POP-Q Stage Research Articles

Extraperitoneal Sacral Hysteropexy by Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Single-center Case Series Study

Study Objective This study evaluated the feasibility, safety and short-term clinical outcomes from extraperitoneal sacral hysteropexy by transvaginal natural orifice transluminal endoscopic surgery in treating uterine prolapse. Design Retrospective study. Setting The First Affiliated Hospital of Third Military Medical University, Chongqing, China Patients or Participants The medical records of patients with POP-Q stage 2 or greater uterine prolapse who were treated with vNOTES-ESH between December 2016 to June 2018(to ensure 1-year follow-up or more) in the Southwest Hospital at the Third Military Medical University were reviewed retrospectively. Interventions Extraperitoneal sacral hysteropexy were performed by vNOTES. Measurements and Main Results 21 patients underwent surgery; 20 were successfully completed, and one that could not maintain pressure at the extraperitoneal cavity site due to peritoneal rupture during surgery who underwent multi-port laparoscopic surgery. Median patient age was 50 years. The body mass index (BMI) was 23.7 kg/m2, the median operative time was 126 min, and the median intraoperative blood loss was 60 mL. One case had presacral hemorrhage that was circumvented by bipolar electrocoagulation. Preoperative POP-Q scores were: Aa-0, Ba-1, C-2, Ap-3, and Bp-3. The average post-operative follow-up was 12 months. The POP-Q scores were: Aa-2, Ba-2, C-7, Ap-3, and Bp-3. Associated symptoms disappeared or improved significantly without sexual discomfort or pain on intercourse, mesh erosion, exposure, infection or other complications. The objective cure rate was 100 percent. Conclusion vNOTES was a feasible approach in completing extraperitoneal sacral hysteropexy for apical support, with promising short-term efficacy and safety. However, further studies across multiple sites are needed in evaluating long-term efficacy and safety profile of vNOTES extraperitoneal sacrocolpopexy.

1201 Laparoscoic Supracervical Hysterectomy and Sacrocervicopexy Using Flexdex's Platform Technology with Extraction of The Surgical Specimen by the Posterior Colpotomy for the Treatment of Uterine Prolapse

Video Objective Demonstrate the functionality and capabilities of the FlexDex platform in a high technical complexity procedure, a videolaproscopy supracervical hysterectomy with cervicosacropexy. Setting A 76-years-old patient with uterine prolapse (POP-Q stage III) was selected for laparoscopic treatment with the aid of the FlexDex platform. Interventions Initially, the supracervical hysterectomy was performed, followed by the cervix closure and the opening of the peritoneum at the level of the promontory – identifying the hypogastric nerve, lateralizing it with the endopelvic fascia and medializing the mesosigmoid fascia for the development of the pararectal space. Thus, allowing continuity to rectovaginal space and preparing the mesh bed. Next, a lightweight, macroporous, Y-shaped polypropylene mesh was fixated to the cervix stump – being assisted by the FlexDex platform, which enables the suturing to be made backhanded in a angulated topography. Then, the anatomical landmarks were identified before proceeding to the sacropexy - middle sacral vessels, sacral promontory, anterior longitudinal ligament, aortic bifurcation, inferior vena cava, right common iliac vessels and right ureter. After the mesh fixation to the promontory, the burial of the mesh was achieved with the closure of the peritoneum with a continuous suture. All the suturing during the surgery was accomplished utilizing only one trocar arrangement, enabled by the virtual center of rotation of the FlexDex platform. The surgical specimen was removed by posterior colpotomy, avoiding its morcellation. Once again, the closure of the posterior vaginal wall was facilitated by the endless rotation of the platform, enabling the ideal movement of the needle, following its curvature. Conclusion The FlexDex platform allows similar amplitude and intuitive wrist movement of the surgeon during complex procedures such as the one here presented – being a cost-effective alternative to the robot technology in countries where it is not readily available.

2738 Comparing Postoperative Pain with Laparoscopic Versus Robotic Sacrocolpopexy

Study Objective To compare postoperative pain and pain-related outcomes following laparoscopic (LS-MISC) versus robotic minimally invasive sacrocolpopexy (R-MISC). Design Secondary analysis of placebo-controlled RCT examining preoperative IV acetaminophen on postoperative pain following MISC. Setting Planned secondary analysis of multicenter RCT. Patients or Participants Women undergoing MISC. Interventions Primary outcome was total narcotics within 24 hours in morphine mg equivalents (MME) comparing LS-MISC and R-MISC. Measurements and Main Results We included 90 subjects undergoing MISC: 65 LS-MISC and 25 R-MISC. Most were Caucasian (97.8%) and postmenopausal (88.9%) with mean age 61.2±7.2 years and BMI 27.6±4.4 kg/m2. IV acetaminophen did not impact pain in the original study and was similar between LS-MISC and R-MISC. Baseline POP-Q stage was similar between groups. Concomitant hysterectomy was performed in 67% with LS-MISC, 60% with R-MISC (p=0.49). LS-MISC underwent more concomitant perineorrhaphies (15.4% vs 0%, p=0.04) and posterior repairs (18.5% vs 0%, p=0.02). Operative time was longer with LS-MISC (208.5±57.3 vs 143.6±21.0 minutes, p= Conclusion L-MISC showed increased length of stay and drowsiness. Most other outcomes showed either no difference or differences disappeared once adjusting for confounders as with primary outcome. Overall, MME narcotic use and VAS pain scales were low as were narcotic medication side effects.

