Pelvic Organ Prolapse Repair Research Articles

Harvest of large fascia lata autograft: Outcomes in 108 patients.

Due to the reclassification of transvaginal mesh as a high-risk device, there has been renewed interest in the use of fascia lata in pelvic floor reconstruction. Here we report our experience in 108 patients who underwent large fascia lata harvest for pelvic organ prolapse (POP) repair. Our primary objective was to highlight the postoperative morbidity of the large fascia lata harvest in patients who underwent POP repair using fascia lata autograft. Surgery involved harvesting a fascia lata graft through a small lateral upper thigh incision and was used for either autologous transvaginal POP repair or autologous sacrocolpopexy. To prevent seroma, a temporary Jackson-Pratt drain was intraoperatively placed and a mild compression wrap was applied to the area for 4-6 weeks postoperatively. Patient demographics were obtained preoperatively, while physical exam findings and postoperative outcomes related to the fascia lata harvest were collected at sequential follow up visits. One-hundred eight patients underwent 111 large fascia lata harvests for either transvaginal or abdominal/robotic POP repair from July 2016 to January 2022. Mean follow-up was 19.6 months (range: 1-65) with 38 patients having 24 months or more of follow-up. Mean Visual Analog Pain (VAP) score was 1 (range: 0-10). Sixteen patients developed asymptomatic thigh bulges, 16 patients developed harvest site seromas (of which 14 resolved), and 59 patients experienced mild, non-bothersome paresthesia near the incision. Large fascia lata harvest offers a robust autograft for transvaginal or transabdominal POP repair with minimal morbidity. Harvest site complications are minor and typically resolve with expectant management. This technique can be safely utilized in patients who desire graft-augmented repair of POP without the use of synthetic mesh, allograft, or xenograft.

Resolution of Overactive Bladder Symptoms After Anterior and Apical Prolapse Repair.

Patients often present with both overactive bladder (OAB) and pelvic organ prolapse (POP) concerns. It is unknown whether treatment of POP improves OAB. This study aimed to evaluate whether OAB improves after anterior/apical POP repair for anterior wall prolapse. This was a prospective study of women with anterior/apical prolapse at or beyond the hymen and concomitant OAB symptoms, undergoing apical repair. Overactive bladder severity was evaluated with the Urogenital Distress Inventory-6 (UDI-6) questionnaire and the Incontinence Impact Questionnaire-7 preoperatively and 2, 6, 12, and 24 weeks postoperatively. The primary outcome was a reduction of ≥11 points or greater on the UDI-6 at 6 months. Those who reported an ≥11-point reduction were termed responders. Multivariable regression analyses were performed to evaluate factors associated with reduction in OAB symptoms after POP surgery. A total of 117 patients met the criteria for analysis, with 79.5% reporting improved OAB symptoms after POP repair at 6 months. There were no preoperative differences between groups. The mean preoperative UDI-6 and Incontinence Impact Questionnaire-7 scores were higher in the responder group (51.1 ± 16.8 vs 26.4 ± 15.1 [P < 0.001] and 44.6 ± 23.8 vs 22.8 ± 21.4 [P = 0.001], respectively), and the presence of detrusor overactivity was lower (29.0% vs 54.2%, P = 0.02). After regression, a higher preoperative UDI-6 total was associated with an increased likelihood of symptom improvement at 6 months (adjusted odds ratio, 1.14 per point [1.08-1.19]), whereas detrusor overactivity on preoperative urodynamics was associated with a decreased likelihood of OAB symptom improvement (adjusted odds ratio, 0.10 [0.02-0.44]). Overactive bladder symptoms improve in the majority of patients undergoing apical repair for anterior/apical prolapse beyond the hymen.

How Old Is Too Old? Outcomes of Prolapse Native-Tissue Repair through Uterosacral Suspension in Octogenarians.

