Prolapse Repair Research Articles

The EnPlace® sacrospinous ligament fixation-A novel minimally invasive transvaginal procedure for apical pelvic organ prolapse repair: Safety and short-term outcome results.

The EnPlace® device is a novel minimally invasive tool allowing transvaginal sacrospinous ligament (SSL) fixation of apical pelvic organ prolapse (POP). The study aimed to investigate the safety and short-term efficacy of the EnPlace® SSL fixation for significant apical POP repair. A retrospective cohort study of 123 consecutive patients (mean age 64.4 ± 11.1 years) with stage III or IV apical POP who underwent SSL fixation by the EnPlace® device. Safety and 6-month outcome results were analyzed and compared between 91 (74%) patients with uterine prolapse versus 32 (26%) patients with vaginal vault prolapse. There were no intraoperative or early postoperative complications. The mean (± standard deviation) duration of surgery was 30 ± 6.9 min and mean blood loss was 30.5 ± 18.5 mL. The average position of point C by POP-Quantification measurements before surgery and at 6 months postoperatively was 4.5 ± 2.8 cm and -3.1 ± 3.3 cm, respectively. Of 91 patients with preoperative uterine prolapse, eight (8.8%) patients developed a recurrent uterine prolapse within 6 months postoperatively. Of 32 patients with preoperative vault prolapse, two patients (6.3%) had recurrent vault prolapse. Short-term outcome results of EnPlace® SSL fixation suggest that it is a safe and effective minimally invasive transvaginal procedure for significant apical POP repair.

Laparoscopic sacral colpopexy without the robot: Safe, effective and easier than you think

Objective:The purpose of the study is to evaluate the outcomes of laparoscopic sacral colpopexy operations performed by faculty and resident surgeons using simple laparoscopic suturing and tying techniques, and to compare those results with those reported by other institutions performing laparoscopic and robotic sacral colpopexy. Methods:This is a retrospective cohort study of 206 consecutive laparoscopic sacral colpopexy cases (with or without concomitant procedures) between October 2014 and July 2020. Laparoscopic sacral colpopexies were performed using a carefully selected set of instruments and techniques which are quickly mastered by trainees. Residents performed up to 50% of the work in each operation. Descriptive statistics were used to compare primary outcomes with published literature. Results:The average operative time was 153.3 minutes. The overall complication rate was 16.5%, including 3.4% cystotomy, 0.5% enterotomy, 0.5% small bowel obstruction, 2.4% mesh complications including erosion, detachment and removal. Most recent follow up occurred at a mean of 325.5 days (SD 397.9) and median of 183 days (IQR 48-471) postoperatively. Recurrent prolapse was noted in 6.3% of patients and 3.9% underwent a subsequent prolapse repair. These results compare favorably with those published by other institutions. Conclusion:Using simple suturing and tying techniques, laparoscopic sacral colpopexy can be performed without robotic assistance by a large portion of laparoscopically trained surgeons, including trainee co-surgeons. Significant cost savings accrue from the use of conventional laparoscopy in place of robotic technology. Residents can participate in laparoscopic sacral colpopexy cases with comparable operative times and favorable surgical outcomes.

Prolapse repair for aortic regurgitation in tricuspid aortic valves

ObjectiveCusp prolapse is an important cause of aortic regurgitation (AR) in tricuspid aortic valves (TAVs) and can be caused by myxomatous degeneration or cusp fenestration. Long-term data for prolapse repair in TAVs are scarce. We analyzed the results of aortic valve repair in patients with TAV morphology and AR caused by prolapse and compared the results for cusp fenestration and myxomatous degeneration. MethodsBetween October 2000 and December 2020, 237 patients (221 male; 15-83 years) underwent TAV repair for cusp prolapse. Prolapse was associated with fenestrations in 94 (group I) and myxomatous degeneration in 143 patients (group II). Fenestrations were closed using a pericardial patch (n = 75) or suture (n = 19). In myxomatous degeneration, prolapse was corrected by free margin plication (n = 132) or triangular resection (n = 11). Follow-up was 97% complete (cumulatively 1531, mean 6.5, median 5.8 years). Cardiac comorbidities were present in 111 patients (46.8%), and more frequent in group II (P = .003). ResultsTen-year survival was better in group I (I: 84.5%; II: 72.4%; P = .037), and patients without cardiac comorbidities (89.2% vs 67.0%; P = .002). Ten-year freedom from reoperation (P = .778), moderate or greater AR (P = .070), and valve-related complications (P = .977) were similar in both groups. AR at discharge was the only significant predictor for reoperation (P = .042). The type of annuloplasty did not affect repair durability. ConclusionsRepair of cusp prolapse in TAVs with preserved root dimensions can be performed with acceptable durability, even in the presence of fenestrations.

Comparison of Readmission Rates for Same-Day Versus Next-Day Discharge After Benign Vaginal Hysterectomy.