Single-Port Robotic-Assisted Sacrocolpopexy Using the Sp Surgical System: First Clinical Experience

Study Objective To describe the result of robotic-assisted single port sacrocolpopexy (SCP) using the da Vinci SP® surgical system. Design Retrospective case series study Setting Robot Surgery Center of Ewha Womans University Hospital. Patients or Participants 7 patients with advanced pelvic organ prolapse (POP-Q stage III and IV). Interventions Robotic-assisted single port SCP using the da Vinci SP® surgical system performed by a single surgeon from January 8th-28th 2019. Measurements and Main Results The recently introduced da Vinci SP® surgical system includes three multi-jointed wristed instruments with a fully wristed camera. This surgical system offers the patients the same cosmetic benefits and make surgeon to perform suturing and tying more easily compared to the da Vinci Single-Site® platform. We present the operation results of the first seven cases of robotic-assisted single port SCP using the da Vinci SP® system and provide a detailed description of the technique. All consecutive cases were completed successfully without conversion. The mean patient age was 65.3 years and the mean operative time was 140.71 minutes. The mean docking time was only 2.3 min and the mean estimated blood loss was 60 mL. No operative or major postoperative complications occurred. To the best of our knowledge, this is the first report of robotic-assisted single port SCP, and we found this procedure is feasible and safe. Conclusion Robotic-assisted single port SCP using the da Vinci SP® surgical system is a feasible and safe option for advanced stage pelvic organ prolapse.

Hysteropexy with single-incision vaginal support system associated with a modified culdoplasty for enterocele prevention

Our study assessed the safety and clinical outcomes of hysteropexy with a single-incision mesh associated with a modified culdoplasty, for the surgical management or prevention of enterocele, in women with pelvic organ prolapse (POP). We carried out a 1-year prospective single-cohort study, including 51 women with symptomatic, multi-compartmental POP. Anatomical outcome was assessed with a POP-Q system and the subjective outcomes were assessed using ICSQ-SF and PGI-I. One-year follow-up data were available for 48 out of 51 patients. The POP-Q cure rate was 91%, 83% of patients were satisfied or very satisfied (PGI-I ≤ 2). No major complications occurred; the most common minor complications were mesh erosion (6%) and pelvic pain (8%). Lower urinary tract dysfunctions arose in 16% of the patients. Anatomical prolapse recurrence (POP-Q stage ≥2) in anterior or apical compartments occurred in four patients (8%). No case of de novo prolapse occurred in the posterior compartment. None of the patients required further surgery for recurrent prolapse. This standardised procedure provided satisfactory ‘restitutio ad integrum’ of the vaginal anatomy and symptom relief.Impact statementWhat is already known on this subject? The post-surgical evidence of de novo prolapse in untreated compartments is well-known, especially in prosthetic surgery. The insertion of polypropylene mesh causes a vigorous support, consequently the forces on the pelvic floor are transmitted to the least consolidated vaginal compartment. A lack of simultaneous repair of all the segments involved in the POP increases the risk of surgical recurrence even in those areas that did not appear to be pre-operatively affected by the uterine descensus.What the results of this study add? Our prospective study showed that hysteropexy with a single-incision vaginal support system plus a modified culdoplasty was able to prevent the enterocele and the occurrence of prolapse in the posterior compartment, by closing the Douglas pouch and restoring the connection of the rectovaginal septum with the apical support.What the implications are of these findings for clinical practice and/or further research? This study may be relevant for clinicians in selecting the technique for pelvic floor surgery, and it may be of interest for researchers investigating the reasons for de novo occurrence of posterior segment prolapse.

Long-Term Assessment of a Prospective Cohort of Patients Undergoing Laparoscopic Sacrocolpopexy.