Medical advancements are expected to lead to a substantial increase in the population of women aged 80 and older by 2050. Consequently, a significant number of individuals undergoing corrective prolapse surgery will fall into the elderly-patient category. The research indicates a notable rise in complications associated with prolapse surgery in patients older than 80, irrespective of frailty and other risk factors. Despite these challenges, the vaginal approach has been identified as the safest surgical method for pelvic organ prolapse (POP) repair in the elderly population. For this reason, we aimed to investigate the efficacy, complication rate, and functional outcomes associated with vaginal hysterectomy and an apical suspension/high uterosacral ligaments suspension as a primary technique for prolapse repair, both within a cohort of elderly patients. We retrospectively analyzed patients who underwent transvaginal hysterectomy plus an apical suspension procedure for stage ≥ II and symptomatic genital prolapse between January 2006 and December 2013. Anatomical and functional outcomes were evaluated. The Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. Sixty-five patients were included in the analysis. The median age was 81.3 years. All individuals exhibited an anterior compartment prolapse stage II or higher, and the majority also a central prolapse stage II or higher. Notably, all participants reported symptoms of vaginal bulging. Over half of the population (58.6%) complained of incomplete bladder emptying. The intervention for all participants involved a vaginal hysterectomy with an apical suspension. Sixty-three patients (96.9%) and forty-four patients (67.6%) underwent a simultaneous anterior or posterior repair, respectively. Long-term complications (>30 days from surgery) were observed during follow-up, with a median duration of 23 ± 20 months. Seven (10.7%) anatomical recurrences were recorded, five (7.69%) concerning the anterior compartment, one (1.5%) the central, and three (4.6%) the posterior. Nevertheless, none of them necessitated further surgical intervention due to symptoms. Significant anatomical improvements for the anterior, central, and posterior compartments were noticed, compared to preoperative assessment (p < 0.001 for Aa and Ba, p < 0.001 for Ap and Bp, and p < 0.001 for C). PGI-I values established that 100% of patients were satisfied (PGI-I ≥ 2), with a median score of 1.12. Consequently, objective and subjective cure rates were 89.5% and 100%, respectively. Vaginal hysterectomy combined with apical suspension, particularly high uterosacral ligaments suspension, is a safe and effective primary surgical approach, even in elderly patients.

Enhanced recovery after surgery (ERAS) in prolapse repair: A prospective study on pre-emptive uterosacral/cervical block.

Enhanced recovery after surgery (ERAS) protocols have been introduced in gynecology. Postoperative pain management after vaginal procedures remains a relevant issue. In the present study we aimed to evaluate the effectiveness of pre-emptive uterosacral/cervical block (PUCB) for postoperative pain control in patients with uterovaginal prolapse undergoing vaginal hysterectomy and pelvic floor repair. We also evaluated the impact on the length of recovery. This was a pilot study analyzing 40 women who underwent pelvic organ prolapse repair through uterosacral ligament suspension. Patients who chose to undergo PUCB were considered as cases, otherwise as controls. After general or spinal anesthesia induction, the treatment group received the PUCB with ropivacaine plus clonidine injections at 2, 4, 8, and 10 o'clock of the cervix. The control group did not receive additional treatment. Pain intensity was measured at rest and after forceful cough at 1, 4, 8, 12, 24, and 48 h postoperatively. We found a significant reduction in pain values at 1 h (rest and forceful cough) and 24 h (forceful cough) in the PUCB group. The incidence of moderate/severe pain was inferior in the PUCB group at 1 h (rest) and 24 h (rest and forceful cough). There were no differences in terms of the use of rescue opioids (0% vs. 5%; P = 0.311) and length of hospital stay (2.5 ± 0.6 vs. 2.3 ± 0.6; P = 0.180). For the first time, we demonstrated the impact of pre-emptive uterosacral/cervical block on pain control up to 24 h after surgery. Clonidine as a sensory blockade extender appears promising in enhancing the efficacy of local anesthetics.

Retrospective analysis of the efficacy and safety of polyacrylamide hydrogel (Bulkamid®) peri-urethral bulking injection at the time of pelvic floor repair in women with pelvic organ prolapse and urodynamic stress incontinence.A pilot study

Aims:Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common conditions that often co-exist. One way of managing women with both conditions is to perform a combined surgical approach with a tension-free vaginal tape (TVT) placed at the time of pelvic floor repair. Raised awareness of complications associated with mesh in the UK has led to a pause in TVT procedures meaning there is no widely available one-step surgical procedure for these patients. We aim to investigate whether peri-urethral bulking with polyacrylamide hydrogel (Bulkamid®) performed at the time of pelvic floor repair is a safe procedure and whether it improves stress urinary incontinence. Methods:Validated questionnaires (ICIQ-UI-SF and ICIQ-VS) were completed by women undergoing peri-urethral bulking alone for stress urinary incontinence (SUI), and women undergoing concomitant pelvic floor repair and peri-urethral bulking for POP and SUI. The scores from questionnaires pre- and post-operatively, and any surgical complications were documented and compared. Results:Both control and study groups showed overall improvement in continence scores with the average improvement in the study group being 7.24 and in the control group being 4.73. Statistical analysis showed that the difference in ICIQ-UI SF scores between the two groups was not statistically significant) (p = 0.059). Using the global impression questionnaire, 80% of women from the study group and 65.4% in the control group reported improvement in their incontinence symptoms. Conclusion:Peri-urethral bulking performed at the time of pelvic floor repair improves urinary symptoms and is a safe procedure.