Same-day discharge (SDD) for laparoscopic hysterectomy is shown to be safe and acceptable, but data for vaginal hysterectomy (VH) are lacking. The aim of this study was to compare 30-day readmission rates, timing, and reasons for readmission for SDD versus next-day discharge (NDD) after VH. This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2019. Cases of VH with or without prolapse repair were identified by Current Procedural Terminology codes. The primary outcome was 30-day readmissions after SDD versus NDD. Secondary outcomes included reasons for and time to readmission and a subanalysis evaluating 30-day readmissions for those with prolapse repair. Unadjusted and adjusted odds ratios were determined using univariate and multivariate analyses. There were 24,277 women included; 4,073 (16.8%) were SDD. The 30-day readmission rate was low (2.0%; 95% confidence interval [CI], 1.8-2.2%), with no difference in odds of readmission for SDD versus NDD after VH in multivariate analysis (SDD adjusted odds ratio [aOR], 0.9; 95% CI, 0.7-1.2). Results were similar in our subanalysis of VH with prolapse surgery (SDD aOR, 0.94; 95% CI, 0.55-1.62). Median time to readmission was 11 days and did not differ (SDD interquartile range, 5, 16 [range, 0-29] vs NDD, 7, 16 [range, 1-30]; Z = -1.30; P = 0.193). The most common reasons for readmission were bleeding (15.9%), infection (11.6%), bowel obstruction (8.7%), pain (6.8%), and nausea/emesis (6.8%). Same-day discharge after VH did not have an increased odds of 30-day readmission compared with NDD. This study, with preexisting data, supports the practice of SDD after benign VH in low-risk patients.

Prediction of Pelvic Organ Prolapse Postsurgical Outcome Using Biomaterial-Induced Blood Cytokine Levels: Machine Learning Approach.

Pelvic organ prolapse (POP) refers to symptomatic descent of the vaginal wall. To reduce surgical failure rates, surgical correction can be augmented with the insertion of polypropylene mesh. This benefit is offset by the risk of mesh complication, predominantly mesh exposure through the vaginal wall. If mesh placement is under consideration as part of prolapse repair, patient selection and counseling would benefit from the prediction of mesh exposure; yet, no such reliable preoperative method currently exists. Past studies indicate that inflammation and associated cytokine release is correlated with mesh complication. While some degree of mesh-induced cytokine response accompanies implantation, excessive or persistent cytokine responses may elicit inflammation and implant rejection. Here, we explore the levels of biomaterial-induced blood cytokines from patients who have undergone POP repair surgery to (1) identify correlations among cytokine expression and (2) predict postsurgical mesh exposure through the vaginal wall. Blood samples from 20 female patients who previously underwent surgical intervention with transvaginal placement of polypropylene mesh to correct POP were collected for the study. These included 10 who experienced postsurgical mesh exposure through the vaginal wall and 10 who did not. Blood samples incubated with inflammatory agent lipopolysaccharide, with sterile polypropylene mesh, or alone were analyzed for plasma levels of 13 proinflammatory and anti-inflammatory cytokines using multiplex assay. Data were analyzed by principal component analysis (PCA) to uncover associations among cytokines and identify cytokine patterns that correlate with postsurgical mesh exposure through the vaginal wall. Supervised machine learning models were created to predict the presence or absence of mesh exposure and probe the number of cytokine measurements required for effective predictions. PCA revealed that proinflammatory cytokines interferon gamma, interleukin 12p70, and interleukin 2 are the largest contributors to the variance explained in PC 1, while anti-inflammatory cytokines interleukins 10, 4, and 6 are the largest contributors to the variance explained in PC 2. Additionally, PCA distinguished cytokine correlations that implicate prospective therapies to improve postsurgical outcomes. Among machine learning models trained with all 13 cytokines, the artificial neural network, the highest performing model, predicted POP surgical outcomes with 83% (15/18) accuracy; the same model predicted POP surgical outcomes with 78% (14/18) accuracy when trained with just 7 cytokines, demonstrating retention of predictive capability using a smaller cytokine group. This preliminary study, incorporating a sample size of just 20 participants, identified correlations among cytokines and demonstrated the potential of this novel approach to predict mesh exposure through the vaginal wall following transvaginal POP repair surgery. Further study with a larger sample size will be pursued to confirm these results. If corroborated, this method could provide a personalized medicine approach to assist surgeons in their recommendation of POP repair surgeries with minimal potential for adverse outcomes.

New native tissue repair for pelvic organ prolapse: Medium-term outcomes of laparoscopic vaginal stump-round ligament fixation.

