POP-Q Stage Research Articles

Implementation of Robotic-Assisted Sacrocervicopexy for Apical Organ Prolapse Using the Semitendinosus Tendon—Pilot Study and Analysis of Clinical Outcome

Abstract Introduction and Hypothesis This video demonstrates a robotic-assisted sacrocervicopexy using the semitendinosus tendon. Methods Between June 2022 and February 2023, we performed the worldwide first Da Vinci robotic-assisted sacrocervicopexies (SCP) for apical organ prolapse using the semitendinosus tendon of the left knee. Analysis of safety, feasibility, and clinical outcome of the first ten patients operated on using this new surgical technique included the German pelvic floor questionnaire (GPFQ) as well as a clinical examination. Results Ten patients with a follow-up of 12 months were included. There was a significant reduction of the patient’s symptoms according to the GPFQ regarding the domain bladder (preoperatively versus 3 months postoperatively, mean 3.85 vs 1.61, p = 0.034), total score (preoperatively versus 3 months postoperatively, mean 12.79 vs 3.28, p = 0.034), and descensus symptoms (preoperatively versus 12 months postoperatively, mean 4.74 vs 0.67, p = 0.022). POP-Q stage (point C) was significantly reduced between the preoperative period and at the time of discharge (mean 2.2 vs 0, p = 0.004). No serious intra- and postoperative complications occurred. Conclusions This pilot study showed satisfying clinical outcomes after a follow-up of 12 months, with a low mid-term complication rate.

A novel pelvic magnetic resonance imaging measurement for pelvic organ prolapse evaluation

BackgroundPelvic magnetic resonance imaging has been proven effective for quantifying the extent of prolapse. The pubococcygeal line is used universally as a reference line in measuring pelvic organ prolapse, however, it focuses solely on three lowest points in the anterior, middle, and posterior pelvic compartments, without taking into account other pelvic floor structures and their interactions. ObjectivesThis study aimed to introduce and validate the area under the pubococcygeal line, a novel measurement method for evaluating pelvic organ prolapse, to examine its correlation with clinical Pelvic Organ Prolapse Quantification staging, and assess its reliability across different raters. Study DesignThis study recruited 225 women who underwent evaluations involving both magnetic resonance imaging measurements and clinical Pelvic Organ Prolapse Quantification staging. A comprehensive statistical approach involving descriptive analysis, correlation analysis, reliability assessment, and ordinal logistic regression analysis was adopted to evaluate the applicability and reliability of the area under the pubococcygeal line measurement. ResultsAnalysis of participant characteristics across different POP-Q stages revealed a significant association between increased values of the area under the pubococcygeal line and severity of Pelvic Organ Prolapse Quantification staging. Correlation analysis was performed to identify and quantify the strength of the associations between the variables. The area under the pubococcygeal line showed a strong positive correlation with Pelvic Organ Prolapse Quantification stages (Spearman's r = 0.878, p < 0.001), outperforming the pubococcygeal line grades (Spearman's r = 0.777, p < 0.001). Reliability assessments yielded excellent intra- and inter-rater reliability, with intraclass correlation coefficient values of 0.980 and 0.906, respectively. Ordinal logistic regression analysis was used to determine the association between these variables and POP severity, highlighting significant associations between the area under the pubococcygeal line and Pelvic Organ Prolapse Quantification stages. ConclusionThe area under the pubococcygeal line measurement method is a novel and comprehensive magnetic resonance imaging technique for evaluating pelvic organ prolapse. This method strongly correlates with clinical Pelvic Organ Prolapse Quantification stages and exhibits excellent intra- and inter-rater reliability, holding a potential for enhanced diagnostic accuracy, optimized treatment strategies, and improved patient outcomes.

Explorative Identification of Anatomical Parameters Associated with Successful Pessary Fitting in Pelvic Organ Prolapse Using Dynamic Magnetic Resonance Imaging.