The effect of advanced age on peri- and post-operative complications following pelvic floor repair surgeries.

To assess whether advanced age is a risk factor for complications following pelvic organ prolapse (POP) repair surgeries using the Clavien-Dindo classification system. In this retrospective cohort study, 260 women who had undergone POP repair surgery at the Soroka University Medical Center (SUMC) between the years 2014-2019 were included. A univariate analysis was conducted to compare the demographical, clinical, obstetrical and operative characteristics of patients by age group (younger or older than 70years). We performed a similar analysis to assess for the possible association between several variables and post-operative complications. Variables that were found to be associated with post-operative complications (P < 0.2) were included in a multivariate analysis along with advanced age. During the 12months follow-up period, more than half of the women had experienced at least one post-operative complication. Minor complications (grades 1-2 according to the Clavian-Dindo classification system) were the most common. One woman had died during the follow-up period, and none had experienced organ failure (grade 4). Hysterectomy, as part of POP surgery, was found to be significantly associated with post-operative complications. Additionally, grandmultiparity (> 5 births) showed a tendency towards an increased risk for post-operative complications, however this reached only borderline significance. We found no association between advanced age and post-operative complications. POP repair surgeries are safe for women of all ages. Major complications (grades 3-5) are rare in all age groups. Although advanced age was associated with a higher prevalence of comorbidity and a higher grade of prolapse, no significant difference in the post-operative complications was found between age groups. Concomitant hysterectomy at the time of POP repair surgery is a risk factor for post-operative complications.

Evaluation of Outcomes Between the Top-down Versus the Bottom-up Approach for Retropubic Midurethral Sling

Introduction and hypothesisRetropubic midurethral sling (MUS) placement is the gold standard for the treatment of stress urinary incontinence in the USA. The procedure can be approached from either a top-down or a bottom-up direction, but there is a paucity of contemporary data regarding outcomes between these approaches. The aim of this study was to provide updated clinical outcomes data.MethodsThis was a retrospective cohort study of women undergoing the retropubic MUS procedure alone or at the time of pelvic organ prolapse repair between 2010 and 2020 at a single academic medical center. The electronic medical record was used to extract demographic data, operative approach, and perioperative complications. The primary outcome was a composite incidence of any perioperative complication.ResultsOf the 309 patients analyzed, 140 (45.3%) underwent top-down and 169 (54.7%) underwent bottom-up retropubic MUS placement. Patients undergoing top-down MUS placement were more likely to be older (mean age 58 vs 54, p=0.02), have a history of diabetes mellitus (20% vs 8.9%, p=0.004), and have had a prior hysterectomy (27% vs 16%, p=0.02). They were less likely to have a concurrent anterior (p<0.001) or posterior repair (p<0.001). Patients undergoing the top-down procedure were less likely to experience sling exposure (p=0.02); complications in the two groups were otherwise similar.ConclusionsThe top-down approach to retropubic MUS placement was associated with lower rates of mesh erosion in this population of patients. Neither approach is associated with an increased overall risk of complications or de novo overactive bladder symptoms.

Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis.

To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes. PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared. In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted. Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39). Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair. PROSPERO CRD42022326255.

Analysis of British Columbia practice patterns in the management of female stress urinary incontinence with emphasis on mesh use.