Laparoscopic sacrocolpopexy for pelvic organ prolapse (POP) is a new and widely used approach; however, ever since the United States Food and Drug Administration warned against the use of surgical mesh, repairs performed using patients' tissues [i.e. native tissue repair (NTR)] instead of mesh have attracted much attention. At our hospital, laparoscopic sacrocolpopexy (the Shull method) was introduced in 2017. However, patients with more severe POP who have a long vaginal canal and overextended uterosacral ligaments may not be candidates for this procedure. To validate a new NTR treatment for POP, we examined patients undergoing laparoscopic vaginal stump-round ligament fixation (the Kakinuma method). The study patients were 30 individuals with POP who underwent surgery using the Kakinuma method between January 2020 and December 2021 and who were followed up for > 12 mo after surgery. We retrospectively examined surgical outcomes for surgery duration, blood loss, intraoperative complications, and incidence of recurrence. The Kakinuma method involves round ligament suturing and fixation on both sides, effectively lifting the vaginal stump after laparoscopic hysterectomy. The patients' mean age was 66.5 ± 9.1 (45-82) years, gravidity was 3.1 ± 1.4 (2-7), parity was 2.5 ± 0.6 (2-4) times, and body mass index was 24.5 ± 3.3 (20.9-32.8) kg/m2. According to the POP quantification stage classification, there were 8 patients with stage II, 11 with stage III, and 11 with stage IV. The mean surgery duration was 113.4 ± 22.6 (88-148) min, and the mean blood loss was 26.5 ± 39.7 (10-150) mL. There were no perioperative complications. None of the patients exhibited reduced activities of daily living or cognitive impairment after hospital discharge. No cases of POP recurrence were observed 12 mo after the operation. The Kakinuma method, similar to conventional NTR, may be an effective treatment for POP.

Statewide geographic variation in hysterectomy approach for pelvic organ prolapse: a county-level analysis

There are no definitive guidelines for surgical treatment of pelvic organ prolapse. Previous data suggests geographic variation in apical repair rates in health systems throughout the United States. Such variation can reflect lack of standardized treatment pathways. An additional area of variation for pelvic organ prolapse repair may be hysterectomy approach which could not only influence concurrent repair procedures, but also healthcare utilization. This study aimed to examine statewide geographic variation in surgical approach of hysterectomy for prolapse repair and concurrent use of colporrhaphy and colpopexy. We conducted a retrospective analysis of Blue Cross Blue Shield, Medicare, and Medicaid fee-for-service insurance claims for hysterectomies performed for prolapse in Michigan between October 2015 and December 2021. Prolapse was identified with International Classification of Disease Tenth Revision codes. The primary outcome was variation in surgical approach for hysterectomy as determined by Current Procedural Terminology code (vaginal, laparoscopic, laparoscopic assisted vaginal, or abdominal) on a county level. Patient home address zip codes were used to determine county of residence. A hierarchical multivariable logistic regression model with vaginal approach as the dependent variable and county-level random effects was estimated. Patient attributes, including age, comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, morbid obesity), concurrent gynecologic diagnoses, health insurance type, and social vulnerability index were used as fixed-effects. To estimate variation between counties in vaginal hysterectomy rates, a median odds ratio was calculated. There were 6974 hysterectomies for prolapse representing 78 total counties that met eligibility criteria. Of these, 2865 (41.1%) underwent vaginal hysterectomy, 1119 (16.0%) underwent laparoscopic assisted vaginal hysterectomy, and 2990 (42.9%) underwent laparoscopic hysterectomy. The proportion of vaginal hysterectomy across 78 counties ranged from 5.8% to 86.8%. The median odds ratio was 1.86 (95% credible interval, 1.33-3.83), consistent with a high level of variation. Thirty-seven counties were considered statistical outliers because the observed proportion of vaginal hysterectomy was outside the predicted range (as defined by confidence intervals of the funnel plot). Vaginal hysterectomy was associated with higher rates of concurrent colporrhaphy than laparoscopic assisted vaginal hysterectomy or laparoscopic hysterectomy (88.5% vs 65.6% vs 41.1%, respectively; P<.001) and lower rates of concurrent colpopexy (45.7% vs 51.7% vs 80.1%, respectively; P<.001). This statewide analysis reveals a significant level of variation in the surgical approach for hysterectomies performed for prolapse. The variation in surgical approach for hysterectomy may help account for high rates of variation in concurrent procedures, especially apical suspension procedures. These data highlight how geographic location may influence the surgical procedures a patient undergoes for uterine prolapse.

(144) Clitoral Anatomy and its Relation to Sexual Function after Apical Prolapse Repair using Pelvic MRI