Background: Pelvic organ prolapse (POP) affects many women and is often managed with pessary treatment, yet predicting the success of fitting remains challenging. This study aims to identify anatomical parameters associated with successful and unsuccessful pessary treatment using dynamic magnetic resonance imaging (dMRI). Methods: A cross-sectional study in Maastricht University Medical Centre (MUMC+), the Netherlands. Sixteen women with a cystocele and/or descensus uteri minimal POP-Q stage 2, using pessary treatment, were included. All women underwent a dynamic MRI of the pelvic floor at rest, during contraction and on Valsalva. The anatomical parameters evaluated included various lengths and angles. The association between the anatomical parameters and pessary fitted is assessed using partial least squares regression. The predictive accuracy was tested using cross-validation based on the partial least squares model with the most important variables. Results: Seven of the sixteen women (43.8%) were in the non-fitting group (due to movement, rotation or expulsion of the pessary), and nine women (56.3%) were in the fitting group. Participants in the non-fitting group had a significantly lower body mass index (BMI). Variables such as total vaginal length (TVL) and certain angles were highly predictive of pessary fitting success, with variable importance of projection (VIP) scores indicating their importance. The prediction models showed accuracies ranging from 53.3% to 80.0%. Conclusions: In this explorative study, TVL, cervical length (CL), sacrococcygeal angle and pubococcygeal angle were key variables associated with pessary fitting success. These findings offer valuable insights for optimizing pessary fitting procedures and the development of new pessaries.

Expression of insulin-like growth factor binding protein 5 in the vaginal wall tissues of older women with pelvic organ prolapse

This study aimed to investigate the expression and significance of insulin-like growth factor binding protein 5 (IGFBP5) and extracellular matrix (ECM) related proteins in anterior vaginal wall tissues among aged pelvic organ prolapse (POP) patients. Tissues from the anterior vaginal wall were collected from 28 patients with POP and 20 patients without POP. The expression of protein and mRNA levels of IGFBP5 and ECM related proteins were evaluated in the vaginal wall tissues using immunohistochemistry, western blotting, and RT-qPCR techniques. The expression levels were then compared with clinical parameters. The expression levels of protein and mRNA of IGFBP5, collagen I, and collagen III were significantly lower in the POP group. Protein and mRNA expression levels of MMP2 were significantly higher in the POP group. IGFBP5 protein and mRNA expression levels were negatively correlated with age and significantly lower in older POP patients (≥ 65 years old) compared to younger POP patients (< 65 years old). IGFBP5 protein and mRNA expression levels were also significantly lower in POP-Q stage IV patients compared to POP-Q stage III patients. IGFBP5 expression level is negatively correlated with the age and severity of prolapse. The significant decrease in IGFBP5 expression may play a crucial part in the aging process and the occurrence of POP.

Валидация русскоязычной версии опросника P-QoL и его апробация для оценки влияния пролапса тазовых органов на качество жизни женщин и определения эффективности реконструктивных операций.

Introduction. The prolapse quality-of-life questionnaire (P-QoL) is one of a few standardized questionnaires developed to assess the impact of pelvic organ prolapse (POP) on the quality of life (QoL) of patients and determine the effectiveness of reconstructive surgery. The lack of a validated Russian-language version of the P-QoL questionnaire limits studies assessing the severity of symptoms and QoL in women with POP before and after reconstructive surgery in Russia. Materials and methods. Assessment of the reliability and validity of the adapted P-QoL questionnaire for Russian-speaking patients. Study participants (n=303) were asked to fill out the P-QoL, PFDI-20, SF-36 questionnaires and a medical and social questionnaire before reconstructive surgery and 2 months after the treatment. Then they underwent gynecological examination using the POP-Quantification System (POP-Q). Results. The language adaptation of the P-QoL questionnaire was carried out and its reliability and validity were established. Indicators of general health perception (p&lt;0.001), role limitations (p=0.001), physical limitations (p=0.004), social limitations (p&lt;0.001) and symptom severity (p&lt;0.001) were significantly higher in women with POP-Q stages 3 and 4 compared to women with POP-Q stage 2. General health perception scores were higher in women with POP-Q stage 4 than with POP-Q stage 3 (p=0.002). Statistically significant differences in sleep/energy scores were found between women with POP-Q stages 2 and 3 (p=0.033). Statistically significant improvement in QoL 2 months after surgery (p &lt; 0.05) indicated that P-QoL is sensitive to change. Conclusion. The adapted P-QoL questionnaire is a reliable tool for determination of the severity of POP symptoms, QoL impairment and assessment of the treatment outcomes.

Anatomical outcomes and complications of sacrocolpopexy using Surelift Uplift mesh: A multicentric observational study.

