Sacrospinous Colpopexy Research Articles

Risk factors of surgical failure following sacrospinous colpopexy for the treatment of uterovaginal prolapse

Trans-vaginal sacrospinous colpopexy is one of the surgical procedures used to repair varying degrees of vaginal vault and uterovaginal prolapse. The purpose of this study is to analyse the potential risk factors of surgical failure following sacrospinous colpopexy. A retrospective study of 114 women who underwent unilateral sacrospinous colpopexy at Jordan University Hospital from January 2005 to January 2008 were included. Patient demographics, clinical characteristics and concomitant pelvic organ prolapse surgery were assessed. The patients were evaluated at 6 weeks, and every 6 months thereafter. Twelve (11 %) had recurrent apical (vaginal cuff) prolapse, 26 (23 %) had recurrent prolapse at any compartment were compared with those who had successful surgery. Univariate and logistic regression analyses were used to assess the independent prognostic values of the variables associated with surgical failure. After a mean follow-up of 40 months, the statistically significant predictors of surgical failure included the presence of advanced pre-operative stages of prolapse (stages III and IV), the more distally located points Ba, Bp and C and a lack of mesh augmentation of the anterior vaginal wall during surgery (P = 0.01, 0.027, 0.024, 0.034 and 0.006, respectively). However, a history of prior vaginal repair, the more distally located point Ba and a lack of anterior vaginal wall mesh augmentation were defined as independent predictive variables based on logistic regression analyses (P = 0.04, 0.005 and 0.046, respectively). The presence of advanced anterior vaginal wall prolapse, prior vaginal repair and a lack of mesh augmentation of the anterior compartment are significant risk factors for the surgical failure of sacrospinous suspension surgery.

Vaginal sacrospinous colpopexy using the Capio suture-capturing device versus traditional technique: feasibility and outcome

This study compares the feasibility and outcome of sacrospinous colpopexy for treating vaginal vault prolapse (VVP) performed by either the traditional technique or a simplified procedure using the Capio™ suture-capturing device. Eighty-six patients with VVP were included in the study. Forty-two patients were treated by traditional sacrospinous colpopexy (TSC group) and 44 patients were treated by the modified technique using the Capio device (CSC group). Additional procedures were performed to restore concomitant pelvic floor defects. The mean (±SD) total operative time was significantly lower in the CSC group (71.7 ± 24.5 min) than in the TSC group (105.5 ± 31.5 min; p < 0.001); the intraoperative blood loss was higher in the TSC group than in the CSC group. In the CSC group, the mean operative time required to perform sacrospinous colpopexy was 21.4 ± 3.2 min. In patients who underwent only sacrospinous colpopexy, the time required to perform surgery was significantly lower in the CSC group (20.9 ± 3.3 min) than in the TSC group (39.1 ± 5.2 min; p < 0.001). There was no significant difference in the incidence of surgical complications between the two study groups. The objective and subjective success rates at 3-year follow-up were 88.1 and 92.9 % in the TSC group while in the CSC group they were 86.4 and 92.9 %. The modified technique of sacrospinous ligament fixation using the Capio device reduces the operative time and blood loss when compared to the traditional technique.

Transvaginal cystocele repair using tension-free polypropylene mesh at the time of sacrospinous colpopexy for advanced uterovaginal prolapse: a prospective randomised study