Abstract Introduction The clitoris is the primary sexual organ involved in the physiological changes that occur during the female sexual response. Sparse research and contradictory evidence concerning clitoral anatomy and its role in female sexual function exist, especially in the context of pelvic floor disorders and their surgical correction. Comprehensive description of clitoral anatomy and how it relates to postoperative sexual function in women surgically treated for pelvic floor disorders is necessary to better understand the pathophysiological mechanisms of female sexual dysfunction following gynecologic surgery. Objective To identify characteristics of clitoral anatomy (size, location, shape) associated with female sexual function in women after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair, NTR) or transvaginal mesh (VM) hysteropexy for uterovaginal prolapse. We hypothesized that a smaller clitoris and clitoral components would correlate with poorer sexual function. Methods In this ancillary study of women enrolled in a randomized clinical trial, 30–42-month postoperative axial MRIs of 82 women surgically treated (41 NTR, 41 VM) were obtained at rest. The clitoral components (glans, body, crura) and vestibular bulbs were segmented to create 3D models of the “clitoral complex” (Figure 1). Using these models and computational morphometry, clitoral dimensions and position were computed with respect to a 3D pelvic coordinate system (Figure 2). After aligning, normalizing (scaling), and establishing corresponding points between models, statistical shape modeling was performed via Principal Component Analysis (PCA) to identify/quantify significant modes of anatomic variation of the clitoris. Participant data included demographics, medical history, sexual activity status, and Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). The relationships between clitoral measurements/shape and sexual function were evaluated using Spearman rank correlation. Results For this group of mostly postmenopausal women (80/82 [97.6%]), median (min-max) age was 65.3 (47-79), 15/82 (18.3%) were sexually active (SA), and 21/82 (25.6%) were not sexually active (NSA) postoperatively (46/82 [56.1%] did not respond). Among SA women, a smaller glans width correlated with overall poorer sexual function (lower PISQ-IR mean score) (r=0.74, p=0.002), frequent feelings of shame/fear with leakage of urine/stool during sex (r=0.69, p=0.004), and low sexual arousal (r=0.61, p=0.02). A smaller glans height correlated with dyspareunia (r=-0.64, p=0.02) and less intense orgasms postoperatively (r=0.64, p=0.01). A smaller glans volume correlated with low sexual arousal (r=0.60, p=0.02) and a clitoral complex farther away from participants’ midline (midsagittal plane) correlated with greater negative impact of incontinence/prolapse on sex life (r=-0.66, p=0.007). Among NSA women, a clitoris farther away from participants’ midline was associated with dyspareunia as a strong reason for sexual inactivity (r=0.49, p=0.03). From the PCA, 11 significant modes of shape variation were found. For SA women, Modes 5 and 8 correlated with leakage of urine/stool during sex (r=-0.65, p=0.009) and dyspareunia (r=-0.59, p=0.04), respectively (Figure 3). For NSA women, Mode 4 correlated with dyspareunia as a strong reason for sexual inactivity (r=0.46, p=0.04) (Figure 3). Conclusions Poorer sexual function was associated with a smaller clitoral glans (width, height, volume) among SA women and a clitoral complex positioned farther away from participants’ midline in SA and NSA women following prolapse surgery. Disclosure Yes, this is sponsored by industry/sponsor: Boston Scientific Clarification Industry funding only - investigator initiated and executed study

Study of Post-hysterectomy Vault Prolapse and Surgical Management.

To study the epidemiology and various methods of repair of vaginal vault prolapse in selected group of patients and the benefits of various modes of treatment in the management of vault prolapse. Thirty-seven patients with grade lll or lV vault prolapse were enrolled in our study. Sacrospinous fixation was performed in 37 patients. High risk factors for prolapse, surgical results and complications were evaluated. In the current study, maximum cases of vault prolapse, 67.6%, were in the age group of 51-60years. Out of 37 patients, 18.9% had a history of chronic cough secondary to bronchial asthma or past history of tuberculosis And 13.5% had a bowel dysfunction (chronic constipation). Vaginal vault prolapse most commonly was seen following vaginal hysterectomy (43.3%) as compared to total abdominal hysterectomy (29.7%). Most common surgery was performed for post-hysterectomy vault prolapse being sacrospinous fixation in the current study. In total, 29.7% of the patients had early post-operative complications like urinary tract infection (16.2%), urinary retention (5.4%) and buttock pain (5.4%), and 2.7% had vaginal cuff cellulitis. Dyspareunia is a common complication post-operatively following sacrospinous fixation, due to shortening of vaginal length post-procedure. Only 29.7% patients had complications, among which most common complication was urinary tract infection, which was treated with injectable antibiotics, urinary retention and buttock pain being the less common complication. Dyspareunia was present only in 18.9% cases post-operatively due to vaginal shortening associated with the procedure. Sacrospinous fixation is a safe and effective procedure. The online version contains supplementary material available at 10.1007/s13224-023-01757-9.

Intraoperative ultrasound assessment of ureteral patency after uterosacral ligaments apical suspension for prolapse surgical repair: A feasibility study.

To prospectively compare power Doppler ultrasound diagnostic performance with reference standard cystoscopy in evaluating ureteral patency in a population at high risk of ureteral lesions. We analyzed 100 women who underwent pelvic organ prolapse repair. All ultrasound scans were obtained, at the end of the procedures, before cystoscopic evaluation. Bilateral simultaneous ureteral jet evaluation with power Doppler was performed at the level of the ureterovesical junctions with a pulse repetition frequency set to detect low flow for a maximum of 3 min. According to the reference standard urethrocystoscopy, at least one ureter not ejaculating was observed in 6% of patients, for a total of seven ureters jets not visualized. No false-negative results were obtained. Ultrasound with power Doppler showed 100% sensitivity and 95.9% specificity in detecting the lack of ureteral jet. The negative predictive value was 100%, and the positive predictive value was 46.7%. Ultrasound with power Doppler represents an effective and reliable non-invasive screening test to exclude ureteral kinking and reduce the need for intraoperative cystoscopy.