Female stress urinary incontinence (SUI) is common and has a profound impact on quality of life. Suburethral slings are the most common treatment for SUI in this population. These can be placed with synthetic mesh or autologous fascia. Mesh-related complications after midurethral sling procedures are documented in the literature but the risk of complications and reoperation is lower than the use of transvaginal mesh for pelvic organ prolapse repair. In this study, we sought to evaluate local practice patterns of management of female SUI with specific emphasis on mesh use. A survey created by an expert panel was disseminated to respective provincial societies. Sixty-eight percent of respondents offer midurethral slings in their practice but only 60.6% of these respondents would offer surgical removal of the sling if there were complications, such as mesh erosion or pain. A large portion (39.4%) of respondents are performing transobturator slings as compared to retropubic midurethral slings (36.3%) and only 8.5% have removed the leg component associated with the transobturator sling in their practice. Furthermore, compared to most respondents offering midurethral slings (64.8%), only a minority of surgeons offer alternatives: 23.9% of respondents offer periurethral bulking agent injections, 15.5% offer pubovaginal slings, and 12.7% offer retropubic urethropexies. Our study supports that surgeons should continue to review surgical risks and alternative treatment options as part of the surgical consent process. As such, surgeons should be able to offer a variety of surgical approaches to manage female SUI.

Clinician perspectives on hysterectomy versus uterine preservation in pelvic organ prolapse surgery: A systematic review and meta-analysis.

Previous reviews on hysterectomy versus uterine-sparing surgery in pelvic organ prolapse (POP) repair did not consider that the open abdominal approach or transvaginal mesh use have been largely abandoned. To provide up-to-date evidence by examining only studies investigating techniques currently in use for POP repair. MEDLINE and Embase databases were searched from inception to January 2023. We included randomized and non-randomized studies comparing surgical procedures for POP with or without concomitant hysterectomy. Studies describing open abdominal approaches or transvaginal mesh implantation were excluded. A random effect meta-analysis was conducted on extracted data reporting pooled mean differences and odds ratios (OR) between groups with 95% confidence intervals (CI). Thirty-eight studies were included. Hysterectomy and uterine-sparing procedures did not differ in reoperation rate (OR 0.93; 95% CI 0.74-1.17), intraoperative major (OR 1.34; 95% CI 0.79-2.26) and minor (OR 1.38; 95% CI 0.79-2.4) complications, postoperative major (OR 1.42; 95% CI 0.85-2.37) and minor (OR 1.18; 95% CI 0.9-1.53) complications, and objective (OR 1.38; 95% CI 0.92-2.07) or subjective (OR 1.23; 95% CI 0.8-1.88) success. Uterine preservation was associated with a shorter operative time (-22.7 min; 95% CI -16.92 to -28.51 min), shorter hospital stay (-0.35 days, 95% CI -0.04 to -0.65 days), and less blood loss (-61.7 mL; 95% CI -31.3 to -92.1 mL). When only studies using a laparoscopic approach for both arms were considered, no differences were observed in investigated outcomes between the two groups. No major differences were observed in POP outcomes between procedures with and without concomitant hysterectomy. The decision to preserve or remove the uterus should be tailored on individual factors.

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

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

Pelvic floor reconstruction-update 2024: prolapse-associated symptoms and their treatment

Pelvic organ prolapse (POP) and associated symptoms of urinary incontinence, fecal incontinence, obstructive micturition, defecation, and pain are frequent and awidespread disease with relevant reduction of quality of life and high costs. New insights into functional anatomy and pathophysiology of these pelvic floor dysfunctions let us recognize how ligamentous laxities/defects lead to these dysfunctions. Results of the PROpel study (ClinicalTrials.gov-Identifier: NCT00638235) are shown in which adetailed observation of symptoms (patient-related outcome measures) pre- and postoperatively was performed. Ligamentous vaginal repair of POP enables symptom cure in high percentages for urinary urge incontinence (up to 82%), nocturia (up to 92%), obstructive micturition (up to 87%), fecal incontinence (58-72%), obstructive defecation (71-84%), and pain (53-90%), if caused by POP. Women with POP‑Q stage2 have similar symptom frequencies as women with POP‑Q stage3-4, and also similar cure rates of their symptoms. If good anatomical prolapse repair (in responders) was achieved, the cure rates for obstructive micturition, urinary urgency incontinence, and nocturia were significantly higher than in those women with less effective surgical repair. In the future, pelvic floor surgery should have symptom cure as the primary objective and should lead to improved quality of life. The different, currently performed techniques for POP repair have to be investigated concerning this matter.

