Postoperative Pelvic Organ Prolapse Quantification Research Articles

Preoperative prolapse phenotype is predictive of surgical outcome with minimally invasive sacrocolpopexy

The gold-standard treatment for advanced pelvic organ prolapse is sacrocolpopexy. However, the preoperative features of prolapse that predict optimal outcomes are unknown. This study aimed to develop a clinical prediction model that uses preoperative scores on the Pelvic Organ Prolapse Quantification examination to predict outcomes after minimally invasive sacrocolpopexy for stages 2, 3, and 4 uterovaginal prolapse and vaginal vault prolapse. A 2-institution database of pre- and postoperative variables from 881 cases of minimally invasive sacrocolpopexy was analyzed. Data from patients were analyzed in the following 4 groups: stage 2 uterovaginal prolapse, stage 3 to 4 uterovaginal prolapse, stage 2 vaginal vault prolapse, and stage 3 to 4 vaginal vault prolapse. Unsupervised machine learning was used to identify clusters and investigate associations between clusters and outcome. The k-means clustering analysis was performed with preoperative Pelvic Organ Prolapse Quantification points and stratified by previous hysterectomy status. The "optimal" surgical outcome was defined as postoperative Pelvic Organ Prolapse Quantification stage <2. Demographic variables were compared by cluster with Student t and chi-square tests. Odds ratios were calculated to determine whether clusters could predict the outcome. Age at surgery, body mass index, and previous prolapse surgery were used for adjusted odds ratios. Five statistically distinct prolapse clusters (phenotypes C, A, A>P, P, and P>A) were found. These phenotypes reflected the predominant region of prolapse (apical, anterior, or posterior) and whether support was preserved in the nonpredominant region. Phenotype A (anterior compartment prolapse predominant, posterior support preserved) was found in all 4 groups of patients and was considered the reference in the analysis. In 111 patients with stage 2 uterovaginal prolapse, phenotypes A and A>P (greater anterior prolapse than posterior prolapse) were found, and patients with phenotype A were more likely than those with phenotype A>P to have an optimal surgical outcome. In 401 patients with stage 3 to 4 uterovaginal prolapse, phenotypes C (apical compartment predominant, prolapse in all compartments), A, and A>P were found, and patients with phenotype A>P were more likely than those with phenotype A to have ideal surgical outcome. In 72 patients with stage 2 vaginal vault prolapse, phenotypes A, A>P, and P (posterior compartment predominant, anterior support preserved) were found, and those with phenotype A>P were less likely to have an ideal outcome than patients with phenotype A. In 297 patients with stage 3 to 4 vaginal vault prolapse, phenotypes C, A, and P>A (prolapse greater in posterior than in anterior compartment) were found, but there were no significant differences in rate of ideal outcome between phenotypes. Five anatomic phenotypes based on preoperative Pelvic Organ Prolapse Quantification scores were present in patients with stages 2 and 3 to 4 uterovaginal prolapse and vaginal vault prolapse. These phenotypes are predictive of surgical outcome after minimally invasive sacrocolpopexy. Further work needs to confirm the presence and predictive nature of these phenotypes. In addition, whether the phenotypes represent a progression of prolapse or discrete prolapse presentations resulting from different anatomic and life course risk profiles is unknown. These phenotypes may be useful in surgical counseling and planning.

Robotic Vaginal Hernia Repair for Recurrent Vaginal Prolapse Status Post-Radical Cystectomy with an Indiana Pouch.

Pelvic organ prolapse following a radical cystectomy is challenging to treat and recurrence of prolapse after primary repair is common owing to compromised pelvic floor support and tissue quality. Vaginal prolapse repairs are often preferred because of concern for patients' complex intraabdominal pathological conditions. However, for those with recurrent prolapse following colpocleisis, limited definitive treatment options exist. This surgical video presents a 64-year-old G4P4 with a history of radical cystectomy with an Indiana Pouch for invasive urothelial carcinoma who presented with recurrent stage IV vaginal prolapse two years following colpocleisis. Owing to thin vaginal tissue, a sacrocolpopexy with vaginal mesh could not be performed, thus, the patient underwent robotic-assisted vaginal hernia repair with a polypropylene-reinforced ovine tissue matrix attached to Cooper's ligament and the levator ani muscles. The surgery was free from complications and her postoperative Pelvic Organ Prolapse Quantification examination revealed a leading vaginal tissue remnant at the level of the hymen. The patient reported overall improved health and quality of life following surgery and recovery on postoperative validated questionnaires. Vaginal and pelvic floor hernia repair with a polypropylene-reinforced tissue matrix is a feasible definitive surgical treatment for patients with prior radical cystectomy in whom colpocleisis has failed.