The study evaluated the anatomical and functional outcomes, as well as the safety data of laparoscopic sacrocolpopexy (LSC) for pelvic organ prolapse (POP) using a lightweight macroporous mesh. A multicentric observational study was developed including five expert centers between March 2011 and December 2019. Inclusion criteria were female patients with symptomatic ≥stage II POP (POP-Q classification), who underwent a LSC. A lightweight and macroporous mesh device (Surelift Uplift) was used. Baseline anatomical positions were evaluated using POP-Q stage. The anatomical outcomes and procedural complications were assessed during the postoperative period. Primary outcomes were anatomical success, defined as POP-Q stage ≤I, and subjective success, defined as no bothersome bulge symptoms, and no repeat surgery or pessary use for recurrent prolapse. A total of 325 LSCs were analyzed with a median patient age of 66 (interquartile range [IQR] 61-73). After a median follow-up of 68 months (IQR 46.5-89), anatomical success was found in 88.9%, whereas subjective success was seen in 98.5% of the patients. Recurrent prolapse presented as cystocele (1.5%). Reported complications were bladder (4.6%) or rectum lesions (0.6%), de novo urinary incontinence (12.9%), and mesh extrusion (1.2%). LSC provides significant clinical improvement and excellent anatomical results, with a low risk of serious complications for women with ≥2 grade POP in a real clinical practice setting.

Mid-term outcomes of laparoscopic vaginal stump?round (Kakinuma method) and stump?uterosacral (Shull method) ligament fixation for pelvic organ prolapse: A retrospective comparative study

BackgroundLaparoscopic sacrocolpopexy (LSC) and robot-assisted sacrocolpopexy (RSC) using mesh are popular approaches for treating pelvic organ prolapse (POP). However, it is not uncommon that native tissue repair (NTR) should be presented as an option to patients who are expected to have extensive intraperitoneal adhesion or patients for whom LSC or RSC is difficult owing to various risk factors. Laparoscopic vaginal stump–uterosacral ligament fixation (Shull method) has been introduced as a method for NTR in case of POP. However, effective repair using this surgical procedure may not be possible in severe POPs. To solve the problems of the Shull method, we devised the laparoscopic vaginal stump–round ligament fixation (Kakinuma method) in which the vaginal stump is fixed to the uterine round ligament, a histologically strong tissue positioned anatomically higher than the uterosacral ligament. This study aimed to retrospectively and clinically compare the two methods.MethodsOf the 78 patients who underwent surgery for POP between January 2017 and June 2022 and postoperative follow-up for at least a year, 40 patients who underwent the Shull method (Shull group) and 38 who underwent the Kakinuma method (Kakinuma group) were retrospectively analyzed.ResultsNo significant differences were observed between the two groups in patient background variables such as mean age, parity, body mass index, and POP-Q stage. The mean operative duration and mean blood loss in the Shull group were 140.5 ± 31.7 min and 91.3 ± 96.3 ml, respectively, whereas the respective values in the Kakinuma group were 112.2 ± 25.3 min and 31.4 ± 47.7 ml, respectively. Thus, compared with the Shull group, the operative duration was significantly shorter (P < 0.001) and blood loss was significantly less (P = 0.003) in the Kakinuma group. Recurrence was observed in six patients (15.0%) in the Shull group and two patients (5.3%) in the Kakinuma group. Hence, compared with the Shull group, recurrence was significantly less in the Kakinuma group (P = 0.015). No patients experienced perioperative complications in either group.ConclusionsThe results suggest that the Kakinuma method can serve as a novel and viable NTR procedure for POP.

Prevalence of colorectal symptoms and anal incontinence in patients with pelvic organ prolapse attended at an outpatient urogynecology service.

To analyze data of patients with symptomatic pelvic organ prolapse evaluated with PFDI20 and its subscales to report the prevalence of lower gastrointestinal symptoms and anal incontinence in the population of a public hospital and analyze its impact on quality of life. Cross-sectional study of patients with symptomatic POP. Patients were evaluated with demographic data, POP-Q, pelvic floor ultrasonography, urological parameters, and pelvic floor symptoms (PFDI-20), and quality of life (P-QoL) surveys. Patients were classified as CRADI-8 "positive" for colorectal symptoms, with responses "moderate" in at least 3 and/or "severe" in at least 2 of the items in the CRADI-8 questionnaires. One hundred thirteen patients were included. 42.5% (48) were considered positive for colorectal symptoms on CRADI-8. 53.4% presented anal incontinence. No significant differences were found in sociodemographic variables, POP-Q stage, ultrasound parameters, or urological parameters. Positive patients had a significantly worse result in PFDI-20, POPDI (48 vs 28; p<0.001), UDI6 (51 vs 24; p<0.001), and in the areas of social limitation (44.4 vs 22.2; p = 0.045), sleep- energy (61.5 vs 44.4; p = 0.08), and severity (56.8 vs 43.7, p=0.015) according to P-QoL. Moderate or severe colorectal symptoms are seen in 40% of patients with symptomatic POP in our unit. Full evaluation of pelvic floor dysfunction symptoms should be performed routinely in urogynecology units.(FONIS SA12I2I53 - NCT02113969).