Outcomes of Lightweight Mesh Sacrocolpopexy for Pelvic Organ Prolapse Repair

Objective: The research objective is to present and evaluate 3 years of experience in sacrospinal fixation using polypropylene mesh in the surgical treatment of genital prolapse in women. Methods: This retrospective study evaluated perioperative and mid-term outcomes in 68 women who underwent transvaginal sacroscopic cervicocolpopexy with lightweight polypropylene mesh for stage II-IV prolapse with apical involvement. Anatomical outcomes, complications, and symptoms were assessed using POP-Q staging and validated questionnaires preoperatively and at 12 and 36 months postoperatively. Results: No intraoperative complications were observed. In the long-term postoperative period, the following were observed: vaginal wall erosion in transvaginal Mesh-systems placement along the postoperative suture line at 2.9 % (2/68), and chronic pelvic pain at 2.9 % (2/68). The percentage of anatomical success in restoring the position of the apical vaginal segment was 98.5 % (67/68) 12 months after surgery and remained unchanged after 36 months of follow-up.

The Independent Medicines and Medical Devices Safety Review: Regulatory Reform and Remedies

For years, groups of patients and their families in the United Kingdom raised their concerns about three medical interventions. The first was a possible link between hormone pregnancy tests and fetal malformations and deaths; the second was the physical and neurodevelopmental impacts of in utero valproate exposure; and the third was life-changing adverse events caused by pelvic mesh implants for pelvic organ prolapse repair and stress urinary incontinence management. In response to their tireless campaigning, the Independent Medicines and Medical Devices Safety (IMMDS) Review was commissioned by the Secretary of State for Health and Social Care in 2018. The review, chaired by Baroness Cumberlege, found a catalogue of institutional, systems and structural failures within both the medical establishment and healthcare system more broadly. Drawing on the IMMDS Review findings on pelvic mesh, in this article, I consider the dire consequences when medical devices go wrong. Drawing on firsthand experience as lead researcher for the IMMDS Review, I examine some of the background, outline some key findings and reflect on the strategic changes recommended to medical device regulation and the redress prompted by the pelvic mesh scandal. In so doing, I contextualise and consider the relevant regulatory frameworks, the fundamental systems failures and the other issues identified. Three years on, this article also provides an opportunity to assess the extent to which the IMMDS Review recommendations have been successfully operationalised, as well as to take stock of the improvements that still need to be made.

Impact of preoperative pelvic floor muscle function on the success of surgical treatment of pelvic organ prolapse

Introduction and hypothesisThe objective of this study was to identify the potential characteristics of pelvic floor muscles (PFM) in the preoperative assessment that could be associated with post-surgical prolapse severity. We hypothesized that the same variables, if identified, could be addressed in preoperative rehabilitation to improve surgical results.MethodsThis was a single-center prospective observational study that included women who underwent surgical pelvic organ prolapse repair between 2020–2022. Genital prolapse was evaluated according to the Pelvic Organ Prolapse Quantification (POP-Q) system. All the participants underwent a PFM assessment, including a vaginal digital assessment and manometry (Peritron™ 9300 V) before surgery and at 1-, 3-, and 6-month follow-ups. Several PFM variables were recorded: vaginal resting pressure, vaginal pressure during maximal voluntary contraction (MVC), area under the curve during a 10-second MVC, ability to correctly contract the PFMs, and reflexive activation during cough and relaxation. The primary endpoint of the analysis was objective surgical success defined as POP-Q 0 or 1 at the 6-month follow-up. Additionally, a change in pelvic floor muscle function was recorded during postoperative visits.ResultsA total of 106 females were included in the study. Fifty-one were lost during the 6-month follow-up, which is a major limitation of the study. None of the examined parameters evaluating PFM were associated with surgical success. No statistically significant difference was found in MVC and PFM endurance before and after surgery. Post-surgery, a significant change was observed in the vaginal resting pressure and the ability to correct PFM activation and relaxation.ConclusionsPreoperative PFM function is not associated with surgical success 6 months after surgery.

Patient Outcomes After Robotic Ventral Rectopexy With Sacrocolpopexy.