Outcomes of Abdominal Apical Suspension Using Mesh in a Tertiary Training Hospital: A Seven-year Retrospective Review.

Pelvic organ prolapse (POP) is an inconvenience that can affect a woman's well-being. Reconstructive pelvic floor surgery involves repairing defects in the endopelvic fascia and pelvic floor musculature as close to the physiologic and anatomic norm. The cornerstone of successful prolapse repair is a strong apical support. The aim of the study is to determine the outcomes of abdominal sacrocolpopexy (ASC) and abdominal sacrohysteropexy (ASH) in the Philippines. The study utilized a descriptive study design to compare the pre-operative and post-operative Pelvic Organ Prolapse Quantification Score (POP-Q Score), presence of mesh complications, and urinary/bowel symptoms in patients operated within 2010-2016 in a Philippine tertiary training hospital. Based on recovered charts and inclusion/exclusion criteria, this study sampled 34 of 50 patient records. Statistical measures of median and range were used to describe pre-operative and post-operative POP-Q scores in any two follow-ups within 6-, 12-, 18-, and 24-month interval. The objective success rate and incidence of urinary/bowel symptoms were described using frequencies and percentages. Presence of any mesh erosion was noted for each follow-up. McNemar's test was applied to assess the comparative occurrence of each symptom comparing between the pre-operative and first follow-up periods. ASC had a success rate of 73.7% at six months and 56.3% at 12 months post-surgery. ASH showed an 84.6% success rate at six months and 71.4% at 12 months. Apical support has a 97% success rate without affecting the anterior or posterior compartments. Out of 20 ASC patients, 5 (25%) exhibited anterior compartment descent, whereas two out of 14 ASH patients (14.2%) had the same condition. It is observed that the anterior vaginal wall has the higher tendency to descend after reconstructive surgery, independent of route or technique. In addition, not all patients with surgical prolapse beyond -1 experienced symptomatic vaginal bulges. Overall, a notable decrease in the occurrence of urine symptoms was seen after the surgery. No mesh erosion was seen within the initial two years of follow-up but there was a single reported instance of abdominal hernia, an uncommon consequence. This study demonstrated that ASC and ASH have good success rate in apical support; however, descent of the anterior or posterior compartment diminishes the overall success rate in terms of over-all objective POP-Q score. Both resulted to improvement in symptoms with minimal complications.

High Uterosacral Ligament Fixation Versus McCall's Culdoplasty for Vaginal Vault Suspension in Utero-Vaginal Prolapse Surgery.

Introduction: There are high chances of post-hysterectomy vault prolapse (PHVP) if the vault is not well supported after vaginal hysterectomy in cases of pelvic organ prolapse (POP). High uterosacral ligament suspension (HUSLS) and McCall's culdoplasty are the well-recommended modalities to suspend the vault after vaginal hysterectomy. As both the procedures are accessible to non-urologic gynaecologists, the study was planned in cases of POP. Objective: The study was conducted to compare the anatomic and functional outcomes of patients undergoing vaginal HUSLS vs. McCall's culdoplasty at the time of vaginal hysterectomy.Materials and methods: This prospective interventional study was done in a tertiary care hospital. A total of 80 patients were included and divided into two groups of 40 patients each. In one group, patients underwent high uterosacral ligament suspension and in the second group, McCall's culdoplasty was done for vault suspension. All procedures were done by two trained surgeons. The effectiveness of both the procedures was assessed by preoperative and postoperative pelvic organ prolapse quantification (POP-Q) (up to two years). Patients were followed for two years to see for any postoperative problem/recurrence.Results: Vault suspension by HUSLS showed better results than McCall's culdoplasty, in terms of POP-Q point C, perineal body (PB), genital hiatus (GH) and total vaginal length (TVL) as compared to McCall's culdoplasty.Conclusion: The anatomical correction is much better with HUSLS, which suspends the vault in the normal vaginal axis. However, it takes longer compared to McCall's culdoplasty, so the procedure should be individualised and performed with several precautions.