To report long-term outcomes after laparoscopic sacrocolpopexy. We conducted a prospective descriptive cohort study on 331 consecutive patients who underwent laparoscopic sacrocolpopexy for symptomatic prolapse (Pelvic Organ Prolapse Quantification [POP-Q] system stage 2 or greater) at one center, with minimum 1.5 years of follow-up by April 30, 2014. Primary outcome measures were Patient Global Impression of Change score and failure at the apex (C≥-1 cm; POP-Q stage 2 or greater). Secondary outcomes were anatomical failure in other compartments, duration of follow-up, occurrence and time point of complications, reinterventions, and functional outcomes by response to a standardized 24-question interview on prolapse and bladder, bowel, and sexual function. Assessment was by an experienced clinician not involved in patient management. The follow-up rate was 84.6% (280/331); 185 of 331 (55.9%) patients were both physically examined and interviewed, and 95 of 331 (25.7%) were interviewed only. The median age at interview was 72 years (interquartile range 13 years), with a follow-up period of 85.5 months (interquartile range 46 months). Approximately 83% (231/280) reported improvement; 5.7% (16/280) were unchanged, 5.7% (16/280) felt slightly worse, and 6.8% (17/280) reported clear deterioration. Anatomical failure at point-C was 8.6% (16/185); anterior (22.2%, 41/185) and posterior (28.6%, 53/185) prolapse were more common than apical prolapse. Of those with level-I anatomical cure, 10.1% (17/185) felt worse; half of them (9/17) because of prolapse in another compartment. The others had urinary problems (41.2%, 7/17), obstructive defecation (11.8%, 2/17), or dyspareunia (11.8%, 2/17). Conversely, the majority of patients with recurrence at the vault (62.5%, 10/16) self-reported to be improved. The reoperation rate was 17.8% (48/270), including 19 (7.0%) for graft-related complications and nine (3.3%) for prolapse. More than four out of five patients (82.5%) felt improved 86 months after laparoscopic sacrocolpopexy. Of those not improved, two thirds had recurrent prolapse; however, typically mid-vaginal. The other third reported urinary or bowel problems or dyspareunia. Reintervention for prolapse was 3.3%. The most common reasons for reoperation were graft-related complications (7.0%) and urinary incontinence (6.7%).

Efficacy and safety of the Calistar and Elevate anterior vaginal mesh procedures

ObjectivesThe pelvic organ prolapse (POP) surgery with implantation of anterior transvaginal mesh (e.g. Elevate or Calistar) may provide objective and subjective improvement as compared to traditional POP repair without mesh. Given differences between the Elevate and the Calistar mesh and their different placement methods, some variation inlong-term clinical outcomes of these anterior vaginal mesh procedures can be expected. Study designThe purpose of the study was to compare the 18-month operative success in patients who had undergone anterior POP surgery with either the Calistar (n = 54) or Elevate mesh (n = 50). ResultsThere were no between-group differences in objective measures of operative efficacy, including POP-Q anterior stage 0 or I (94% for Calistar, 92% for Elevate) and "no descent beyond the hymen" (98% for Calistar, 94% for Elevate). The proportion of patients with subjective measure of operative efficacy (no vaginal bulge symptoms) did not differ between the groups (91% for Calistar, 78% for Elevate). There were no between-group differences in the proportion of women suffering from vaginal exposure, de novo stress urinary incontinence (SUI), de novo overactive bladder (OAB) symptoms, pelvic floor pain or dyspareunia. The operative cure of OAB symptoms was similar in the groups. The proportion of patients with the operative cure of SUI symptoms was significantly higher in the Calistar as compared to the Elevate group. ConclusionsThe results suggestthat the Calistar system offers similar efficacy in the treatment of anterior and both anterior and apical POP as compared to the Elevate. The use of anterior Calistar is associated with some additional benefits, i.e. SUI treatment in patients with concomitant anterior and both anterior and apical POP and SUI symptoms.

Laparoscopic sacrocolpopexy for neovaginal prolapse in a patient after male-to-female sex reassignment surgery.