As few studies exist examining postoperative functional outcomes in patients undergoing robotic sacrocolpopexy and ventral rectopexy, results from this study can help guide surgeons in counseling patients on their outcomes. The aim of the study was to evaluate functional outcomes and overall postoperative satisfaction as measured by the Pelvic Floor Disability Index 20 (PFDI-20), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and Patient Global Impression of Improvement Scale (PGI-I) in patients who underwent combined robotic ventral rectopexy and sacrocolpopexy for concomitant pelvic organ prolapse (POP) and rectal prolapse or intussusception (RP/I). This was a retrospective cohort and survey study of patients with combined POP and RP/I who underwent the previously mentioned surgical repair between January 2018 and July 2021. Each patient was contacted to participate in a survey evaluating postoperative symptoms related bother, sexual function, and overall satisfaction using the PFDI-20, PISQ-12, and PGI-I. A total of 107 patients met study inclusion criteria with 67 patients completing the surveys. The mean age and body mass index were 63.7 ± 11.5 years and 25.0 ± 5.4, respectively. Of the patients, 19% had a prior RP repair and 23% had a prior POP repair. Rectal prolapse or intussusception recurrence was reported in 10.4% of patients and objective POP recurrence was found in 7.5% of patients. Sixty-seven patients (62%) completed the surveys. The median time to survey follow-up was 18 (8.8-51.8) months. At the time of survey, the mean PFDI-20 score was 95.7 ± 53.7. The mean PISQ-12 score for all patients was 32.8 ± 7.2 and the median PGI-I score was 2.0 (interquartile range, 1.0-3.0). In this cohort of patients who underwent a combined robotic ventral rectopexy and sacrocolpopexy, patient-reported postoperative symptom bother was low, sexual function was high, and their overall condition was much improved.

Development of new surgical mesh geometries with different mechanical properties using the design freedom of 3D printing

AbstractThe emergence of new rapid prototyping techniques such as melt electrowriting and their application in the development of medical devices, enables new geometries for surgical meshes that were previously limited by current conventional manufacturing methods. The change in geometry allows a direct impact on the mechanical behavior of surgical meshes using identical polymers. The adaptation of the mechanical properties of surgical meshes, based on sinusoidal auxetic design with varying amplitude and number of waves per total fiber length, aims to improve biocompatibility by mimicking and matching the mechanical properties of vaginal soft tissue, which is not provided by current polypropylene nondegradable meshes. The auxetic design of the meshes can supply dimensionally stable pores under tensile load, which is a limitation of the current meshes. The mechanical properties can be controlled with mesh deformations up to 100%, Young's modulus ranging from 50 to 400 N/mm2 and a variable toe region. The printed meshes show an effective porosity of over 70% and are lightweight or ultra‐lightweight. By combining matching mechanical properties with good porosity and weight, 3D printed sinusoidal meshes, made of biodegradable Poly‐ε‐caprolactone, show promising results to improve surgical meshes for use in pelvic organ prolapse repair.

Practice of laparoscopic prolapse surgery in Europe - ESGE Survey.

Sacrocolpopexy is considered as the "gold standard" for management of women with apical prolapse. Numerous technical variants are being practiced. The first aim of this survey was to determine the habits of practice of laparoscopic sacrocolpopexy (LSCP) in Europe. The second aim was to determine whether surgeons who perform laparoscopic pelvic organ prolapse (POP) repair are familiar with the practice of alternative techniques and with mesh-less laparoscopic treatment of prolapse. The questionnaire was designed by the Urogynaecology Special Interest Group of the European Society for Gynaecological Endoscopy (ESGE). All ESGE-members were invited by email to respond to this survey consisting of 54 questions divided in different categories. Following review of ESGE member's responses, we have highlighted the great heterogeneity concerning the practice of LSCP and important variability in performance of concomitant surgeries. Alternative techniques are rarely used in practice. Furthermore, the lack of standardisation of the many surgical steps of a laparoscopic sacrocolpopexy is mainly due to the lack of evidence. There is a need for training and teaching in both standard and newer innovative techniques as well as the reporting of medium and long-term outcomes of both standard laparoscopic sacrocolpopexy and any of its alternatives.