Chordal force profile after neochordal repair of anterior mitral valve prolapse: An ex vivo study

ObjectiveThis study aimed to biomechanically evaluate the force profiles on the anterior primary and secondary chordae after neochord repair for anterior valve prolapse with varied degrees of residual mitral regurgitation using an ex vivo heart simulator. MethodsThe experiment used 8 healthy porcine mitral valves. Chordal forces were measured using fiber Bragg grating sensors on primary and secondary chordae from A2 segments. The anterior valve prolapse model was generated by excising 2 primary chordae at the A2 segment. Neochord repair was performed with 2 pairs of neochords. Varying neochord lengths simulated postrepair residual mitral regurgitation with regurgitant fraction at >30% (moderate), 10% to 30% (mild), and <10% (perfect repair). ResultsRegurgitant fractions of baseline, moderate, mild, and perfect repair were 4.7% ± 0.8%, 35.8% ± 2.1%, 19.8% ± 2.0%, and 6.0% ± 0.7%, respectively (P < .001). Moderate had a greater peak force of the anterior primary chordae (0.43 ± 0.06 N) than those of baseline (0.19 ± 0.04 N; P = .011), mild (0.23 ± 0.05 N; P = .041), and perfect repair (0.21 ± 0.03 N; P = .006). In addition, moderate had a greater peak force of the anterior secondary chordae (1.67 ± 0.17 N) than those of baseline (0.64 ± 0.13 N; P = .003), mild (0.84 ± 0.24 N; P = .019), and perfect repair (0.68 ± 0.14 N; P = .001). No significant differences in peak and average forces on both primary and secondary anterior chordae were observed between the baseline and perfect repair as well as the mild and perfect repair. ConclusionsModerate residual mitral regurgitation after neochord repair was associated with increased anterior primary and secondary chordae forces in our ex vivo anterior valve prolapse model. This difference in chordal force profile may influence long-term repair durability, providing biomechanical evidence in support of obtaining minimal regurgitation when repairing mitral anterior valve prolapse.

PROMIS pain intensity and interference after pelvic organ prolapse surgery.

Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires provide valid comparisons across disciplines. Pain measures can be used to track functional outcomes. Limited PROMIS pain data exist in gynecological surgery. We sought to use pain intensity and pain interference short forms to assess pain and recovery after pelvic organ prolapse surgery. The PROMIS pain intensity and pain interference questionnaires were given to patients undergoing uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF) or minimally invasive sacrocolpopexy (MISC) at baseline, 1 week, and 6 weeks postoperatively. Clinical minimally important change was defined as a difference of 2-6T-score points. Mean pain intensity and pain interference T-scores were compared at baseline, 1 week and 6 weeks with ANOVA. Multiple linear regression assessed 1-week scores adjusted for apical suspension type, advanced prolapse, concurrent hysterectomy, concurrent anterior or posterior repair, and concurrent sling. At 1 week, all apical suspension groups showed minimally important change in pain intensity and pain interference T-scores. Between groups at 1 week, pain interference was higher in USLS (66.3±6.6) and MISC (65.5±5.9) than in SSLF (59.2±9.8), p=0.01. Multiple linear regression showed an association of hysterectomy with increases in pain intensity and pain interference. USLS had a higher proportion of concurrent hysterectomy (100%) than SSLF (0%) and MISC (30.8%), p<0.01. No difference was found based on apical suspension type alone. No differences were found in PROMIS pain intensity and pain at 1week postoperatively after apical suspension procedures.

From thigh to pelvis: female genital prolapse repair with an autologous semitendinosus tendon transplant

Introduction and hypothesisThe use of synthetic mesh for prolapse and incontinence surgery is discussed controversially and in several countries is either no longer used or permissible. Previous approaches with autologous tissue did not show from a patient´s perspective convincing long-term results. As there have been repeatedly significant complications with synthetic mesh, a new approach is urgently needed.During orthopedics and trauma surgeries, tendons from the thigh have been used for decades to replace cruciate ligament. The procedure of tendon removal from the thigh is fast, easy to learn and morbidity is low. In addition, a long-term durability of the transplant ought to be expected. The objective of this investigation was to show our experience with a semitendinosus tendon instead of a mesh for genital prolapse repair.MethodAfter the first successful attempts using such tendons in cervicosacropexy and pectopexy in patients with genital prolapse, we initiated a national multicenter study in 2020. Five German hospitals participated in order to determine the feasibility of cervicosacropexy with tendon tissue instead of mesh.ResultUp until now, we have operated and observed 113 patients for at least 6 months and have seen stable results in terms of fixation of the apical compartment. The expected low morbidity at the donor site was also confirmed through subjective assessment of the patients (Knee and Osteoarthritis Outcome Score). Improvement of quality of life was confirmed after the procedure with the Short Form Health Survey 12, Version 2.0. The results of this multicenter study showed that the desired elevation of the apical compartment with tendon tissue can be achieved with low morbidity and without a synthetic mesh.ConclusionWomen with uterine prolapse can be treated minimally invasively and with very low morbidity by using the semitendinosus tendon. The involvement of multiple (five) medical centers confirms that the technique is easy to learn and be transferred to other clinical centers.