ABSTRACTIntroduction:Male / female sex reassignment surgery is performed on transsexuals, and includes removal of the male external genitalia, and creation of the neovagina from the skin of the penis, usually allowing sexual intercourse (1, 2). The incidence of the prolapse of the neovagina is not known; however, such complication is observed relatively rarely (3, 4). the long-term outcomes of prolapse treatment in transsexual patients are not available in the literature. The purpose of this study was to demonstrate laparoscopic sacrocolpopexy to repair a neovagina prolapse in a patient after male-to-female sex reassignment surgery.Materials and Methods:In september 2013, a laparoscopic repair was performed on a 44-year-old woman who presented a neovaginal prolapse of pelvic organ prolapse quantification (pop-q) stage iii, twenty one years after sex reassignment surgery. This condition caused painful or even indisposed intercourse. in may 2013, the patient underwent unsuccessful vaginal treatment with the suturing device. Before the initial surgery, the patient was examined with cystoscopy, urodynamics and microbiology; no pathologies were found. laparoscopic repair of the neovaginal prolapse followed the principles described previously in the natural female (5). In the supine lithotomy position, a standard multiport laparoscopic sacrocolpopexy was performed with the use of the polypropylene mesh (Artisyn® y-shaped mesh, ethicon, inc somerville, nj.) and coated polyglactin sutures.The following steps were applied:exposure of the anterior and posterior neovaginal walls; suturing the bifurcated end of the mesh to the neovagina; longitudinal incision of the parietal peritoneum and creation of a tunnel for the mesh; fixation of the proximal end of the mesh to the promontorium; and closure of the parietal peritoneum over the mesh that was placed retroperitoneally. The draining tube was left for 24 hours.Results:The operation was completed successfully, with no blood loss or complications. The operative time was 115 minutes. The patient was discharged on the 2nd postoperative day. In a four-year follow-up, the patient presented significant improvement of symptoms, a small prolapse of approximate pop-q stage i, and declared performing satisfying intercourse.Conclusions:Laparoscopic sacrocolpopexy with the use of a polypropylene mesh to repair a neovaginal prolapse in transsexuals seems to be a valuable alternative to other procedures. Further observations and evaluation of a greater number of patients will be necessary to assess the actual value of the method.

Assessment of Overactive Bladder after Laparoscopic Lateral Suspension for Pelvic Organ Prolapse.

Background Pelvic organ prolapses (POP) and overactive bladder (OAB) may coexist and both negatively impact quality of life in women. The correlation between POP and OAB remains unclear, but these patients may have the OAB resolution after the surgical treatment of POP. Aim of our study was to assess the anatomical results and the effect on OAB symptoms in women who underwent laparoscopic lateral suspension for POP. Materials and Methods This prospective study included all women with apical POP who underwent surgical repair with laparoscopic uterine lateral suspension from January 2016 to December 2017. The baseline and the 1-year follow-up included post-void residual measurement, urinalysis, vaginal examination, OAB symptoms evaluation, and administration of questionnaires (PFDI-20, UDI 6). Results 64 women underwent laparoscopic lateral suspension for uterine prolapse and 78.1% had concomitant anterior vaginal wall defect. At 1-year follow-up the anatomic success rates were 84.4% for the apical and 76.2% for the anterior compartment. The comparison between OAB symptoms before and after the surgical procedure showed the resolution of OAB in 76% of the women, while de novo OAB was present in 2.6%. With the questionnaires 95.3% (61/64) of our patients were satisfied after the POP repair. We documented a trend in ameliorating of OAB regardless of the POP-Q stage. However, the Pearson test showed this correlation as statistically significant only in women with anterior vaginal wall defect stage III and apical stage II. No patient had vaginal exposure of the polypropylene mesh. Conclusion Our data show how laparoscopic lateral suspension is an effective procedure for apical and anterior vaginal wall defects. This study provides further evidence for the concept that OAB in women with POP >II stage improves after a successful POP surgery. These women may benefit from a resolution of OAB and POP symptoms with the improvement of patient's quality of life.

96: Pelvic organ prolapse recurrence in young women undergoing vaginal and abdominal colpopexy for the management of apical prolapse

To compare the incidence of pelvic organ prolapse (POP) recurrence between vaginal and abdominal colpopexy in women <49 years and to describe postoperative satisfaction and pelvic floor symptoms. This is a retrospective cohort study with a cross-sectional component of women aged 18 to 49 years who underwent primary POP surgery from January 2003 to September 2013. Patients were identified by CPT codes for vaginal and abdominal (open and minimally invasive) colpopexy and were included if they underwent apical prolapse surgery for either post-hysterectomy POP or uterovaginal POP with concurrent hysterectomy. The medical record was queried for perioperative data. POP recurrence was defined as vaginal bulge symptoms, retreatment of POP (pessary or surgery) and a composite of the two. Informed consent was obtained and surveys with validated questionnaires (PFDI-20, ISI, PISQ-IR, PGI-I) were used to assess pelvic floor symptoms, patient satisfaction and improvement. Three hundred thirty-three women met criteria. Mean age and BMI were 43 (+5.3) years and 27.9 (+5.8) kg/m2, respectively. The majority of women had a preoperative POP-Q stage of 2 (50.2%) or 3 (47.1%). A total of 29.1% (97) patients had an abdominal colpopexy and 70.9% (236) had a vaginal colpopexy. Patients who underwent abdominal colpopexy were more likely to have had a prior hysterectomy (20.6% vs 4.2%, p<.001) while the vaginal group was more likely to undergo concurrent hysterectomy and anterior repair (94.1% vs 78.4%, p<.001 and 66.5% vs 10.3%, p<.001, respectively). The composite recurrence rate was 32.0% (31) in the abdominal group and 24.2% (57) in the vaginal group (p=.15), with a retreatment rate of 10.3% (10) in the abdominal group and 5.9% (14) in the vaginal group (p=.16). The survey response rate was 45% (149) with a median response time of 2880 (1146-5540) days. The majority of patients (80.5%) reported prolapse improvement, which did not differ by colpopexy approach. However, more women in the abdominal group reported satisfaction with their surgery (100% vs 89.8%, p=.02). 26.8% (40) of women complained of a pelvic floor symptom (pain, bowel and/or bladder) and this did not differ by colpopexy approach. The composite recurrence rate in respondents was 13.7% (7) in the abdominal group and 15.3% (15) in the vaginal group (p=.80) with an overall retreatment rate of 5.9% (3) in the abdominal and 5.2% (5) in the vaginal group (p=.85). For women ≤49 years of age, 1 in 3 will experience subjective POP recurrence and/or retreatment after apical prolapse surgery but only 5-10% will undergo retreatment. There does not appear to be a difference in the incidence of recurrence between the vaginal and abdominal routes of surgery. While 1 in 4 women report pelvic floor symptoms postoperatively, the majority report high satisfaction rates.