PD44-04 NATIVE TISSUE REPAIR OF ANTERIOR COMPARTMENT PROLAPSE FROM MULTIPLE INSTITUTIONS IS DURABLE OVER 3 YEARS

You have accessJournal of UrologyCME1 May 2022PD44-04 NATIVE TISSUE REPAIR OF ANTERIOR COMPARTMENT PROLAPSE FROM MULTIPLE INSTITUTIONS IS DURABLE OVER 3 YEARS Ramzy Burns, Leo Song, Feras Alhalabi, Lauren Snodgrass, Philippe Zimmern, and CR Powell Ramzy BurnsRamzy Burns More articles by this author , Leo SongLeo Song More articles by this author , Feras AlhalabiFeras Alhalabi More articles by this author , Lauren SnodgrassLauren Snodgrass More articles by this author , Philippe ZimmernPhilippe Zimmern More articles by this author , and CR PowellCR Powell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002605.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The US Food and Drug Association has recommended removal of all transvaginal mesh kits from the market for anterior compartment pelvic organ prolapse (POP) repair, stimulating renewed interest in native tissue POP repair. Specifically, anterior vaginal wall suspension (AVWS) has emerged as a reproducible option for stage 2-3 isolated anterior compartment prolapse repair using native tissue. Zimmern et al. (2016) found a 7.4% rate of failure after AVWS in 121 patients over a follow-up of 5.8 years. We sought to update this experience in multiple institutions. The hypothesis is that well selected patients will have durable results supported by validated patient reported outcome measures and pelvic organ prolapse - quantification (POP-Q) exam. METHODS: We reviewed an institutional review board approved prospectively maintained database of women undergoing anterior vaginal wall suspension without concomitant apical support procedures across multiple institutions. The primary outcome was prolapse recurrence in the anterior compartment. Secondary outcomes included preoperative and postoperative POPQ values, Urinary Distress Inventory-6 (UDI6), and Incontinence Impact Questionnaire-7 (IIQ7) scores. Statistical analysis was performed using STATA 17.0. Significance for continuous variables was by 2-tailed T-test. Predictive modeling was logistic regression. RESULTS: 651 patients underwent AVWS at participating institutions. Table 1 displays preoperative and postoperative POP-Q and validated patient reported outcomes. Failure as defined by Aa>=0 was seen in 8% of patients at 38.3 months follow up. Logistic regression revealed that preoperative POP-Q “Aa” severity was predictive of failure in the anterior compartment (OR 2.6, p<0.05). Preoperative POP-Q “C” severity also weakly predicted failure (OR 1.1, p<0.05). UDI6 item 5 “difficulty emptying your bladder” score was predictive of failure (OR 1.6, p<0.05), however there were no parameters that predicted failure using IIQ7. CONCLUSIONS: AVWS is durable and re-producible. Validated questionnaires are sensitive to improvement in POP-Q measurements and failures in the anterior compartment. Source of Funding: This project was supported by a Project Development Team within the ICTSI NIH/NCRR Grant Number RR025761 SUBAWARD (Powell, PI) and NIDDK DiaComp Pilot & Feasibility project, sub-award DK076169 (Powell, PI) and Indiana University CTSI MedSTAR program (Song). Indiana Clinical and Translational Sciences Institute is funded in part by Award Number UL1TR002529 from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Awtard © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e709 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ramzy Burns More articles by this author Leo Song More articles by this author Feras Alhalabi More articles by this author Lauren Snodgrass More articles by this author Philippe Zimmern More articles by this author CR Powell More articles by this author Expand All Advertisement PDF DownloadLoading ...

A blind spot: Manchester Fothergill operation for cervical elongation without uterine descensus

ObjectiveTo evaluate the anatomical results of Manchester Fothergill operation performed due to cervical elongation cases without uterine descensus and its effects on quality of life and sexual function. Materials and methodsThirty-six women who underwent Manchester Fothergill operation for cervical elongation without uterine descensus were analyzed retrospectively. Pre- and postoperative Pelvic Organ Prolapse-Quantification (POP-Q) measurements, Prolapse Quality of Life (P-QoL) Questionnaire and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) scores were collected. ResultsThere were significant improvements in POP-Q measurements, P-QoL Questionnaire and PISQ-12 scores postoperatively. There was no relationship between the change in POP-Q measurements and the changes in questionnaires scores. Reoperation was performed in only one patient due to anterior compartment prolapse. No serious complications were detected. ConclusionManchester Fothergill operation is an effective and safe surgical option in the surgical treatment of cervical elongation cases without uterine descensus. It provides anatomical improvement, increases the quality of life and improves sexual function in women.