Sacrospinous Fixation and Vaginal Uterosacral Suspension-Evaluation in Uterine Preservation Surgery

ABSTRACT Although hysterectomy is traditionally performed at the time of pelvic organ prolapse repair for apical prolapse, women are increasingly interested in uterine preservation during pelvic organ prolapse surgical management. Approximately 36% to 60% of women indicate interest in uterine preservation, assuming equal efficacy. This has led to more uterus-preserving prolapse repairs (hysteropexy) being performed. After the removal of mesh products from the US market in 2019, transvaginal native tissue techniques are commonly used for hysteropexy. This study aimed to compare 6-week and 1-year anatomical failure rates between vaginal uterosacral ligament hysteropexy and sacrospinous ligament hysteropexy. Secondary outcomes included retreatment for prolapse, symptoms of recurrent prolapse, and perioperative adverse event rates in these 2 groups. This was a multicenter retrospective cohort study of patients undergoing vaginal uterosacral hysteropexy (USHP) or sacrospinous hysteropexy (SSHP) with a urogynecologist between January 1, 2015 and December 31, 2019. The pool of patient data was extrapolated from 4 geographically unique urban locations. Patient identification took place via querying the respective electronic medical records for the current procedural terminology codes of extraperitoneal colpopexy (57,282, SSHP) and intraperitoneal colpopexy (57,283, USHP). These operative reports underwent review in order to confirm that each patient had a uterus at time of surgery, underwent either USHP or SSHP, and did not undergo concurrent hysterectomy. Exclusion criteria included patients undergoing different types of uterine-preserving procedures or patients with less than 6 weeks of follow-up. The study included 147 patients undergoing SSHP and 114 having USHP over 5 years at the 4 clinical sites. The study population included mostly nonsmoking (179, 68.6%), White (224, 85.5%) patients with no history of pelvic surgery (142, 54.4%), and a mean Charleston Comorbidity Index score of 2. Overall, USHP patients exhibited a higher likelihood to undergo concurrent anterior repair, posterior repair, and incontinence procedures. The follow-up rate was 95% at 6 postoperative weeks with 4 anatomic failures. Not all patients had formal prolapse quantitation examinations recorded. However, only 32% (83/261) of patients were available for follow-up at 1 year after surgery when 10 patients met criteria for anatomic failure. Notably, although there was no statistically significant difference between failure rates for SSHP and USHP at either time point, there were roughly 3 times as many failures for USHP compared with SSHP, despite the SSHP representing a larger portion of the total cohort. At 1 year, however, 26 patients had undergone retreatment for prolapse, with 12 undergoing hysterectomy (11 due to prolapse, 1 due to colorectal cancer debulking). Of those undergoing hysterectomy, 10 were from the SSHP cohort, whereas 1 was from the USHP cohort. The 1 year anatomic outcomes presumably included prolapse assessments after these salvage surgeries. One year after vaginal native tissue hysteropexy, only 1 in 3 patients were available for follow-up, but this limited cohort demonstrated that no differences for prolapse recurrence between SSHP and UHSP. Adverse events incidence rates were low, with only 5% of patients undergoing subsequent hysterectomy for prolapse. Any next step in research should include more rigorous prospective trials.

Accelerated in vitro oxidative degradation testing of polypropylene surgical mesh.

Polypropylene (PP) surgical mesh had reasonable success in repair of hernia and treatment of stress urinary incontinence (SUI); however, their use for the repair of pelvic organ prolapse (POP) resulted in highly variable results with lifelong complications in some patients. One of several factors that could be associated with mesh-related POP complications is changes in the properties of the implanted surgical mesh due to oxidative degradation of PP in vivo. Currently, there are no standardized in vitro bench testing methods available for assessing the susceptibility to oxidative degradation and estimating long-term in vivo stability of surgical mesh. In this work, we adapted a previously reported automated reactive accelerated aging (aRAA) system, which uses elevated temperatures and high concentrations of hydrogen peroxide (H2 O2 ), for accelerated bench-top oxidative degradation testing of PP surgical mesh. Since H2 O2 is highly unstable at elevated temperatures and for prolonged periods, the aRAA system involves a feedback loop based on electrochemical detection methods to maintain consistent H2 O2 concentration in test solutions. Four PP mesh samples with varying mesh knit designs, filament diameter, weight, and % porosity, were selected for testing using aRAA up to 4 weeks and characterized using thermal analysis, Fourier-transform infrared spectroscopy-attenuated total reflectance (FTIR-ATR) and scanning electron microscopy (SEM). Additionally, the oxidation index (OI) values were calculated based on the FTIR-ATR spectra to estimate the oxidative degradation and oxidation reaction kinetics of PP surgical mesh. The OI values and surface damage in the form of surface flaking, peeling, and formation of transverse cracks increased with aRAA aging time. The aRAA test method introduced here could be used to standardize the assessment of long-term stability of surgical mesh and may also be adopted for accelerated oxidative degradation testing of other polymer-based medical devices.