Effects of topical dehydroepiandrosterone therapy in women after pelvic organ prolapse surgery.

Pelvic organ prolapse (POP) occurs predominantly in postmenopausal women. Restoration of the proper estrogenization of vaginal mucosa is important in preoperative and postoperative treatment, increasing the effectiveness of this approach. The objective of this study was the development of intravaginal vaginal suppositories containing DHEA and comparison of the clinical effects of vaginal topical therapy with DHEA, estradiol, or antibiotic after POP surgery. Nine types of vaginal suppositories containing 6.5 mg DHEA in different bases were prepared to find optimal formulation for the vaginal conditions. Ninety women referred for POP surgery were randomly assigned to one of three groups receiving topical treatment in the postoperative period (estradiol, DHEA, or antibiotic). On admission to hospital and during follow-up vaginal pH, vaginal maturation index and vaginal symptoms were assessed. Vaginal suppositories with the base made from polyethylene glycol 1,000 without surfactants characterized the highest percentage of the released DHEA. In women treated with topical estradiol or DHEA a significant decrease in the number of parabasal cells, increase in superficial and intermediate cells in the vaginal smears, decrease in vaginal pH, and reduction of vaginal symptoms were observed. The use of topical therapy with DHEA or the use of topical therapy with estradiol in the postoperative period were both shown to improve maturation index, vaginal pH, and vaginal symptoms. The benefits of topical therapy with DHEA after pelvic organ prolapse repair brings similar results as estradiol, without potential systemic exposure to increased concentrations of sex steroids above levels observed in postmenopausal women.

Rectal Prolapse Following Repair of Anorectal Malformation: Incidence, Risk Factors, and Management

BackgroundThe incidence and optimal management of rectal prolapse following repair of an anorectal malformation (ARM) has not been well-defined. MethodsA retrospective cohort study was performed utilizing data from the Pediatric Colorectal and Pelvic Learning Consortium registry. All children with a history of ARM repair were included. Our primary outcome was rectal prolapse. Secondary outcomes included operative management of prolapse and anoplasty stricture following operative management of prolapse. Univariate analyses were performed to identify patient factors associated with our primary and secondary outcomes. A multivariable logistic regression was developed to assess the association between laparoscopic ARM repair and rectal prolapse. ResultsA total of 1140 patients met inclusion criteria; 163 (14.3%) developed rectal prolapse. On univariate analysis, prolapse was significantly associated with male sex, sacral abnormalities, ARM type, ARM complexity, and laparoscopic ARM repairs (p < 0.001). ARM types with the highest rates of prolapse included rectourethral-prostatic fistula (29.2%), rectovesical/bladder neck fistula (28.8%), and cloaca (25.0%). Of those who developed prolapse, 110 (67.5%) underwent operative management. Anoplasty strictures developed in 27 (24.5%) patients after prolapse repair. After controlling for ARM type and hospital, laparoscopic ARM repair was not significantly associated with prolapse (adjusted odds ratio (95% CI): 1.50 (0.84, 2.66), p = 0.17). ConclusionRectal prolapse develops in a significant subset of patients following ARM repair. Risk factors for prolapse include male sex, complex ARM type, and sacral abnormalities. Further research investigating the indications for operative management of prolapse and operative techniques for prolapse repair are needed to define optimal treatment. Type of studyRetrospective cohort study. Level of evidenceII.

Posterior rectus fascia prolapse (PREFAP) repair: a new native tissue approach to pelvic organ prolapse via vaginal natural orifice transluminal endoscopic surgery.

Pelvic organ prolapse (POP) is a common condition in women. During lifetime, up to 40% of all women will develop (POP). Between June and December 2021, five patients were successfully treated via vNOTES Posterior Rectus Fascia Prolapse ( PREFAP) repair. No intra-operative complications or conversions occurred. In this study we demonstrated a new technique for prolapse repair, harvesting the autologous posterior rectus fascia sheath via vaginal natural orifice transluminal endoscopic surgery (vNOTES) as an alternative for a synthetic mesh.

Knowledge mapping and visualization analysis of pelvic organ prolapse repair with mesh from 2001 to 2021.

Aims: In recent decades, extensive attention has been paid to the application of mesh to repair pelvic floor defects. However, a large body of related literature has not been system summarized. The purpose of this study is to summarize and visualize the literature on pelvic organ prolapse (POP) repair with mesh using bibliometrics. Methods: Medical literature regarding POP repair with mesh were searched and obtained in the Web of Science™ Core (WoSCC) database from 2001 to 2021. Microsoft Excel 2020, CiteSpace and VOSviewer were used to conduct the bibliometric and knowledge-map analysis. Results: In the past 20 years, a total of 2,550 articles and reviews have been published in 35 journals, and the published and cited results show a growing trend. Cosson M and International Urogynecology Journal were the authors and journals with the highest output, respectively. The United States, France and the United Kingdom are among the top three countries/organizations in relevant publications in worldwide. 584 key words in the literature are divided into 8 clusters, which are mainly related to prolapse type, risk factors, surgical methods, imaging, quality of life and bioengineering. Using clinical research and tissue engineering technology to reduce mesh complications is the current hot spot in this field. Conclusion: Reasonable application of mesh and avoiding mesh complications are still the most concerned topics in POP research. Although clinical research, surgical improvement, biological mesh and bioengineering technology have shown promising results, it is still urgent to carry out clinical transformation application research.