The management of an advanced multi-compartment prolapse requires a combination of techniques. The objective of this study was to report the anatomical outcomes of a prospective randomised trial comparing tension-free polypropylene mesh-reinforced anterior vaginal prolapse with anterior colporrhaphy at the time sacrospinous colpopexy and posterior fascial plication for the management of massive uterovaginal prolapse. A total of 116 patients with a stage III or IV (Pelvic Organ Prolapse Quantification System/International Continence Society) uterovaginal prolapse were randomised into two groups. The mesh group includes transvaginal cystocele repair using a tension-free polypropylene mesh, while the non-mesh group includes anterior colporrhaphy. All patients in the two groups underwent a sacrospinous colpopexy and posterior fascial plication. The primary outcome was objective success < stage 2 prolapse. The secondary outcomes were reoperation for recurrent prolapse, subjective success rates, patient satisfaction with the surgery and complications. The overall objective success rates (in all compartments) were 79 % (42/53) in the mesh group and 62 % (39/63) in the non-mesh group (p = 0.043). The objective success rates in the anterior compartment were 85 % (45/53) in the mesh group and 62 % (39/63) in the non-mesh group (p = 0.006). Three (6 %) patients in the mesh group and 12 (19 %) in the non-mesh group underwent repeat surgery for recurrent pelvic organ prolapse (p = 0.03). The subjective success rates were 89 % (47/53) in the mesh group and 76 % (48/63) in the non-mesh group (p value = 0.08). The mean patient satisfaction rates with the surgery were 84 % in the mesh group and 76 % in the non-mesh group (p = 0.08). The development of a urinary tract infection, right-sided buttock pain (temporary sciatic neuralgia) and new-onset stress urinary incontinence were not significantly different between the two groups. The mesh exposure rate was 8 %. Transvaginal cystocele repair using tension-free polypropylene mesh at the time of sacrospinous colpopexy and posterior fascial plication offers lower anatomic recurrence and less need for further prolapse surgery to correct recurrent pelvic floor defects than anterior colporrhaphy, sacrospinous colpopexy and posterior fascial plication.

Are Costs for Robotic Assisted Sacrocolpopexy Lower Than Those for Open Sacrocolpopexy?

No AccessJournal of UrologyAdult Urology1 Feb 2012Are Costs for Robotic Assisted Sacrocolpopexy Lower Than Those for Open Sacrocolpopexy? Toby C. Chai Toby C. ChaiToby C. Chai More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.11.003AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Are Costs for Robotic Assisted Sacrocolpopexy Lower Than Those for Open Sacrocolpopexy?." The Journal of Urology, 187(2), pp. 644–645 References 1 : Vaginal versus abdominal reconstructive surgery for the treatment of pelvic floor support defects: a prospective randomized study with long-term outcome evaluation. Am J Obstet Gynecol1996; 175: 1418. Google Scholar 2 : Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study. Am J Obstet Gynecol2004; 190: 20. Google Scholar 3 : The death of cost-minimization analysis?. Health Economics2001; 10: 179. Google Scholar Departments of Surgery (Urology), and Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland© 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 2February 2012Page: 644-645Supplementary Materials Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Toby C. Chai More articles by this author Expand All Advertisement PDF downloadLoading ...

Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review

A previous version of the Cochrane review for prolapse surgery in 2008 provided two conclusions: abdominal sacrocolpopexy had lower recurrent vault prolapse rates than sacrospinous colpopexy but this was balanced against a longer time to return to activities of daily life. An additional continence procedure at the time of prolapse surgery might be beneficial in reducing post-operative stress urinary incontinence; however, this was weighed against potential adverse effects. The aim of this review is to provide an updated summary version of the current Cochrane review on the surgical management of pelvic organ prolapse. We searched the Cochrane Incontinence Group Specialised Register and reference lists of randomised or quasi-randomised controlled trials on surgery for pelvic organ prolapse. Trials were assessed independently by two reviewers. We identified 40 trials including 18 new and three updates. There were no additional studies on surgery for posterior prolapse. Native tissue anterior repair was associated with more anterior compartment failures than polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23-3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29-5.51). There were no differences in subjective outcomes, quality of life data, de novo dyspareunia, stress urinary incontinence, reoperation rates for prolapse or incontinence, although some of these data were limited. Mesh erosions were reported in 10% (30/293). Including new studies on the impact of continence surgery at the time of prolapse surgery, meta-analysis revealed that concurrent continence surgery did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53-3.70; random-effects model). The inclusion of new randomised controlled trials showed that the use of mesh at the time of anterior vaginal wall repair reduced the risk of recurrent anterior vaginal wall prolapse on examination. However, this was not translated into improved functional or quality of life outcomes. The value of a continence procedure in addition to a prolapse operation in women who are continent pre-operatively remains uncertain. Adequately powered randomised controlled trials are needed and should particularly include women's perceptions of prolapse symptoms and functional outcome.

