) is a common procedure for apical pelvic organ prolapse. The procedure has been described using only permanent suture, only absorbable suture and a combination of permanent and absorbable suture. We hypothesized that the use of absorbable suture is not inferior to the use of permanent suture. All women undergoing USLS between October 2016 and November 2017 were approached. Subjects were randomized to permanent or absorbable suture. The primary outcome was POP-Q point C 12months after surgery (non-inferiority limit = 2cm). A composite outcome of success at 12months was defined as no apical prolapse ≥ 1/2 TVL, no prolapse beyond the hymen, no prolapse retreatment and no bulge symptoms. Forty-four subjects with mean (SD) age 62.9 (12.0) years and body mass index 29.1 (5.4) kg/m2 were enrolled and underwent USLS. Fifteen (34.1%) had POP-Q stage II and 29 (65.9%) stage III prolapse. Twenty-two were randomized to permanent and 22 to absorbable suture. Forty (90.9%) completed the 12-month follow-up. Median (IQR) POP-Q point C at 12months was -7 (-10, -6) for the permanent and - 7 (-9, -5.5) for the absorbable suture groups (p = 0.65, non-inferiority p < 0.0002). Four (20%) in the permanent and one (5%) in the absorbable suture group reported bulge symptoms (p = 0.34). Fifteen (75%) in the permanent and 18 (90%) in the absorbable suture groups met criteria for composite success (p = 0.41). Intervention-related adverse outcomes were uncommon and not different between groups. Absorbable suture for USLS is not inferior to permanent suture for apical anatomic outcomes.

National Analysis of Perioperative Morbidity of Vaginal Versus Laparoscopic Hysterectomy at The Time of Uterosacral Ligament Suspension

Study Objective The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension (USLS). Design Retrospective cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program database. Patients or Participants We included all patients who underwent USLS and concurrent vaginal or laparoscopic hysterectomy from 2010 to 2017. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. Interventions We compared 30-day complication rates in patients who underwent vaginal versus laparoscopic hysterectomy at the time of USLS. Measurements and Main Results We compared groups using chi-squared analysis and students t-test for categorical and continuous variables, respectively. Stepwise backward multivariate logistic regression was used to identify independent predictors of experiencing complications. The cohort was comprised of 3,349 patients who underwent vaginal hysterectomy with USLS and 484 who underwent laparoscopic hysterectomy with USLS. Patients who underwent the vaginal approach were older (58.3 vs 50.9 years), more likely to have hypertension, and to undergo concurrent minor urogynecologic procedures such as midurethral sling or colporrhaphy. Patients in the laparoscopic group had higher BMI and were more likely to smoke. Groups were otherwise similar. Patients who underwent the vaginal approach had a significantly higher rate of complications than the laparoscopic group for all complications (11.4% vs 6.4%, OR 1.9, 1.3-2.8, p=0.0005) as well as serious complications-only (5.6% vs 3.1%, OR 1.8, 1.1-3.1, p=0.02). After controlling for confounding variables on multivariate logistic regression, vaginal hysterectomy at the time of USLS remained a significant predictor of all complications (OR 2.0, 1.4-2.9, p=0.001), as well as serious complications (OR 2.1, 1.2-3.7, p=0.009). Conclusion In this large national cohort, after adjusting for known medical and surgical risk factors, vaginal hysterectomy at the time of USLS was associated with a higher complication rate than the laparoscopic route of surgery. The objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension (USLS). Retrospective cohort study. American College of Surgeons National Surgical Quality Improvement Program database. We included all patients who underwent USLS and concurrent vaginal or laparoscopic hysterectomy from 2010 to 2017. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy. We compared 30-day complication rates in patients who underwent vaginal versus laparoscopic hysterectomy at the time of USLS. We compared groups using chi-squared analysis and students t-test for categorical and continuous variables, respectively. Stepwise backward multivariate logistic regression was used to identify independent predictors of experiencing complications. The cohort was comprised of 3,349 patients who underwent vaginal hysterectomy with USLS and 484 who underwent laparoscopic hysterectomy with USLS. Patients who underwent the vaginal approach were older (58.3 vs 50.9 years), more likely to have hypertension, and to undergo concurrent minor urogynecologic procedures such as midurethral sling or colporrhaphy. Patients in the laparoscopic group had higher BMI and were more likely to smoke. Groups were otherwise similar. Patients who underwent the vaginal approach had a significantly higher rate of complications than the laparoscopic group for all complications (11.4% vs 6.4%, OR 1.9, 1.3-2.8, p=0.0005) as well as serious complications-only (5.6% vs 3.1%, OR 1.8, 1.1-3.1, p=0.02). After controlling for confounding variables on multivariate logistic regression, vaginal hysterectomy at the time of USLS remained a significant predictor of all complications (OR 2.0, 1.4-2.9, p=0.001), as well as serious complications (OR 2.1, 1.2-3.7, p=0.009). In this large national cohort, after adjusting for known medical and surgical risk factors, vaginal hysterectomy at the time of USLS was associated with a higher complication rate than the laparoscopic route of surgery.