Stepwises Technique in Robotic Assisted Notes Sacrocolpopexy

<h3>Study Objective</h3> To demonstrate stepwise techniques for the successful utilization of the single-site technique for safely performing transvaginal sacrocolpopexy for pelvic organ prolapse. <h3>Design</h3> Stepwise demonstration with narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> The patient is a 69-year-old G2P2002 with a history of SVD x2 who presented with symptomatic stage II anterior vaginal prolapse (Aa +1) and stage II posterior vaginal prolapse (Ap -1). The preoperative vaginal length was measured at 9 cm. <h3>Interventions</h3> Laparoscopic transvaginal single-site sacrocolpopexy has been demonstrated to be feasible and safe in the surgical management of pelvic organ prolapse. However, retroperitoneal dissection or suturing/knot tying can be technically challenging to perform, especially in the event of an anatomical variation of a deeply angled S1 vertebra. Wristed robotic instrumentation may overcome some of these obstacles and result in easier suturing and knot tying. Integration of a robotic platform for sacrocolpopexy is a novel alternative minimally invasive approach that is more cosmetic, safer and effective. <h3>Measurements and Main Results</h3> The procedure was successfully performed in approximately 227 minutes with a measured postoperative vaginal length of 7 cm. The patient's postoperative pelvic organ prolapse quantification was stage 0. <h3>Conclusion</h3> Robotic-assisted transvaginal single-site sacrocolpopexy for pelvic organ prolapse is feasible, effective, and safe in patients with pelvic organ prolapse.

Preliminary evaluation of the short-term outcomes of polytetrafluoroethylene mesh for pelvic organ prolapse.

Tension-free vaginal mesh (TVM) surgery using synthetic polypropylene (PP) soft mesh had spread rapidly. However, the frequency of mesh-related postoperative complications had increased, and PP was banned in April 2019. In Japan, however, transvaginal surgery using polytetrafluoroethylene (PTFE) mesh had been approved. In this study, we evaluated the clinical outcome and quality of life (QOL) of the postoperative course using PP mesh and PTFE mesh (named "ORIHIME™" ) in a combination surgery for utero-sacral ligament suspension and anterior vaginal support using anterior TVM. The vaginal hysterectomy and utero-sacral ligament colpopexy augmented by anterior vaginal mesh implants using PP mesh and PTFE mesh were performed on patients with stage III to IV cystocele and uterine prolapse. The clinical outcome and QOL changes in their postoperative course were evaluated by comparing 15 cases of PP mesh and 13 cases of PTFE mesh. There was no difference between the PP group and PTFE group in characteristics. No mesh-related complications occurred during the follow-up period. With regard to the pelvic organ prolapse quantification (POP-Q) score, no significant difference was found between the two groups. Comparing the postoperative QOL of both groups, the PTFE group had significantly higher values in two domains than PP group (SF-12v2 questionnaire). We used the world's first PTFE mesh to compare PP mesh with postoperative POP-Q and QOL after the same surgery, with the same operator, and at the same institution. The results showed no significant difference between both mesh materials in the short-term.