Assessment of pelvic organ prolapse with the Pelvic Inclination Correction System: defining the normal range and threshold to pathology

PurposeTo define the normal range and threshold values for pathologic prolapse on MRI using the PICS line and assess its correlation with the pubococcygeal line (PCL).MethodsThis prospective, IRB-approved study included 20 nulliparous volunteers and 18 prolapse patients (POP-Q Stage ≥ 2). Organ positions (bladder, cervix, anorectal junction) relative to PICS and PCL were measured on dynamic MRI. Differences in organ position were compared. Receiver-operating characteristic (ROC) analysis was performed to identify cutoff values for prolapse using the PICS line. The correlation between PICS and PCL measurements was tested with Spearman’s rank correlation.ResultsIn volunteers, median bladder and cervix positions measured to the PICS at rest were − 2.7 cm and − 5.3 cm compared to − 1.9 cm and − 2.7 cm in patients (p < 0.001). During straining, bladder and cervix were at − 0.9 cm and − 3.2 cm in volunteers versus + 2.5 cm and + 2.5 cm in patients (p < 0.001). Correlation was strong for PICS and PCL measurements for all three compartments (δ = 0.883–0.970, p ≤ 0.001). AUCs of PICS for the anterior and middle compartment were 0.98 (95% confidence interval [CI] 0.96–1.00, p < 0.001) and 0.96 (95% CI 0.89–1.00, p < 0.001) for differentiating patients from healthy volunteers. AUC for the posterior compartment was 0.76 (95% CI 0.57–0.96, p = 0.034).ConclusionPICS measurements reliably differentiate patients from volunteers in the anterior and middle compartment. Future studies need to identify a reliable threshold for the posterior compartment. PICS and PCL measurements are strongly correlated.Graphical abstract

Association of the second birth mode of delivery and interval with maternal pelvic floor changes: a prospective cohort study

BackgroundThis study aimed to explore the association of the second birth delivery mode and interval with maternal pelvic floor changes.MethodsThis prospective cohort study included women who had a first delivery and were in weeks 36–41 of a subsequent pregnancy at Panzhihua Central Hospital between July 2017 and June 2018. The primary outcomes of the study were the hiatus area at 6 months postpartum and bladder neck (mm) at rest and during a maximum Valsalva maneuver.ResultsThere were 112 women with vaginal delivery and 182 with Cesarean section. The hiatus area and hiatus circumference decreased at all time points (all P < 0.001). The women with Cesarean section had a smaller hiatus area and circumference (P < 0.001 and P < 0.001). The hiatus diameters decreased with time in both groups (all P < 0.001) and were smaller after Cesarean section (both P < 0.001). The bladder neck at maximum Valsalva increased with time (all P < 0.001) without significant differences between the two groups. Finally, the proportion of patients with POP-Q stage 0/I increased with time in both groups (all P < 0.001), with the proportions being higher in the Cesarean group (P = 0.002). The birth interval was negatively correlated with the hiatus area (B=-0.17, 95%CI: -0.25, -0.08, P < 0.001) and positively correlated with the bladder neck at rest (B = 0.22, 95%CI: 0.08, 0.35, P = 0.001) and at maximum Valsalva (B = 0.85, 95%CI: 0.65, 1.05, P < 0.001).ConclusionsIn conclusion, the mode of delivery at the second birth could influence the hiatus area and circumference and bladder neck size. The birth interval was negatively correlated with the hiatus area and positively correlated with the bladder neck at rest and at maximum Valsalva.

Patient Impression of Improvement 1 year After Sacrospinous Hysteropexy Versus Vaginal Hysterectomy in Women with Pelvic Organ Prolapse Stage 2 or Higher