Effects of continuous epidural analgesia during labor on the early postpartum recovery of pelvic floor function

Objective To explore the effect of continuous epidural analgesia on the early postpartum recovery of pelvic floor function. Methods This retrospective analysis involves two hundred cases of maternal deliveries in our hospital, including 57 cases received continuous epidural analgesia and 143 cases did not. The pelvic floor muscle strength, fatigue and myoelectric value, pelvic and abdomen dynamics, POP-Q stage assessment of pelvic organ prolapse, and pelvic floor dysfunction were compared between the two groups 6 post partum. Results Postpartum pelvic floor muscle strength was significantly higher in cases received epidural analgesia than in those did not received analgesia. Muscle fatigue of maternal Ⅰ and Ⅱ fibers in the analgesia group was significantly worse than that in the non-analgesic group (P<0.05). The pelvic floor muscle electrical values of maternal Ⅰ fibers in the analgesia group were higher than those of the non-analgesia group (P<0.05). Compared with non-analgesia group, analgesia group showed significantly lower incidence of abnormality in vaginal dynamic pressure, pelvic floor muscle static tension, pelvic floor contraction, maternal pelvic organ prolapse, and pelvic floor function (P<0.05). Conclusions Continuous epidural anesthesia during labor has a positive impact on the early postpartum recovery of pelvic floor function. Key words: Epidural analgesia; Primipara; Pelvic floor function

Prevalence of metabolic syndrome and its components in women with and without pelvic organ prolapse and its association with prolapse severity according to the Pelvic Organ Prolapse Quantification system.

Data regarding possible associations between metabolic syndrome (MS) and pelvic organ prolapse (POP) are scarce. The primary hypothesis was that the prevalence of MS and its components was higher in postmenopausal women with POP than in age-matched women without POP staged with the Pelvic Organ Prolapse Quantification system (POP-Q). The secondary aim of the study was to analyze the association between MS and its components with POP severity. Presence of MS and its components [elevated triglycerides (TG), waist circumference, blood pressure, and fasting glucose (FG) and decreased high-density lipoprotein cholesterol (HDL-C)] were assessed in 122 women with POP (POP-Q stage I-IV) and 77 without (POP-Q 0). Fasting insulin resistance [homeostasis model assessment for fasting insulin resistance (HOMA-IR)] was also assessed. TG levels, FG, and HOMA index were significantly higher in POP-Q stage I-IV compared with POP-Q 0 (p = 0.04, p = 0.0005 and p = 0.04); HDL-C was significantly reduced in POP-Q stage I-IV compared with POP-Q 0 (p = 0.0003). TG levels (p = 0.0315) were significantly higher in POP-Q stage III and IV vs. POP-Q 0; FG and HOMA-IR (p = 0.0015 and p = 0.0204) were significantly higher in POP-Q stage IV vs. POP-Q 0; HDL-C (p = 0.0047) was significantly lower in all stages vs. POP-Q 0. The prevalence of MS was different between groups (p = 0.04) and higher in POP-Q IV. Elevated TG [odds ratio (OR) 4.6, 95% confidence interval (CI) 1.5-9.3, p = 0.004] and reduced HDL-C (OR 2.0, 95% CI 1.1-3.7, p = 0.0241) significantly increased the risk of POP-Q stage ≥III. MS and its components may be associated with POP. Elevated TG and reduced HDL-C are associated with POP severity.