Robot-assisted Transvaginal Single-site Sacrocolpopexy for Pelvic Organ Prolapse

To demonstrate stepwise techniques for the successful use of the laparoscopic single-site technique for safely performing transvaginal sacrocolpopexy for pelvic organ prolapse. Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Academic tertiary care hospital. The patient, aged 69 years gravida 2 para 2-0-0-2 with a history of SVD × 2, presented with symptomatic stage II anterior vaginal prolapse (Aa +1) and stage II posterior vaginal prolapse (Ap -1). The preoperative vaginal length was measured at 9 cm. Laparoscopic transvaginal single-site sacrocolpopexy has been demonstrated to be feasible and safe in the surgical management of pelvic organ prolapse. However, the retroperitoneal dissection or suturing/knot tying can be technically challenging to perform, especially in the event of an anatomic variation of a deeply angled S1 vertebra. Wristed robotic instrumentation may overcome some of these obstacles and result in easier suturing and knot tying. Integration of a robotic platform for sacrocolpopexy is a novel alternative minimally invasive approach that is more cosmetic, safer, and effective. Several helpful techniques in robot-assisted transvaginal single-site include the following: (1)The use of a 30°-angled scope alternating between "facing up" and "facing down" depending on the need for dissection or suturing. (2) The use of 3-dimensional visualization with a robotic camera that can highlight the depth of the surgical anatomy, therefore facilitating easier identification in the dissection of a surgical pedicle. (3) The use of wristed instruments that permit increased articulation and triangulation that are lacking in traditional laparoscopic single-site surgery, allowing for much easier and proficient suturing and knot tying. (4) Integration of the robotic platform that stabilizes the fine motor movement in a surgeon's hands improving the precision of the suturing and knot tying. The procedure was successfully performed in approximately 227 minutes with a measured postoperative vaginal length of 7 cm. The patient's postoperative pelvic organ prolapse quantification was stage 0. Robot-assisted transvaginal single-site sacrocolpopexy for pelvic organ prolapse is feasible, effective, and safe in patients with pelvic organ prolapse. Patients experience improved cosmesis, decreased postoperative pain, and faster recovery compared with abdominal sacrocolpopexy.

Techniques for Apical Prolapse Management in Transvaginal Natural Orifice Transluminal Endoscopic Surgery High Uterosacral Ligament Suspension

To demonstrate practical tips and tricks for successful use of the transvaginal natural orifice transluminal endoscopic surgery (NOTES) technique for performing high uterosacral ligament suspension (HUS). Stepwise demonstration with narrated video footage (Canadian Task Force classification III). An academic tertiary care hospital. A 58-year-old G2P2, NSVDx2 with stage III anterior vaginal prolapse, stage II uterine prolapse, and posterior vaginal prolapse. The preoperative vaginal length was 7-cm. Transvaginal NOTES is a creative yet difficult approach that averts an abdominal incision while simultaneously providing enhanced visualization in comparison with traditional vaginal surgery [1]. However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and bilateral salpingo-oophorectomy was subsequently performed. The following key techniques were used to perform NOTES-HUS: tagging the sutures for bilateral uterosacral ligament before single-site port placement, identifying the ischial spine and ureters, pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament, grasping and lifting the uterosacral ligament while placing a suture, and giving the suture a tug after placement to confirm the correct location [2-4]. The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 5-cm. Postoperative pelvic organ prolapse quantification was stage 0. Transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. There is an increased cost to using laparoscopically assisted NOTES surgery as well as a risk of pneumoperitoneum. Applying the tips and tricks presented here, such as tagging the uterosacral ligament before port placement and so on, the challenging transvaginal NOTES-HUS technique can be performed efficiently and safely.

Stepwise Laparoendoscopic Single-site Pectopexy for Pelvic Organ Prolapse

To demonstrate stepwise techniques for the successful use of the laparoendoscopic single-site surgery (LESS) technique for safely performing pectopexy. Stepwise demonstration with narrated video footage (Canadian Task Force classification III). An academic tertiary care hospital. Patient was a 48-year-old, gravida 2 para 2, having had 2 normal spontaneous vaginal deliveries, with stage III anterior vaginal prolapse and stage III uterine prolapse and posterior vaginal prolapse. The preoperative vaginal length was 6 cm. Laparoscopic sacrocolpopexy is the current gold standard for pelvic organ prolapse demonstrating a low recurrence rate; however, it can be technically challenging to perform, particularly in women with obesity or in the event of an anatomic variation. The pectineal ligament, also known as Cooper's ligament, is familiar to surgeons and can be used for a tension-free mesh suspension in patients with prolapse. Integration of LESS and pectopexy is a novel alternative, minimally invasive approach that is more cosmetic, simpler, and effective. The key steps in LESS pectopexy include the following: MEASUREMENTS AND MAIN RESULTS: The procedure was performed successfully in approximately 80 minutes with a postoperative vaginal length of 6 cm. Postoperative pelvic organ prolapse quantification was stage 0. LESS is a feasible technique for pectopexy in patients with pelvic organ prolapse. A LESS pectopexy results in better cosmesis and offers an alternative for patients with challenging pelvic organ prolapse, such as those with obesity.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery High Uterosacral Ligament Suspension (NOTES-HUS) for Apical Prolapse