Introduction and hypothesisPatient-reported outcomes are relevant outcomes in studies on pelvic organ prolapse (POP) surgery, as anatomical recurrence alone does not have a significant correlation with perceived improvement. In the present study, the patient’s impression of improvement after 1 year is studied after vaginal hysterectomy (VH) versus sacrospinous hysteropexy (SSH) in large cohorts from daily clinical practice. We hypothesize that there is no difference between the groups.MethodsThis is a secondary analysis on prospectively collected data in a multicenter cohort of patients who underwent VH or SSH for symptomatic POP. All patients had a POP-Q stage ≥ 2 in at least one compartment at baseline and were treated with VH or SSH between 2002 and 2019. The primary outcome was the patient-reported score on the patient global impression of improvement index (PGI-I) 1 year after surgery. The secondary outcome was a composite outcome of surgical success, defined as the absence of recurrent POP beyond the hymen with bothersome bulge symptoms and/or repeat surgery.ResultsA total of 378 women (196 VH and 182 SSH) were included. The median score on the PGI-I did not differ between VH and SSH. At 1 year post-operatively, 77 women after VH (73%) and 77 women after SSH (75%) considered their condition (very) much improved (p = 0.86). There was no difference in composite outcome of surgical success (126 out of 137 women [92%] after VH, 118 out of 125 women [94%] after SSH; p = 0.44).ConclusionsOur study shows that there was no difference in the type of surgery, VH or SSH, with regard to the patient’s impression of improvement 1 year postoperatively in a large cohort from daily clinical practice.

Comparison of Surgical Outcome of Laparoscopic Sacrocolpopexy between the Novice and Experienced Surgeon in Laparoscopic Surgery

We retrospectively analyzed the safety and surgical outcomes of laparoscopic sacrocolpopexy (LSC) by the novice surgeon (performed ＜5 laparoscopic surgery). Between November 2017 and December 2020, there were 15 cases in which the novice surgeon performed part of LSC, 8 cases in which the novice performed all of LSC, and 50 cases in which the experienced surgeon (performed ＞100 laparoscopic surgery) performed all of LSC. We compared surgical outcome of the 50 cases operated by the experienced surgeon and 23 cases operated by the novice. The laparoscopic time was longer when performed by the novice than by the experienced surgeon (median 208 minutes vs 189 minutes, p＝0.039). Cases of pelvic organ prolapse quantification system (POP-Q) stage 4 were operated more often by the experienced surgeon than by the novice (28% vs 4.8%, p＝0.027). There were no significant differences in the complications and recurrence of pelvic organ prolapse (POP-Q≧2). The LSC process was divided into five steps. The laparoscopic time of all steps was longer when performed by the novice than by the experienced surgeon except the step of lifting up the sigmoid colon and hysterectomy. As the number of cases performed by the novice increased, the laparoscopic time of all steps decreased. The short-term surgical outcomes for cases operated by the novice and experienced surgeon were comparable when the novice avoided cases of POP-Q stage 4. LSC has been said to be difficult, but in this study, even novice surgeons in laparoscopic surgery may be able to perform LSC by accumulating cases. Although this study is not generalizable due to limitations, we believe it will inspire many young doctors to perform LSC.

Quality of Life and Sexual Function after Laparoscopic Posterior Vaginal Plication Plus Sacral Colpopexy for Severe Posterior Vaginal Prolapse.

Laparoscopic sacral colpopexy (LSC) is the gold standard treatment for women with apical/anterior pelvic organ prolapse (POP). For isolated posterior vaginal prolapse, instead, the literature suggests fascial native tissue repair. This is a retrospective 2-year quality-of-life follow-up study after laparoscopic posterior plication (LPP) combined with LSC in patients with anterior/apical prolapse combined with severe posterior colpocele. The primary endpoint was to evaluate the subjective outcomes quality of life (QoL), sexual function, and patient satisfaction rate. The secondary endpoint was to evaluate perioperative and anatomical outcomes at the 2-year follow-up. A total of 139 consecutive patients with anterior and/or apical prolapse (POP-Q stage ≥ II) and severe posterior vaginal prolapse (posterior POP-Q stage ≥ III) were retrospectively selected from our database among women who underwent, from November 2018 to February 2021, a "two-meshes" LSC. The patients were classified into Group A (81 patients; LSC plus LPP) and Group B (67 patients; LSC alone). The primary endpoint was evaluated using the Patient Global Impression of Improvement (PGI-I), the Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6), the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), the Female Sexual Distress Scale (FSDS), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and the EuroQol (EQ-5D). The secondary endpoint was studied using the POP-Q study and an intra-, peri-, and post-operative complications assessment. Two-year follow-up data were analyzed for the study. At 2 years, all women showed a statistically significant amelioration of their symptoms on the QoL questionnaires. We found a statistical difference in favor of posterior plication in terms of the PGI-I successful outcome rate (Group A versus B: 85.3% versus 67.1%), FSDS (median 11 versus 21), and PISQ-12 (median 89 versus 62) (p < 0.05 for all comparisons). A significant improvement of all EQ-5D values was observed from baseline to 2-year follow-up, and only for the "pain/discomfort" domains did we observe a significant improvement in LSC plus LPP patients versus LSC alone (p < 0.05). LSC plus LPP women showed, at 2 years, a significant amelioration of their Ap and GH POP-Q points. We observed no statistical differences in terms of intra-post-operative complications or anatomic failure rate between groups. Our LPP approach to LSC appears to be a safe, feasible, and effective treatment for advanced pelvic organ prolapse with a significant impact on the patient's general health and sexual quality of life. Adding laparoscopic posterior vaginal plication to "two-meshes" sacral colpopexy is recommended in patients with apical/anterior prolapse and concomitant severe posterior colpocele. This surgical approach, in addition to improving the anatomical results of these patients, is associated with a significant improvement in sexual and quality of life indexes.