A qualitative study of women's values and decision-making surrounding LeFort colpocleisis.

LeFort colpocleisis for uterovaginal prolapse can be appealing to elderly non-sexually active patients given the durability and low risk, particularly when the alternative procedure is more invasive and includes a hysterectomy. We used qualitative methods to explore women's decision-making and feelings after this procedure. We interviewed ten women after a LeFort colpocleisis (with or without mid-urethral sling) for uterovaginal prolapse. We conducted semi-structured interviews that were recorded and transcribed and then analyzed using grounded theory. The main themes were: the process of decision-making about whether to have an obliterative procedure, adequacy of preoperative counseling, and comparison against an alternative, more invasive surgical procedure with a hysterectomy. We also used the Decision Regret Scale and the Satisfaction with Decision Scale for Pelvic Floor Disorders. Women made the decision to pursue LeFort colpocleisis mainly by themselves. They felt positive about the ability to control their body and their life through their own decision. None of the women regretted the procedure on the basis of the inability to have penetrative intercourse and did not feel it affected their sexual function in a negative way. Women felt adequately counseled regarding other options and the surgical procedure. Many patients wished they had pursued surgery earlier because they were very satisfied with the results. Women who underwent LeFort colpocleisis were very happy with their decision. They primarily made the decision to have surgery autonomously. None of them regretted having an obliterative procedure for pelvic organ prolapse for reasons of sexual function.

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.

Effectiveness of vaginal high uterosacral ligament suspension for treatment of recurrent pelvic organ prolapse

Objective: To evaluate the indications and clinic outcomes of vaginal high uterosacral ligament suspension (HUS) for treatment of recurrent advanced pelvic organ prolapse (POP). Methods: This retrospective study analyzed 42 women with recurrent advanced POP who were referred to Fourth Medical Center of PLA General Hospital and underwent transvaginal HUS between November 2005 and January 2018. Primary surgeries included 30 vaginal colporrhaphy, 5 Manchester operation, 5 transvaginal mesh repair,2 sacrospinous ligament fixation.The median time for recurrence from primary pelvic floor repair surgery was 9 months, including 14 cases (33%, 14/42) ≤3 months (median time was 2 months) and 25 cases (67%, 28/42) longer than 3 months (median time was 18 months).The rate of recurrent prolapse in stage Ⅲ or Ⅳ was 79% (33 cases), 45% (19 cases) and 17%(7 cases) in anterior, apical and posterior compartment respectively. Results: Transvaginal high bilateral uterosacral ligaments were identified and used for successful vaginal vault suspension after vaginal hysterectomy and residual cervical resection in all 42 consecutive patients. The cases of transvaginal mesh used in anterior wall and posterior wall were 25 (60%, 25/42) and 3 (7%, 3/42) respectively. There was no major intra- and postoperative complications,such as ureter and other pelvic organ injury. The median time of follow-up was 5.3 years after transvaginal HUS. The points of pelvic organ prolapse quantification system reduced significantly and point C improved from +0.3 cm to -8.2 cm after reoperation (P<0.01). The objective cure rate were 100% (42/42) both in apex and posterior compartment,while 93% (39/42) in anterior compartment. None had reoperation or pessary usage for recurrence of prolapse. Conclusion: Transvaginal HUS with vaginal wall repair could be as a safety, cost-effective, minimal traumatic and durable procedure for recurrent POP in the most of cases.