Study Objective To demonstrate practical tips and tricks for successful use of the transvaginal NOTES technique for preforming HUS. Design Stepwise demonstration with narrated video footage (Canadian Task Force classification III). Setting An academic tertiary care hospital. Patients or Participants A 58-year-old G2P2, NSVDx2 with Stage III anterior vaginal prolapse, Stage II uterine prolapse & posterior vaginal prolapse. The preoperative vaginal length was 7 cm. Interventions High uterosacral ligament suspension (HUS) is well accepted for apical prolapse due to its advantages of good apical support and simplification of intraperitoneal suture passage. Transvaginal natural orifice transluminal endoscopic surgery (NOTES) is a novel minimally invasive approach that avoids an abdominal incision while providing improved visualization, leading to simplified intraperitoneal suture placement. However, this approach may be technically challenging. After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and BSO was subsequently performed. The following key techniques were utilized to perform NOTES-HUS: ○ Tagging the sutures for bilateral uterosacral ligament before single-site port placement ○ Identifying the ischial spine and ureters ○ Pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament ○ Grasping and lifting uterosacral ligament while placing a suture ○ Giving the suture a tug after placement to confirm the correct location Measurements and Main Results The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 6 cm. Postoperative pelvic organ prolapse quantification was stage 0. Conclusion The transvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. Applying the tips and tricks presented here, such as tagging uterosacral ligament before port placement, etc., the challenging transvaginal NOTES-HUS can be performed efficiently and safely.

Immediate Postoperative Pelvic Organ Prolapse Quantification Measures and 2-Year Risk of Prolapse Recurrence.

To assess whether resting genital hiatus, perineal body, and total vaginal length measured intraoperatively at the conclusion of surgery are associated with prolapse recurrence 2 years after native tissue pelvic organ prolapse reconstruction. This ancillary analysis of the OPTIMAL (Operations and Pelvic Muscle Training in the Management of Apical Support Loss) trial included women who had an immediate postoperative pelvic organ prolapse quantification (POP-Q) examination and 2-year follow-up. Primary outcome was bothersome bulge symptoms. Secondary outcomes were anatomic failure, surgical failure (either anatomic failure or bothersome bulge symptoms), and sexual function. Descriptive statistics assessed relationships between postprocedure POP-Q measures and these four outcomes. Multivariable models were fit to the data to control for baseline differences in bivariate comparisons. Receiver operating characteristic curves were generated to identify an optimal genital hiatus cut point associated with bothersome bulge, and this threshold was explored. This analysis included 368 participants. Bivariate analyses identified age, body mass index, vaginal deliveries, baseline genital hiatus, perineal body, and advanced POP-Q stage (3 or higher vs 2) as clinically relevant variables to include in multivariable models. After adjusting for these variables, the association between immediate postoperative genital hiatus and bothersome bulge (adjusted odds ratio [aOR] 1.4; 95% CI 0.9-2.1) was not significant at the P<.05 level; however, immediate postoperative genital hiatus was associated with anatomic (aOR 1.6; 95% CI 1.1-2.3) and surgical failure (aOR 1.5; 95% CI 1.0-2.1). Immediate postoperative genital hiatus of 3.5 cm was the selected cutoff (area under the curve 0.58, 95% CI 0.50-0.66 from the bothersome bulge model). Women with genital hiatus 3.5 cm or greater were more likely to have anatomic and surgical failures at 2 years. No POP-Q measures were correlated with 2-year sexual function. A larger immediate postoperative genital hiatus measurement of 3.5 cm or greater is not associated with bothersome bulge symptoms or sexual dysfunction but is associated with anatomic and surgical failures 2 years after native tissue vaginal reconstructive surgery.

Urogynecology

Urogynecology

Effect of BMI on clinical outcomes following minimally invasive sacrocolpopexy.