V12-11 ROBOTIC SACROHYSTEROPEXY WITH CONCURRENT RECTOPEXY USING FASCIA LATA GRAFT

You have accessJournal of UrologyCME1 Apr 2023V12-11 ROBOTIC SACROHYSTEROPEXY WITH CONCURRENT RECTOPEXY USING FASCIA LATA GRAFT Poone Shoureshi, Alexandra Dubinskaya, David Magner, and Karyn S. Eilber Poone ShoureshiPoone Shoureshi More articles by this author , Alexandra DubinskayaAlexandra Dubinskaya More articles by this author , David MagnerDavid Magner More articles by this author , and Karyn S. EilberKaryn S. Eilber More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003347.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Sacrohysteropexy with concurrent rectopexy can be performed in women of childbearing age, with multicompartment prolapse, who wish to preserve their uterus. There is limited data regarding the use of mesh for prolapse repair in this population, therefore a biologic graft is often used to decrease the risk of contamination with colorectal surgery and allow for future pregnancy. We present the surgical management of prolapse repair in a young woman who presented with uterine and rectosigmoid prolapse, causing rectal outlet obstruction. METHODS: Our patient is a 21-year-old woman with over a decade of severe constipation and abdominal pain. Her past medical history includes anxiety, depression and sexual abuse. She previously underwent robotic rectopexy for intra-rectal intussusception and mucosal prolapse with immediate improvement in her symptoms; however, two months after rectopexy, she suffered from persistent abdominal pain and severe difficulty passing stool. Dynamic resonance imaging demonstrated descent of the bladder with significant uterine prolapse, causing impingement of rectum and rectocele, blocking the evacuation of stool. The patient was thus indicated for concurrent sacrohysteropexy and rectopexy. RESULTS: She underwent a robotic procedure. Given the patient’s age, in an effort to preserve future child-bearing potential, we elected to perform the surgery with a biologic graft made of fascia lata. The sacrohysteropexy was performed by suturing the graft to the posterior cervix. Intraoperatively she was noted to have an intact enterocele repair and posterior rectopexy from her previous surgery; however, the rectosigmoid attachment appeared to have stretched, creating an angulation at the rectosigmoid. This was corrected by performing a rectopexy to the fascia lata graft. The patient was discharged home the day of surgery without incident. CONCLUSIONS: Biologic grafts can be used for multicompartment prolapse repair in women of child-bearing age. Fascia lata provides a safe alternative to mesh to allow for future pregnancy. Also, sacrohysteropexy with concurrent rectopexy can be performed with same day discharge. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1068 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Poone Shoureshi More articles by this author Alexandra Dubinskaya More articles by this author David Magner More articles by this author Karyn S. Eilber More articles by this author Expand All Advertisement PDF downloadLoading ...

MP07-06 TWELVE YEAR EXPERIENCE WITH SALVAGE ROBOTIC SACROCOLPOPEXY. SURGICAL TECHNIQUE AND REASONS FOR FAILURE IN THE INITIAL SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP07-06 TWELVE YEAR EXPERIENCE WITH SALVAGE ROBOTIC SACROCOLPOPEXY. SURGICAL TECHNIQUE AND REASONS FOR FAILURE IN THE INITIAL SURGERY Cassandra Schuster, Spencer Kortum, Benjamin Behers, Genesis Dolgetta, Karim Ghazli, Victoria Bird, and Robert Carey Cassandra SchusterCassandra Schuster More articles by this author , Spencer KortumSpencer Kortum More articles by this author , Benjamin BehersBenjamin Behers More articles by this author , Genesis DolgettaGenesis Dolgetta More articles by this author , Karim GhazliKarim Ghazli More articles by this author , Victoria BirdVictoria Bird More articles by this author , and Robert CareyRobert Carey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic sacrocolpopexy (RASCP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that reliably provides durable repair of high grade prolapse. Although reoperation for recurrent prolapse after RASCP should be a rare event, the techniques and problems associated with robotic salvage in these cases is under reported. METHODS: Data is collected from an IRB-approved prospectively maintained database of robotic POP repair in a tertiary care hospital. The surgery is performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port by a single surgeon. Commercially available 4×24 cm Y-shaped wide pore polypropylene mesh is modified to accommodate the anterior and posterior dissections of the vaginal walls and these are attached with running barbed suture with 16-20 sites of fixation. The long Y-arm of the mesh is trimmed to size for attachment to the anterior longitudinal ligament with GoreTex sutures. Posterior peritoneal flaps are created and the entirety of the mesh and repair is completely covered by peritoneum. No mesh or suture is left exposed. Mid-urethral slings were placed at the time of salvage RASCP (sRASCP) to prevent de novo stress incontinence. All repairs restored maximal vaginal length and desired vaginal axis. All patients for RASCP had stage 4 prolapse. There were no conversions from robotic to open. RESULTS: Between 2010 and 2022, a total of 450 patients underwent RASCP at the same institution. 8 (1.8%) were done in the salvage setting with a previous attempt at open or RASCP performed and pre-existing mesh inside the abdomen. On reoperation for these RASCP patients for the purpose of salvage, 8/8 (100%) were found to have no connectivity of the mesh to the anterior longitudinal ligament (ALL). 4/8 (50%) had no connectivity to the either the anterior or posterior vaginal vault. Mean age at salvage operation was 69.5 years and mean BMI 28.5. Cases were completed with robotic console time between 105 and 123 minutes. CONCLUSIONS: sRASCP is a safe and durable surgery for repair of prolapse in the setting of a failed first attempt of RASCP with pre-existing mesh. Every case achieved excellent repair of prolapse. The most common finding is these cases was non-attachment of the mesh to the ALL. All patients required dissection of the ALL for appropriate mesh attachment. Pre-existing mesh can be used to help in repair as long as there is appropriate attachment to the vaginal vault. Pre-existing mesh should be excised if there is no useful vaginal or ALL attachment. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e86 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassandra Schuster More articles by this author Spencer Kortum More articles by this author Benjamin Behers More articles by this author Genesis Dolgetta More articles by this author Karim Ghazli More articles by this author Victoria Bird More articles by this author Robert Carey More articles by this author Expand All Advertisement PDF downloadLoading ...