Outcome of Sacrospinous Ligament Fixation of the Vault during Repair of Pelvic Organ Prolapse

Pelvic organ prolapse includes descent of anterior/ posterior wall and apical (vault) prolapse with significant morbidity. In this study we evaluated the outcome of sacrospinous ligament fixation of vault through vaginal approach as part of the repair for massive uterovaginal (pelvic organ prolapse stage III and stage IV) and vault prolapse. This study on sacrospinous ligament fixation along with repair for Pelvic organ prolapse at Kathmandu Model Hospital from November 2016 to April 2018 was done to assess the outcome in terms of early (during hospital stay) and delayed (six months) post-operative complications and need of removal of sacrospinous fixation suture and recurrence of vault prolapse. Out of 95 Pelvic organ prolapse patients, 80 (84%) were post-menopausal, 28 (29.4%) were in the age group of 70-79 years. There were 61 (64%) POPQ stage III. The post-operative complications during post-operative hospital stay were pain over right buttock in 42 (44%), urinary retention in 7 (7%) and UTI in7 (7%). Sacrospinous suture was released in two patients for severe pain over right buttock. At one-week follow-up, 35 (36%) had right buttock pain of moderate severity and 8 (8%) had vaginal cuff infection. Sacrospinous suture was removed in one patient for neuropraxia two weeks following surgery. At four weeks follow-up, 25 (26%) patients had mild right buttock pain relieved by oral NSAIDs on need. At six months follow-up, five had occasional buttock pain, six had some recurrences and two had some vault prolapse and one each had short vagina and stress incontinence. Sacrospinous ligament fixation is a good procedure for the management of Pelvic organ prolapse with better long-term outcome if performed with good surgical expertise.

Outcome of Sacrospinous Ligament Fixation of the Vault during Repair of Pelvic Organ Prolapse

Background: Pelvic organ prolapse includes descent of anterior/ posterior wall and apical (vault) prolapse with significant morbidity. In this study we evaluated the outcome of sacrospinous ligament fixation of vault through vaginal approach as part of the repair for massive uterovaginal (pelvic organ prolapse stage III and stage IV) and vault prolapse. Methods: This study on sacrospinous ligament fixation along with repair for pelvic organ prolapse at Kathmandu Model Hospital from November 2016 to April 2018 was done to assess the outcome in terms of early (during hospital stay) and delayed (six months) post-operative complications, need of removal of sacrospinous fixation suture and recurrence of prolapse. Results: Out of 95 pelvic organ prolapse patients, 80 (84%) were post-menopausal, 28 (29.4%) were in the age group of 70-79 years. There were 61 (64%) POPQ stage III. The post-operative complications during post-operative hospital stay were pain over right buttock in 42 (44%), urinary retention in 7 (7%) and UTI in 7 (7%). Sacrospinous suture was released in two patients for severe pain over right buttock. At one-week follow-up, 35 (36%) had right buttock pain of moderate severity and 8 (8%) had vaginal cuff infection. Sacrospinous suture was removed in one patient for neuropraxia two weeks following surgery. At four weeks follow-up, 25 (26%) patients had mild right buttock pain relieved by oral NSAIDs on need. At six months follow-up, five had occasional buttock pain, six had some recurrences and two had some vault prolapse and one each had short vagina and stress incontinence. Conclusions: Sacrospinous ligament fixation is a good procedure for the management of pelvic organ prolapse with better long-term outcome if performed with good surgical expertise. Keywords: Prolapse; repair; sacrospinous fixation; vaginal hysterectomy.

SURGICAL TREATMENT OF PATIENTS WITH PELVIC PROLAPSE

AIM. To assess efficacy of surgical procedures with use of meshes for pelvic prolapse. PATIENTS AND METHODS. Retrospective study included 235 females aged 59.3±7.5 years which underwent surgery for pelvic prolapse in 2013-2017. Surgical reconstruction of pelvic floor was performed using several types of meshes: Pelvix («Lintex»), Urosling («Lintex»), Prolift («Gynecare»). Results were assessed clinically (POP-Q stage), by questionnaire, uroflowmetry, evaluation of QoL (PFDI-20 scale). Patients underwent control examinations 2 weeks after surgery, 3,6,12,24,36 months. RESULTS. Post-op complications were obtained in 4 (1.7%) patients and included bladder injury in 2 (0.85%) females and paravesical hematoma in 2 (0.85%). Control examinations after 2 weeks and 1 month were done in 235 (100.0%) patients, after 12 months - in 140 (59.6%), after 24 months - in 98 (41.7%), after 36 - in 58 (24.6%). Recurrence was detected in 11 (4.7%)patients. Eight (3.4%) produced stress urinary incontinence 1 year after surgery. QoL improved significantly from 159.2 to 28.7 points (p<0.05). CONCLUSION. Mesh surgery for pelvic prolapse is safe, provides low recurrence and improves QoL significantly.