Our objective was to compare success and complication rates following minimally invasive sacrocolpopexy (SCP) based on body mass index (BMI). This is a retrospective cohort study of women who underwent laparoscopic or robotic SCP at one academic center from 2006 to 2016. Women were included if they had a postoperative pelvic organ prolapse quantification (POPQ) exam and subjective success documented. For our primary outcome, we compared composite success (POPQ stage ≤ I and report of no bulge symptoms) amongst three groups: normal weight (BMI ≤ 25), overweight (BMI 25-30) and obese (BMI ≥ 30) women. Secondary outcomes included intraoperative complications, 6week postoperative complications, and sacrocolpopexy mesh exposure. Of the 431 women who met inclusion criteria, 140 (32%) had normal BMI (23kg/m2; IQR 22, 24), 177 (41%) were overweight (27kg/m2; IQR 26, 28), and 114 (26%) were obese (32kg/m2; IQR 31, 36). Mean age was 60 ± 11years, and most were Caucasian, with no differences in demographics or Charlson Comorbidity Index (CCI). Median length of follow-up was 49weeks (IQR 9, 104), with similar follow-up for all groups. For our primary outcome, composite success was 72% overall, with no significant differences in composite success rates between groups. For secondary outcomes, there were no differences in the rates of perioperative complications but obese women had a 2.8 increased risk of mesh exposure (p = 0.02). Obesity was not associated with differences in the success or peri-operative complication rates for SCP in our population, but was associated with mesh exposure.

Short-term Outcomes of Non-robotic Single-incision Laparoscopic Sacrocolpopexy: A Surgical Technique

Our main purpose was to describe the surgical technique and short-term outcomes of single-incision laparoscopic sacrocolpopexy (S-LSC) for the treatment of pelvic organ prolapse (POP). This study consisted of a retrospective analysis of 49 consecutive cases. This study was set at the Third Affiliated Hospital of Guangzhou Medical University from October 2016 to November 2017. The population for this study consisted of women with stage II to IV POP who met eligibility criteria for laparoscopic surgery. S-LSC included the use of V-loc barbed suture and retroperitoneal tunneling, in addition to standard single-incision laparoscopic surgery techniques. All 49 cases were successfully completed. All cases included concomitant procedures; 42 (85.7%) had removal of the uterus and adnexa. The main measured outcomes include patient characteristics, perioperative outcomes, and change in pelvic floor support (Pelvic Organ Prolapse Quantification System), and quality of life (Pelvic Floor Impact Questionnaire). All patients were parous, and 42.9% had a history of previous abdominal surgery. The mean operative duration from skin to skin was 201.20 ± 46.53 minutes. The mean estimated blood loss was 27.0 ± 16.6 mL. The mean pre- and post-operative Pelvic Organ Prolapse Quantification System scores were 2.2 ± 1.1 cm versus -2.6 ± 0.5 cm for the Aa point and 3.2 ± 2.8 cm versus -4.6 ± 0.8 cm for the C point (p <.05 for both). The mean pre- and post-operative Pelvic Floor Impact Questionnaire scores were 106.4 ± 18.9 versus 8.9 ± 4.26 (p <.05), suggesting that S-LSC significantly improved physical prolapse and quality of life. Four patients suffered from postoperative complications (3 mesh exposure and 1 lumbosacral pain). Six patients complained of new onset of stress urinary incontinence. Single-incision laparoscopic sacrocolpopexy is a feasible method to manage POP. However, the long-term effects and complications need to be further investigated.

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

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

Laparoscopic Uterosacral Ligament Hysteropexy vs Total Vaginal Hysterectomy with Uterosacral Ligament Suspension for Anterior and Apical Prolapse: Surgical Outcome and Patient Satisfaction