Detrusor underactivity in symptomatic anterior pelvic organ prolapse.

The aim of this study was to assess the detrusor underactivity (DUA) prevalence of females with symptomatic anterior pelvic organ prolapse (POP) and to evaluate the relationship between DUA and POP stage. This was a prospective study recruiting women with symptomatic anterior POP. Patients with symptomatic stage 2-4 POP quantification system (POP-Q) who underwent urodynamics (UD) between January 2018 and April 2021 were included. Data on 330 women (mean age 63.7 ±18.4 years old) with anterior vaginal wall defect were enrolled. Concomitant apical defect (uterine/vaginal vault) requiring surgical correction was diagnosed in 38 women (11.5%). DUA was found in 166 females (50.3%). In DUA women, POP-Q stage 2 was found in 45.2%, stage 3 in 50.9% and stage 4 in 76.5%. Only stage POP-Q stage 4 showed a statistically significant difference between DUA and non-DUA females (p 0.006). In women with symptomatic POP, regardless of the POP-Q stage, the chance of DUA occurrence was high. DUA was diagnosed in approximately half of the women undergoing UD for symptomatic POP, and it was three-fold higher in cases of POP-Q stage 4. Due to the high incidence of DUA in POP-Q 4 stage, it may be advantageous to identify and treat prolapse before they progress to stage 4.

Laparoscopic pectopexy: As a safe and effective new approach for repair of pelvic organ prolapse

Abstract Objective: The objective is to assess the feasibility, safety, and effectiveness of laparoscopic pectopexy for repair of pelvic organ prolapse (POP). Design: This was a prospective study. Materials and Methods: A total of 324 women of POP-Q Stage ≥II who underwent laparoscopic pectopexy between January 2017 and January 2023 at Jaipur Doorbeen Hospital, Jaipur, India were included in this study. All patients underwent laparoscopic mesh fixation to bilateral pectineal ligament with Moschcowitz repair with pelvic floor repair. Results: Among 324 patients, the mean age was 48.29 ± 14.82 years and the mean body mass index was 24.10 ± 3.19 kg/m2 . Out of 324 cases, 24.07% of Stage II, 71.30% of Stage III, and 4.63% of Stage IV. Maximum cases were under Stage III (71.30%). Follow up was done after 1 week, 3 weeks, 6 weeks, 3 months, 6 months, and 1 year. At 1 year of follow up out of 324 cases, 66 patients lost to follow up. Out of the remaining 258 patients, only 9 (3.4%) patients show recurrence of prolapse. Out of nine cases, four cases show Stage I cystocele, three cases show Stage II apical prolapse and two cases show Stage 1 rectocele. Results are promising, with 96.51% all over success rate. Conclusion: The laparoscopic pectopexy is a good alternative to the laparoscopic sacrocolpopexy. It is equally effective and shows no de novo stress urinary incontinence, defecation disorders, backache, or neuralgia in the long term follow up.

Voiding Dysfunction in Patients With Advanced Pelvic Organ Prolapse and Bladder Outlet Obstruction Following Pelvic Reconstructive Surgery: Urodynamic Profile and Predictive Risk Factors

Study ObjectiveTo determine the outcome of voiding function 1 year following Pelvic Reconstructive Surgery (PRS) in women with Bladder Outlet Obstruction (BOO). DesignRetrospective cohort study SettingTertiary Referral Hospital PatientsOne thousand eight hundred and ninety-four (1894) women underwent PRS for advanced Pelvic Organ Prolapse (POP) stage III-IV with urodynamic findings of BOO InterventionsPelvic Reconstructive Surgery MeasurementsThe primary outcome measured was the resumption of normal voiding function, defined clinically with multichannel urodynamic (UDS) testing at one year post-operatively. The secondary outcomes are to identify the different risk factors for persistence voiding dysfunction after 1 year after PRS. Main ResultsTotal of 431 women with POP-Q Stage III and IV, UDS of Qmax ≤15 ml/s and PdetQmax ≥20cmH20 were included. Resumption of normal voiding function were found in 91% (n=392/431), while 9% (n=39/431) remains to have voiding dysfunction (VD) 1 year post operatively. Those with persistent VD, 20.5%(n=8/39) remains having urodynamic diagnosis of BOO. Univariate and multivariate logistic regression reveals factors associated with post-operative VD are pre-operative MCC ≥500 ml and PVR ≥ 200ml. ConclusionVoiding Dysfunction may persist in women with BOO following PRS, particularly in those with pre-operative maximal cystometric capacity (MCC) of >500ml and post-void residual volume > 200ml.