Risk factors for the failure of iliococcygeus suspension for uterine prolapse

ObjectivesThe objective of this study was to evaluate the risk factors for the failure of iliococcygeus suspension (ICG) for uterine prolapse and estimate its long-term success rates using a clinically relevant criterion. Study designThis retrospective cohort study included 144 women who underwent transvaginal reconstructive surgery including ICG for symptomatic pelvic organ prolapse. Surgical failure was defined as anatomic recurrence (descent of the vaginal apex beyond the halfway point of the vagina or descent of the anterior or posterior vaginal wall beyond the hymen), symptomatic recurrence (vaginal bulge symptoms), or retreatment for prolapse. ResultsDuring the median 4-year follow-up period, surgical failure was observed in 20 women (13.9%). Multivariate analysis with the Cox proportional hazard model showed that advanced prolapse (preoperative pelvic organ prolapse quantification [POP-Q] stage >II and point C >0) and uterus-saving techniques were independent risk factors for failure. When the ICG was performed as a vault suspension procedure together with hysterectomy, the estimated 4-year success rates were 100% for mild prolapse (POP-Q stage II or point C ≤0) and 91.2% for advanced prolapse. When the procedure was done as a hysteropexy, the corresponding success rates decreased to 75.3% and 48.0%, respectively. ConclusionsThis study indicates that the severity of prolapse and the uterus-saving technique affect the prognosis after ICG. The ICG provides a durable apical vaginal support when performed together with hysterectomy, irrespective of the severity of the prolapse. In addition, it appears to be an acceptable hysteropexy option for mild uterine prolapse.

Risk factors for anatomic pelvic organ prolapse at 6weeks postpartum: a prospective observational study.

The objective was to identify risk factors for postpartum anatomic pelvic organ prolapse (aPOP) by comparing women with and without aPOP at 6weeks postpartum with regard to pelvic floor measurements antepartum and obstetrical characteristics. We carried out a prospective observational cohort study including nulliparous pregnant women in a Norwegian university hospital. Participants underwent clinical examinations, including pelvic organ prolapse quantification system (POP-Q) and transperineal ultrasound at gestational week 21 and at 6weeks postpartum. Background and obstetrical information was obtained from an electronic questionnaire and from the patient's electronic medical file respectively. Associations were estimated using logistic regression analyses. The dependent variable was aPOP, defined as POP-Q stage ≥2 at 6weeks postpartum. Independent variables were mid-pregnancy measurements of selected POP-Q variables and levator hiatus area (LHarea), delivery route, and the presence of major levator ani muscle (LAM) injuries at 6weeks postpartum. A larger LHarea, a more distensible LAM, a longer distance from the meatus urethra to the anus (Gh + Pb) and a more caudal position of the anterior vaginal wall (Ba) at mid-pregnancy were risk factors for aPOP at 6weeks postpartum, whereas delivery route and the presence of major LAM injuries were not. Prelabor differences in the pelvic floor rather than obstetrical events were risk factors for aPOP at 6weeks postpartum.

Prolapse reduction deteriorates the urethral closure mechanism.

Pelvic organ prolapse (POP) reduction is often performed in the preoperative assessment of women before POP surgery. Using urethral pressure reflectometry (UPR), we sought to investigate how POP reduction affects the urethral closure mechanism. Women with anterior or posterior vaginal wall prolapse stage ≥II with and without POP reduction were examined with a speculum. We performed prolapse staging according to the Pelvic Organ Prolapse Quantification system, UPR measurements at rest and during squeezing, and standardized stress tests with 300ml saline. All examinations were repeated after insertion of a speculum. We included 38 women: 22 with anterior and 16 with posterior vaginal wall prolapse POP-Q stage ≥II. During POP reduction, resting and squeezing urethral pressures decreased by 2.5 cmH2O (p = 0.007) and 5.1 cmH2O (p < 0.0001), respectively, in all women. During POP reduction, the number of positive stress tests increased from four (18%) to eight (36%) in women with anterior vaginal wall prolapse and from one (6%) to nine (56%) in women with posterior vaginal wall prolapse. POP reduction decreases urethral pressure, especially during squeezing, and consequently increases the number of positive stress tests. The test itself artificially deteriorates the urethral closure mechanism.

MP33-12 THE NATURAL HISTORY OF VOIDING EFFICIENCY FOLLOWING CORRECTION OF PARTIAL BLADDER OUTLET OBSTRUCTION IN WOMEN WITH PROLAPSE (2009-2015)