2078 SURGICAL MANAGEMENT OF PELVIC ORGAN PROLAPSE IN FEMALES: ANATOMICAL AND FUNCTIONAL OUTCOMES OF SACROSPINOUS COLPOPEXY AND CYSTOCELE REPAIR AS A COMBINED PROCEDURE

INTRODUCTION AND OBJECTIVES: High stage cystocele usually occurs concomitantly with apical prolapse, and is likely to recur when only the cystocele is surgically corrected. We investigated the anatomical and functional outcome of patients who underwent sacrospinous colpopexy and cystocele repair simultaneously. METHODS: We retrospectively reviewed 71 consecutive women who underwent sacrospinous colpopexy and cystocele repair as a combined procedure and were followed up more than 12 months after surgery. Anti-incontinence surgery was performed when indicated. Severity of prolapse was assessed by the POP-Q staging system. Prolapse-related and lower urinary tact symptoms were assessed. Cystocele was corrected using designed mesh or mesh kits of Perigee or Prolift. For apical correction, sacrospinous ligament fixation was performed. Postoperatively, an anatomical assessment and standardized interview was performed at predetermined intervals. The primary outcome measure was anatomical cure rate. Anatomical cure was defined as stage I or less. Secondary outcomes included subjective cure, symptom status, subjective or objective stress urinary incontinence and uroflowmetric parameters. Women reporting they were never or rarely bothered by prolapse-related symptoms were classified as subjectively cured. RESULTS: All cystoceles were stage III or more and all apical prolapses were stage II or more preoperatively. The success rates of cystocele repair and apical wall repair were 76.1% and 97.2% at postoperative 1 year, respectively. Among the 17 patients in which cystocele recurrence occurred, 15 cases were in stage 2 and none of them showed apical prolapse recurrence or prolapse-related symptoms. There were only 2 cases in which cystocele recurrence occurred higher than stage 3, and all of them had simultaneous apical wall prolapse. In both of these cases, abdominal sacrocolpopexy was performed. Postoperatively, prolapse-related symptoms were completely improved and lower urinary tract symptoms were much improved. Maximal flow rates and postvoid residual urine volumes were significantly improved. De novo incontinence occurred in 23.3% of the patients who did not undergo anti-incontinence surgery simultaneously. All complications were managed conservatively. No mesh erosion was identified. CONCLUSIONS: When apical prolapse was corrected successfully, cystocele recurrence did not exceed stage 2 and no symptoms were identified. When apical correction was not successful, high stage cystocele recurrence occurred.

Sacrospinous vaginal fixation - current status

There has been a trend towards increased use of synthetic meshes and abdominal procedures with decreased use of sacrospinous fixation (SSF). A Medline search was performed for the MeSH terms 'sacrospinous ligament', 'sacrospinous fixation', 'sacrospinous ligament suspension' and 'sacrospinous colpopexy'. Published papers from 1996-2010 were selected for analysis. Outcome measures were assessed in terms of efficacy, complications and quality of life after sacrospinous vaginal fixation. Studies on bilateral SSF and fixing uterus to the sacrospinous ligament, use of concomitant anti-incontinence procedures along with SSF were not included in this review. Sacrospinous vaginal fixation provides good long-term objective and subjective outcomes and improves quality of life of women with pelvic organ prolapse. Further, complication rates of SSF are comparable to abdominal sacrocolpopexy and are much less than transvaginal mesh procedures and SSF is a cost-effective procedure. SSF is a time-tested surgical procedure with a reduction in surgical extent and has a definite place in modern pelvic reconstructive surgery.

Surgical management of pelvic organ prolapse in women.

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with the prolapse. To determine the effects of the many different surgeries used in the management of pelvic organ prolapse. We searched the Cochrane Incontinence Group Specialised Register (9 February 2009) and reference lists of relevant articles. We also contacted researchers in the field. Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse. Trials were assessed and data extracted independently by two review authors. Six investigators were contacted for additional information with five responding. Forty randomised controlled trials were identified evaluating 3773 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86). However there was no statistically significant difference in re-operation rates for prolapse (RR 0.46, 95% CI 0.19 to 1.11). The vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The three trials contributing to this analysis were clinically heterogeneous.For anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented with a polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14); but data on morbidity and other clinical outcomes were lacking. Standard anterior repair was associated with more anterior compartment failures on examination than for polypropylene mesh repair as an overlay (RR 2.14, 95% CI 1.23 to 3.74) or armed transobturator mesh (RR 3.55, 95% CI 2.29 to 5.51). Data relating to polypropylene mesh overlay were extracted from conference abstracts without any peer reviewed manuscripts available and should be interpreted with caution. No differences in subjective outcomes, quality of life data, de novo dyspareunia, stress incontinence, re-operation rates for prolapse or incontinence were identified. Blood loss with transobturator meshes was significantly higher than for native tissue anterior repair. Mesh erosions were reported in 10% (30/293) of anterior repairs with polypropylene mesh.For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele or enterocele, or both, than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64); although there was a higher blood loss and post-operative narcotic use. No data exist on efficacy or otherwise of polypropylene mesh in the posterior vaginal compartment.Meta-analysis on the impact of continence surgery at the time of prolapse surgery was performed with data from seven studies. Continence surgery at the time of prolapse surgery in continent women did not significantly reduce the rate of post-operative stress urinary incontinence (RR 1.39, 95% CI 0.53 to 3.70; random-effects model). Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