Preoperative, Intraoperative and Postoperative Assessment of Pelvic Organ Prolapse by Pelvic Organ Prolapse Quantification System and Surgical Outcome

Background: Pelvic organ prolapse (POP) is a common disease of middle aged and elderly women with an incidence of 7-10% and life time risk for surgery 11 to 20%. Assessing pelvic organ prolapsed in an objective, reproducible and applicable method is essential to have successful surgical outcome. Aim of the study was preoperative, intraoperative pre and postsurgical as well as postoperative assessment of pelvic organ prolapse by POP- Q system in patients undergoing reconstructive surgery and measure optimum surgical outcome stage 0 (Q&lt;-1), Tvl &gt; 4 cm and Genital hiatus (3 to 3.4cm) to prevent recurrence (POP-Q stage &gt; -1) and dyspareunia (Pb d”3 cm). Methods : This was hospital based Prospective study done with 250 patient diagnosed as pelvic organ prolapse at OPD. Excluding 14 patients 236 had surgery in Chattagram Metropolitan Hospital during January 2010 to December 2019. POP-Q measurement was done with Valsalva before anesthesia, intraoperative after anesthesia pre and postsurgical and postoperatively in follow up visit within three months of surgery by same surgeon. All POPQ measurement were done by same surgeon using a wooden Spatula marked in cm (POP-Q popsicle stick). All measurement were recorded in grid form and preoperative &amp; presurgical POP-Q staging was done. The result was then summarized as mean and SD for numerical variable and percentage for categorical variable. Result : A total 236 patient had surgery, 233 had vaginal hysterectomy with Apical vaginal suspension with uterosacral ligament and sacrospinous fixation was done in 3 patients with vault prolapse. Mean age was 51 ± 5SD years (51 to 60 years 51%), 84% sexually active, low socioeconomic group (68%), multiparous 100% mean parity 4 ± 2SD (e” 6 62%), 95% had vaginal delivery with history of home delivery 89%, resuming house hold work within two weeks of delivery in 97% cases. Most were postmenopausal 96%. All intraoperative presurgical measurement except Pb and Tvl showed significant higher descent as compared to preoperative finding before anesthesia, mean difference were Aa 0.7, Ba1.6, C 1.6, Ap 0.25 Bp 1.6 D1.6 Gh. 8cm with highest descent in Ba C, D Bp. Immediate postsurgical measurement all patient showed optimum anatomical outcome (stage 0). But follow up within 3 month (10 to 90 days) 13 patient showed satisfactory anatomical outcome (stage 1 Q&lt;-1)) with no recurrence (Q&gt;-1) nor dyspareunia. Total vaginal length and Pb no change in measurement before and after anesthesia but Tvl reduced by 2.3 cm and Pb increased by .3cm postsurgical. Presurgical measurementof Gh increased by. 8cm but reduced to 3.5 cm postsurgical. No significant difference in postsurgical intraoperative measurements during follow up within 3 months except Gh (3.2 cm) which is narrower even with valsalva menovure. Conclusion : POP-Q technique in assessment of Pelvic organ prolapse was anatomically site specific and is with good reproducibility and less intra and inter observer variation. Significant difference in descent alert surgeon to plan surgical technique to have optimum anatomical outcome and prevent recurrence and dysparunea. Bangladesh J Obstet Gynaecol, 2022; Vol. 37(2): 109-118

A randomized controlled study comparing the objective efficacy and safety of a novel self-inserted disposable vaginal prolapse device and existing ring pessaries.