MP07-07 ROBOTIC SACROCOLPOPEXY WITH UTERUS PRESERVATION: SURGICAL TECHNIQUE AND 12 YEAR EXPERIENCE FOR WOMEN WITH COMPLETE VAGINAL VAULT EVERSION

You have accessJournal of UrologyCME1 Apr 2023MP07-07 ROBOTIC SACROCOLPOPEXY WITH UTERUS PRESERVATION: SURGICAL TECHNIQUE AND 12 YEAR EXPERIENCE FOR WOMEN WITH COMPLETE VAGINAL VAULT EVERSION Cassandra Schuster, Benjamin Behers, Spencer Kortum, Genesis Dolgetta, Karim Ghazli, Victoria Bird, and Robert Carey Cassandra SchusterCassandra Schuster More articles by this author , Benjamin BehersBenjamin Behers More articles by this author , Spencer KortumSpencer Kortum More articles by this author , Genesis DolgettaGenesis Dolgetta More articles by this author , Karim GhazliKarim Ghazli More articles by this author , Victoria BirdVictoria Bird More articles by this author , and Robert CareyRobert Carey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic sacrocolpopexy with uterus preservation (RASCP-UP) is a transabdominal approach for repair of pelvic organ prolapse (POP) that avoids placement of transvaginal mesh and preserves female sexual organs. Although hysterectomy may be performed at the time of POP repair, many women choose to preserve their uterus for reasons of sexuality, female identity, religion, maintenance of maximal vaginal length and undisturbed vaginal blood supply, and resistance to removal of a normal organ. METHODS: Data was collected from an IRB-approved prospectively maintained database of robotic POP repair in a tertiary care hospital. The surgery is performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port. Commercially available 4×24 cm Y-shaped wide pore polypropylene mesh is modified to accommodate >10 cm anterior and posterior dissections of the vaginal walls. The anterior vaginal wall component is brought through the broad ligament and joined with the posteriorly placed component for attachment to the anterior longitudinal ligament with GoreTex sutures. The mesh is then completely covered by peritoneum. Mid-urethral slings were placed at the time of sacrocolpopexy to prevent de novo stress incontinence. All patients for RASCP-UP had stage 4 prolapse with maximal anterior, posterior, and apical descent with the cervix at the apex of the descent. All patients had normal Pap smears and pelvic ultrasounds. RESULTS: Between 2010 and 2022, a total of 450 patients underwent RASCP at the same institution. Of these, 65 presented with complete vaginal vault eversion requesting RASCP-UP. Mean age was 65.9 years and mean BMI 28.0. Cases were completed with robotic console time between 59 and 123 minutes and all patients discharged within 24-48 hours. At mean 78-month (12 – 140 month) follow-up, there were no mesh erosions, hernias, or reoperations for prolapse. There was one reoperation for hysterectomy at 6 year follow up for suspected endometrial carcinoma and two reoperations for small bowel obstruction in patients with extensive lysis of adhesions. CONCLUSIONS: RASCP-UP is feasible for patients with severe POP who desire uterus preservation. The surgery restores normal vaginal axis and length without placement of mesh material through vaginal mucosa. Long-term results show durable functional repair. Women presenting with vaginal vault eversion and maximal descent of cervix can undergo repair of pelvic floor prolapse with concomitant hysterectomy. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e86 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassandra Schuster More articles by this author Benjamin Behers More articles by this author Spencer Kortum More articles by this author Genesis Dolgetta More articles by this author Karim Ghazli More articles by this author Victoria Bird More articles by this author Robert Carey More articles by this author Expand All Advertisement PDF downloadLoading ...