Impact of levator muscle avulsions on Manchester procedure outcomes in pelvic organ prolapse surgery.

Levator ani muscle avulsions potentially increase recurrence after anterior colporrhaphies. We aimed at evaluating the impact of avulsions on anatomical and patient-reported outcomes 1year after the Manchester procedure for primary anterior compartment pelvic organ prolapse. Prospective cohort study of 189 women undergoing the Manchester procedure between October 2014 and January 2017. Avulsions were diagnosed by transperineal ultrasound. Women with and without avulsions were compared for 1-year postoperative outcomes; Pelvic Organ Prolapse Quantification measurements, subjective satisfaction (1-worse to 4-cured), failure (new prolapse treatment), response to validated questionnaires on pelvic floor distress and sexual function, and a composite outcome (subjectively cured and optimal anterior compartment outcome (stage 0-I)). Optimal mid-compartment outcome was defined as cervix≥5cm above the hymen. Factors potentially associated with poor anatomical outcomes (anterior compartment stage ≥II) or pelvic floor distress were analyzed using regression analyses. Fewer women with avulsions (present in 50.8%) obtained optimal mid-compartment outcomes (88.2% vs 77.1%; P=0.05). The groups were otherwise similar in terms of mid-compartment reduction, anterior compartment results, failure rate, subjective satisfaction, pelvic floor/sexual symptoms, and combined optimal subjective and anatomical outcome. Only preoperative anterior compartment stage ≥III was associated with poor anatomical outcome (P<0.01). A high preoperative symptom score was associated with a high postoperative symptom score (P<0.001). Although fewer women with avulsions obtained optimal mid-compartment results, avulsions had no impact on other anatomical or symptomatic outcomes 1year after the Manchester procedure for primary anterior compartment prolapse.

95: Risk factors predicting the loss of functional independence after obliterative procedures for pelvic organ prolapse

To determine the risk factors associated with loss of functional independence after obliterative procedures for pelvic organ prolapse (POP). The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was used to collect data on women who underwent obliterative vaginal procedures from 2011-2016, based on the current procedural terminology (CPT) codes for LeFort Colpocleisis (57120) and vaginectomy (57110). Women who were not functionally independent prior to the procedure and those with unknown discharge destination were excluded from the analysis. Women undergoing a concomitant hysterectomy were identified using CPT codes 59260 to 59294. The criteria for loss of functional independence was a transition of a preoperative functional independent status to a dependent status (discharge to a post-care facility) or death within 30-day postoperative period. Demographic data and peri-operative variables were abstracted and compared between women with postoperative loss of functional independence to the rest of the cohort. Descriptive summaries were frequencies and percentages for categorical variables and mean and standard deviation was for continuous variables. The Pearson’s Chi-square test (or Fisher’s exact test) were utilized to compare the categorical data, and Wilcoxon rank sum test for the continuous variables. Multivariate regression analysis was utilized to determine factors associated with loss of functional independence. P value of <0.05 was considered significant. A total of 1,847 women were included in the analysis. A loss of functional independence was noted in 50 of the 1,847 women (2.6%). Of these, nine (18%) women underwent a concomitant hysterectomy. Majority of the women were whites (84%). The women who suffered loss of functional independence were older than those who were independent postoperatively (mean age 79.3 yrs., SD 7.47 vs 76.7 yrs., SD 8.08 respectively). The factors that were associated with postoperative loss of functional independence were age >80 yrs. (p=0.043), ASA class (p=0.02), duration of procedure (p<0.001), length of stay (p<0.001), and postoperative UTI (p=0.010). On multiple logistic regression analysis, age >80 yrs. (OR 2.774, 95% CI 1.394-5.520), ASA class >3 (OR 2.252, CI 1.071-4.739) and length of stay >5 days (OR 15.188, 95% CI 6.222-37.073) remained significantly associated with an increased risk of loss of functional status. Age >80 years, higher ASA class, and length of stay are associated with an increased risk of loss of functional status after obliterative procedure for pelvic organ prolapse. Consideration of these factors during the operative decision-making process may help improve outcomes in this cohort.