ProVate is a novel, disposable, collapsible self-inserted vaginal device for the nonsurgical management of pelvic organ prolapse (POP). We assessed possible vaginal microflora changes and POP reduction using ProVate and a commercially available ring pessary (control). We performed post-hoc analysis of data obtained from an interventional, prospective, multicenter, open-label, randomized, controlled, statistically powered (noninferiority), home-use, cross-over study conducted at seven sites. Safety and performance data collected for both devices were analyzed to compare objective POP reduction (employing the Pelvic Organ Prolapse Quantification System [POP-Q]), safety (assessed by the incidence of adverse events [AEs]), and the rates of certain AEs. Eighty-five women with symptomatic POP were screened; 71 were randomized, and 58 completed the study per protocol. Forty-nine (90.7%) ProVate users experienced complete prolapse reduction (stage 0), 3 (5.6%) experienced reductions to POP-Q stage 1, and 2 (3.7%%) experienced reductions to stage 2. Collectively, 52/54 (96.3%) ProVate users experienced prolapse reduction to stage 0 or 1. In all, 47/57 (82.5%) control users experienced complete prolapse reduction, while 5 (8.8%), 4 (7.0%), and 1 (1.8%) experienced reductions to stage 1, 2, and stage 3, respectively. Collectively, 52/57 (91.2%) control users experienced reductions to either stage 0 or 1. In 53/54 (98.1%) ProVate and 55/57 (96.5%) control users, there was at least 1 POP-Q stage prolapse reduction, and in 32 (91.4%) ProVate and 31 (83.8%) control users who had stage ≥3 prolapse, there were at least three POP-Q stage reductions. In total, 26/71 (36.6%) ProVate and 22/64 (34.4%) control users in the safety population experienced AEs. The incidence of device-related AEs was 17/71 (23.9%) for ProVate and 13/64 (20.3%) for the control. Most AEs were minor, mild, and anticipated. Our analysis demonstrated that ProVate and the control are highly effective in reducing POP, and both are associated with comparably low numbers of AEs. However, ProVate has the advantage of being more user-friendly, suitable for home use, and expected to allow women with POP to practice better and easier self-care.

Robot-Assisted Sacrocolpopexy versus Trans-Vaginal Multicompartment Prolapse Repair: Impact on Lower Bowel Tract Function.

This study evaluated the effectiveness, safety, and possible changes in bowel symptoms after multicompartment prolapse surgery by comparing two different surgical approaches, transvaginal mesh surgery with levatorplasty (TVMLP) and robot-assisted sacrocolpopexy (RSC). All patients underwent pelvic (POP-Q staging system) and rectal examination to evaluate anal sphincter tone in the lithotomy position with the appropriate Valsalva test. The preoperative evaluation included urodynamics and pelvic magnetic resonance defecography. Patient Global Impression of Improvement (PGI-I) at follow-up measured subjective improvement. All patients completed Agachan-Wexner's questionnaire at 0 and 12 months of follow-up to evaluate bowel symptoms. A total of 73 cases were randomized into the RSC group (36 cases) and TVMLP group (37 cases). After surgery, the main POP-Q stage in both groups was stage I (RCS 80.5% vs. TVMLP 82%). There was a significant difference (p < 0.05) in postoperative anal sphincter tone: 35%. The TVMLP group experienced a hypertonic anal sphincter, while none of the RSC group did. Regarding subjective improvement, the median PGI-I was 1 in both groups. At 12 months of follow-up, both groups exhibited a significant improvement in bowel symptoms. RSC and TVMLP successfully corrected multicompartment POP. RSC showed a greater improvement in the total Agachan-Wexner score and lower bowel symptoms.

The incidence and risk factors of occult malignancy in patients receiving vaginal hysterectomy for pelvic organ prolapse.

The aim of this study was to assess the incidence and risk factors for premalignant and malignant pathology in patients receiving vaginal hysterectomy (VH) and pelvic floor repair (PFR) for pelvic organ prolapse (POP). We performed a retrospective cohort study of pathological results after VH and PFR of 569 women at our institution from January 2011 through December 2020. Age, body mass index (BMI), POP-Q stage, and preoperative ultrasound results were evaluated as risk factors for occult malignancy. Six of the 569 patients (1.1%) had unanticipated premalignant uterine pathology and 2 (0.4%) had unanticipated malignant uterine pathology (endometrial cancer). There was no significant difference in the incidence of premalignant or malignant uterine pathology according to age, BMI, and POP-Q stage. However, if endometrial pathology is confirmed on preoperative ultrasonography, the probability of confirming malignant pathology increases (OR 4.63; 95% CI 1.84-51.4; p=0.016). The incidence of occult malignancy during VH for POP was significantly lower than that found in hysterectomy owing to benign disease. In the case of POP patients, for whom uterine-conserving surgery is not absolutely contraindicated, it can be performed. However, if endometrial pathology is confirmed by preoperative ultrasonography, uterine-conserving surgery is not recommended.