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Pelvic Prolapse1 Apr 2018MP33-12 THE NATURAL HISTORY OF VOIDING EFFICIENCY FOLLOWING CORRECTION OF PARTIAL BLADDER OUTLET OBSTRUCTION IN WOMEN WITH PROLAPSE (2009-2015) Amy D. Dobberfuhl, Robyn K. Shaffer, Steven N. Goodman, and Bertha Chen Amy D. DobberfuhlAmy D. Dobberfuhl More articles by this author , Robyn K. ShafferRobyn K. Shaffer More articles by this author , Steven N. GoodmanSteven N. Goodman More articles by this author , and Bertha ChenBertha Chen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1083AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The diagnosis of partial bladder outlet obstruction (pBOO) in women with prolapse has largely relied on subjective complaints and long term urodynamic (UDS) predictors of outcomes in this population have been poorly characterized. We report our 6-year experience in women following prolapse repair. METHODS We identified 592 women who underwent anterior and/or apical prolapse repair at our institution from 2009 to 2015 and reviewed the records of 266 women with preoperative UDS evaluation. Primary outcome was postoperative voiding efficiency (VE = voided volume ÷ capacity) and/or post void residual (PVR) after surgery. Data were analyzed in SAS using repeated measure mixed effects models to assess within and between group changes over time. RESULTS All 266 women (mean age 61 years) had preoperative UDS tracing, surgical and follow-up data available for analysis. There were 519 PVRs recorded at up to 2,949 days (mean 364, σ=639) and 9 time points (median 2, IQR 1-3) after surgery. Preoperative UDS revealed a mean: [email protected] 22 cmH2O (IQR 12-30), Qmax 18 mL/s (IQR 11-23), capacity 529 mL (IQR 370-659), PVR 120 mL (IQR 5-160). Women with prolapse [POP-Q Stage: I (n=14), II (n=120), III (n=118), IV (n=14)] underwent anterior-only (n=115), apical-only (n=41) or combination anterior-apical (n=110) prolapse repair. Using mixed effects models, significant UDS cutpoints associated with worsening postoperative PVR and/or VE over time were identified: BCI < 60 (11% reduction VE, p<0.05), capacity > 600 mL (59 mL higher PVR, p=0.01); preoperative PVR > 200 mL (93 mL higher PVR, p<0.01; 8% reduction VE, p<0.05). The Qmax < 10 mL/s cutpoint approached significance (7% reduction VE, p=0.053). Sling placement was associated with a 49 mL higher PVR (ref 99 mL, p<0.05) and non-significant 5% lower VE (ref 82%, p=0.058). High grade (Stage III or IV) prolapse was paradoxically associated with 6% higher VE (ref 78%, p<0.05). Urinary tract infections (n=120) were associated with a 77 mL higher PVR (ref 78 mL, p<0.01) and 13% reduction in VE (ref 86%, p<0.01). Factors not significantly predictive of worse PVR and/or VE include: all BOOI and [email protected] cutpoints, anterior versus apical repair, diabetes (n=37, p=0.92), hyperlipidemia (n=91, p=0.08), neuropathy (n=17, p=0.33), and obesity (n=44, p=0.76). CONCLUSIONS BOOI and [email protected] are poorly predictive of VE and/or PVR following prolapse surgery. Women with a BCI < 60, capacity > 600 mL or PVR > 200 mL are at risk of worsening VE and/or PVR following prolapse repair and should be considered for earlier pBOO intervention. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e433 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Amy D. Dobberfuhl More articles by this author Robyn K. Shaffer More articles by this author Steven N. Goodman More articles by this author Bertha Chen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The Manchester procedure: anatomical, subjective and sexual outcomes.

Classical native-tissue techniques for pelvic organ prolapse (POP) repairs, such as the Manchester procedure (MP), have been revitalized because of vaginal mesh complications. However, there are conflicting opinions regarding sufficient apical (mid-compartment) support by the MP and concerns about the risk of dyspareunia. The aims of this study were therefore to investigate anatomical and patient-reported outcomes 1year after MP. Prospective cohort study of 153 females undergoing an MP for anterior compartment POP between October 2014 and June 2016. Pre- and 1-year postoperative evaluations included POP-Q measurements and the questionnaires Pelvic Floor Distress Inventory Short Form 20 (PFDI-20) and POP/Urinary Incontinence Sexual Questionnaire (PISQ-12). At 1year, 97% (148/153) attended the follow-up. Significant anatomical improvements (p < 0.01) were obtained in all compartments. Mean Ba was -1.1 (± 1.4), mean C -5.9 (± 1.7) and mean D -7.0 (± 1.2) at follow-up. Point C ≤ -5 was present in 81.1%. POP-Q stage 0-1 was obtained in 99.3% in the mid-compartment (C < -1), but only in 48.6% in the anterior compartment (Ba < -1). A significant reduction in symptom scores was obtained for PFDI-20 (p < 0.01) and PISQ-12 (p = 0.01). No significant changes were seen in dyspareunia rates (q.5, PISQ-12), but 5.6% reported de novo dyspareunia. Concerning POP symptoms, 96.0% reported being cured or significantly improved. The Manchester procedure provides adequate apical support, albeit inferior anatomical anterior compartment results, and 96.0% reported being subjectively cured or substantially better at 1-year follow-up, with no significant change in dyspareunia.