Incidence and contributing factors of perioperative complications in surgical procedures for pelvic organ prolapse.

Data on the incidence of perioperative complications of surgical procedures for pelvic organ prolapse (POP) and their contributing factors are limited, sometimes conflicting, and often mixed with other urogynecologic surgeries. To estimate the incidence and contributing factors for perioperative complications of POP procedures. A cross-sectional study was carried out between November 2016 and June 2017. POP procedures of different approaches were included irrespective of the surgeon involved, type of surgery (primary or repeat), or concomitant hysterectomy or incontinence repair. Data on perioperative complications were recorded prospectively. A total of 366 women were included in the current analysis. The average age was 61.0 ± 13.4years. The surgical procedures performed were vaginal (75.3%), abdominal (11.3%), or combined (13.4%). Approximately 18.2% of these procedures were repeat surgeries. A total of 38 (11.3%) women developed perioperative complications (3.6% severe and 7.7% minor). These included: 25 (7.4%) intraoperative complications (2.4% severe and 5.1% minor) and 17 (5.1%) postoperative complications (2.1% severe and 3.0% minor). In multivariate analysis, abdominal surgery and McCall culdoplasty were significant predictors of intraoperative complications (alone or when combined with other postoperative complications). On the other hand, concomitant hysterectomy and concomitant incontinence repair procedure were associated with higher postoperative complication rates while vaginal surgery had fewer postoperative complications. There was a low rate of perioperative complications. Abdominal surgery and McCall culdoplasty showed higher intraoperative complications. These data should help in preoperative counseling and target ways to further decrease complication rates.

A systematic review on reporting outcomes and outcome measures in trials on synthetic mesh procedures for pelvic organ prolapse: Urgent action is needed to improve quality of research.

We evaluated outcome and outcome measure reporting across randomized controlled trials on surgical interventions using synthetic mesh for pelvic organ prolapse. Systematic review of randomized controlled trials using synthetic mesh for the treatment of pelvic organ prolapse. The selected studies were evaluated using Jadad and MOMENT criteria. Outcomes and outcome measures were systematically identified and categorized. Seventy-one randomized trials were included. Twenty-four different types of mesh were identified. Included trials reported 110 different outcomes and 60 outcome measures. Erosion (40 trials, 78%), pain (29 trials, 56%), bleeding (31 trials, 61%), and dyspareunia (25 trials, 49%) were the most frequently reported outcomes. The longest follow up was 74 months. Most randomized trials evaluating surgical interventions using synthetic mesh for pelvic organ prolapse failed to report on clinically important outcomes and to evaluate efficacy and safety over the medium- and long-term. Developing and implementing a minimum data set, known as a core outcome set, in future vaginal prolapse trials could help address these issues.

Laparoscopic sacrocolpopexy with or without midurethral sling insertion: Is a two- step approach justified? A prospective study.

Most data support the fact that women with symptomatic pelvic organ prolapse (POP) with concomitant symptomatic or occult stress urinary incontinence (SUI) benefit from concurrent POP and anti-incontinence procedure. However some data support a delayed or 2-step approach. The aim of this study was to demonstrate the effectiveness and safety of laparoscopic sacrocolpopexy (SCP) alone with a delayed approach for SUI to prove the justification of a 2-step approach. A prospective study from 2014 to 2016 including women with symptomatic POP ≥ stage 2 prolapse and concomitant SUI or occult SUI. Laparoscopic SCP for apical or multi-compartment POP with or without concomitant MUS insertion was performed. Primary outcome measures were asymptomatic regarding SUI after prolapse surgery alone, persisting SUI with or without subsequent anti-incontinence surgery. A SCP alone was performed on 62 women. Stress urinary incontinence was seen in 31% with SCP alone and a third of those women needed an additional midurethral sling for persisting SUI. Women who chose a combined surgery for POP and incontinence with SCP and a suburethral sling the postoperative success rate regarding SUI was 100% with two women needing a sling release. We showed that women with POP with concomitant stress urinary incontinence undergoing sacrocolpopexy benefitted from a two-step approach as only 11% needed an additional incontinence procedure. This study highlights the importance of pre-operative counselling. It should be tailored to the individual woman.