To compare anatomic and clinical cure rates as well as patient satisfaction between uterine-preserving laparoscopic uterosacral ligament suspension and total vaginal hysterectomy with uterosacral ligament suspension in women with apical and anterior prolapse. Single-center clinical comparative retrospective cohort study. A female pelvic medicine and reconstructive surgery service at a tertiary teaching hospital. Women with pelvic organ prolapse who underwent surgical treatment for their condition between July 2010 and December 2015. All women underwent laparoscopic uterosacral ligament suspension or total vaginal hysterectomy with uterosacral ligament suspension for apical and anterior prolapse. Concomitant procedures included anterior and posterior repair, as well as a midurethral sling when indicated. Preoperative and postoperative Pelvic Organ Prolapse Quantification (POP-Q) measurements were obtained. The primary outcome was clinical cure rate. Secondary outcomes included anatomic cure rate and outcomes of site-specific POP-Q points Ba, C, and Bp for the whole cohort. Patient satisfaction was measured using the Patient Global Impression of Improvement questionnaire. During the study period, 106 women underwent transvaginal hysterectomy with uterosacral ligament suspension, and 53 women had laparoscopic uterosacral ligament suspension. At a mean follow-up of 14.7 ± 13.23 months for the vaginal group and 17.5 ± 15.84 months for the laparoscopic group (p = .29), there were significant improvements of POP-Q points Ba, C, and Bp (p < .0001 for all comparisons in both groups). The clinical cure rate was 96% in the vaginal group and 98% in the laparoscopic group (p = .50). The anatomic cure rate was 85.4% in the vaginal group and 93.75% in the laparoscopic group (p = .11) Patient satisfaction was high in both groups. In appropriately selected patients, laparoscopic uterosacral ligament suspension is a valid uterus-preserving option for women with anterior and apical prolapse, associated with high anatomic and clinical cure rates and patient satisfaction.

Evaluating the efficacy of the single-incision uphold system for pelvic organ prolapse repair

ObjectiveThe aim of this study was to assess the efficacy and clinical outcomes of pelvic floor reconstruction with transvaginal mesh of the Uphold™ Vaginal Support System (Boston Scientific Corporation). Materials and methodsThis retrospective study reviewed the medical records of patients with pelvic organ prolapse stage 3 or 4 who underwent pelvic reconstructive surgery with transvaginal mesh of the Uphold™ Vaginal Support System from January 2015 to March 2017. Patients who were treated with laparoscopic sacrocolpopexy, transvaginal sacrospinous ligament suspension or other mesh kits were excluded. Assessments included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage, Urogenital Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire-7 (IIQ-7), urodynamic parameters, peri- and postoperative complications and symptoms. ResultsOf the 111 enrolled women, the anatomical success rate was 97.3% after a median 18.4 months of follow-up. POP-Q parameters, UDI-6 and IIQ-7 scores, maximum urine flow rate, and post-void residual urine all significantly improved after surgery. Complications included one case (0.9%) of infected hematoma, two cases (1.8%) of mesh exposure, three cases (2.7%) of recurrent prolapse, and 12 cases (10.8%) of transient urine retention. No bladder or bowel injuries occurred during surgery. ConclusionsPelvic reconstructive surgery with transvaginal mesh of the Uphold™ System yielded satisfactory anatomical and urinary functional outcomes in a median 18.4 months of follow-up. IRB identifierIRB: 201700645B0

Anatomical Outcome and Patient Satisfaction After Laparoscopic Uterosacral Ligament Hysteropexy for Anterior and Apical Prolapse.

The aim of this study was to determine anatomical and clinical cure, as well as patient satisfaction in uterine-preserving laparoscopic uterosacral ligament suspension (LUSLS) in women with anterior and apical prolapse. This was a retrospective cohort study including all women who underwent LUSLS for anterior and apical prolapse between January 2012 and December 2015 at a tertiary-care university hospital. All women had LUSLS hysteropexy and anterior colporrhaphy. Pre- and postoperative pelvic organ prolapse quantification (POP-Q) measurements were taken. Prolapse symptoms were queried via standardized history. Patient satisfaction was measured by the Patient Global Impression of Improvement (PGI-I). Fifty-three women underwent the procedure during the study period. Follow-up data were available for 48 women. The mean preoperative POP-Q Ba point was 2.7 ± 1.6 and C point was -0.8 ± 2.8. At a mean follow-up of 17.5 ± 16.0 months with a median of 12 months (range, 1-54 months), there was a significant improvement of POP-Q points Ba, C, and Bp (P < 0.001 for all comparisons). Anatomical cure, defined as no prolapse of any POP-Q point at or below 1 cm above the hymen (-1), was 85.4%. Clinical cure, defined as a composite outcome of no prolapse outside the hymen, C point above total vaginal length/2, no prolapse symptoms, and no need for further treatment, was 95.8%. At a mean of 22.2 ± 12.4 months postoperatively, patient satisfaction was high, with 95.5% stating their condition was very much better (PGI-I-A) or much better (PGI-I-B). Laparoscopic uterosacral ligament suspension is a valid uterine-preserving option for women with anterior and apical prolapse, with high anatomical and clinical cure rates and patient satisfaction.