Trends in prolapse surgery in England.

Women have a lifetime risk of undergoing pelvic organ prolapse (POP) surgery of 11-19%. Traditional native tissue repairs are associated with reoperation rates of approximately 11% after 20years. Surgery with mesh augmentation was introduced to improve anatomic outcomes. However, the use of synthetic meshes in urogynaecological procedures has been scrutinised by the US Food and Drug Administration (FDA) and by the European Commission (SCENIHR). We aimed to review trends in pelvic organ prolapse (POP) surgery in England. Data were collected from the national hospital episode statistics database. Procedure and interventions-4 character tables were used to quantify POP operations. Annual reports from 2005 to 2016 were considered. The total number of POP procedures increased from 2005, reaching a peak in 2014 (N = 29,228). With regard to vaginal prolapse, native tissue repairs represented more than 90% of the procedures, whereas surgical meshes were considered in a few selected cases. The number of sacrospinous ligament fixations (SSLFs) grew more than 3 times over the years, whereas sacrocolpopexy remained stable. To treat vault prolapse, transvaginal surgical meshes have been progressively abandoned. We also noted a steady increase in uterine-sparing, and obliterative procedures. Following FDA and SCENIHR warnings, a positive trend for meshes has only been seen in uterine-sparing surgery. Native tissue repairs constitute the vast majority of POP operations. SSLFs have been increasingly performed to achieve apical support. Urogynaecologists' training should take into account shifts in surgical practice.

Mechanical Analysis of the Uterosacral Ligament: Swine vs. Human

The uterosacral ligament (USL) is a major suspensory structure of the female pelvic floor, providing support to the cervix and/or upper vagina. It plays a pivotal role in surgical procedures for pelvic organ prolapse (POP) aimed at restoring apical support. Despite its important mechanical function, little is known about the mechanical properties of the USL due to the constraints associated with in vivo testing of human USL and the lack of validated large animal models that enable such investigations. In this study, we provide the first comparison of the mechanical properties of swine and human USLs. Preconditioning and pre-creep data up to a 2 N load and creep data under a 2 N load over 1200 s were obtained on swine (n=9) and human (n=9) USL specimens by performing planar equi-biaxial tensile tests and using the digital image correlation method. No differences in the peak strain during preconditioning tests, secant modulus of the pre-creep response, and strain at the end of creep tests were detected in the USLs from the two species along both axial loading directions (the main in vivo loading direction and the direction that is perpendicular to it). These findings suggest that the swine holds promise as large animal model for studying the mechanical role of the USL in apical vaginal support and treatment of POP.

Mesh use in urogynaecological procedures between 2005 and 2016: An Australian cohort study.

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common conditions. The use of mesh in the surgical treatment of these conditions in Australia is unclear. To examine the use of mesh in POP and SUI procedures in an Australian national cohort of older women. We conducted a population-based cohort study using data from the Australian Government Department of Veterans' Affairs (DVA) database. The cohort consisted of older women who had POP and SUI procedures between 1 July, 2005 and 31 December, 2016. Women who received mesh were identified by matching device billing codes with the Australian Government's Prosthesis List. In total, 3129 women experienced 3472 hospitalisations for POP and SUI procedures, with 74% of the women aged 75years and older. There were 2276 (66%) hospitalisations with single POP repairs, 608 (18%) with single SUI procedures and 588 (17%) with concomitant POP and SUI procedures. Mesh was used in 23% of single procedures for POP, in 89% of single procedures for SUI and in 90% of concomitant POP and SUI procedures. The use of mesh in POP procedures decreased from a peak of 33% in 2008 down to 8% by 2016, whereas the use of mesh in SUI procedures increased from 77% in 2006 to 91% by 2016. Mesh was commonly used in SUI procedures, whereas use of mesh in POP repair was less common and the use decreased rapidly after 2011, when warnings about use of mesh in POP were first issued.