To mesh or not to mesh

We are in the midst of an increasingly acrimonious discussion regarding the use of mesh in pelvic reconstructive surgery. Modern mesh kits, aggressively marketed by biotech companies, have become widespread. At times, they are used inappropriately, and significant complications such as pain syndromes and erosion are not uncommon. While conventional alternatives such as sacrospinous colpopexy and Burch colposuspension are not without their problems either, the discussion surrounding mesh use has a character never encountered before in urogynaecology. Many colleagues feel that the resolution of this conflict may be found in large randomised controlled trials such as the PROSPECT trial currently being planned in the UK. I feel that such a trial may well do more harm than good, unless certain precautions are taken. In this opinion piece I'll try and explain why.

Perioperative course and long term outcome after vaginal sacrospinous colpopexy for vaginal vault prolapse post hysterectomy: comparison of three different suture methods

To compare long-term results of the vaginal sacrospinous colpopexy (VSC) procedure for the treatment of vaginal vault prolapse after previous hysterectomy with the use of either of the three most commonly used devices (the Deschamps ligature carrier, the Shutt Suture Punch System, or an ordinary straight needle holder). The study group consisted of 73 women (out of 84; response rate 86%) who had undergone VSC for vaginal vault prolapse in between January 1994 and April 2005. All these patients were contacted with a mailed questionnaire and asked about symptoms related to prolapse, possible complications, any subsequent surgical repair and their satisfaction with results of the surgery. All data concerning the patients' characteristics at the time of surgery and perioperative events were retrospectively collected using the patient records (charts). There were no significant differences in age, parity, body mass index, or in proportion of previous prolapse or incontinence surgery between groups. The operation time was similar in all groups, with a median duration around 60 min. There was a wide distribution of the estimated blood loss in the groups, but without significant differences between groups. The rate of complications was low in all groups. Most of the patients were 'very satisfied' with the results of the surgery and rated their satisfaction as 8 to 10. The proportions of patients being very satisfied with the results of the surgery were 84%, 80% and 87% in the Deschamps, Shutt and needle holder groups, respectively. In the present study we could not see any major differences in perioperative data when comparing usage of the three instruments. Operation time, complications rate, perioperative blood loss and the patient's satisfaction with the surgery were equal between the three groups. This indicates that the type of instrument used in VSC is of no importance.

Operative Therapie des Descensus genitalis - Was ist Standard? - Was ist experimentell?

Nachdem suburethrale Vaginalschlingen eine neue Ära in der Behandlung der weiblichen Belastungsharninkontinenz eingeläutet haben, finden nun auch für die Behandlung des Deszensus neue Operationsmethoden mit alloplastischen Netzen bei der Beckenbodenrekonstruktion zunehmend Verbreitung. Damit treten sie in Konkurrenz zu den etablierten Standardverfahren. Zum direkten Vergleich sind kontrollierte klinische Studien notwendig. Zu den klassischen Verfahren zählen sowohl vaginale als auch abdominale Techniken. Die typischen klassischen Verfahren ohne Fremdmaterial sowie die neuen Netzverfahren werden vorgestellt. Die derzeit vorliegenden Daten werden aufgeführt und diskutiert. Nach sorgfältiger Diagnostik bieten auch die Standardverfahren weiterhin hohe Erfolgsraten bei einer insgesamt niedrigen Komplikationsrate. Während das abdominale Vorgehen bei Scheidenstumpfdeszensus im mittleren Kompartiment bezüglich Rezidivrate und Sexualfunktion Vorteile gegenüber dem vaginalen Vorgehen bietet, so zeichnet sich die Vaginaefixatio sacrospinalis nach Amreich-Richter durch ihre geringe Morbidität bei annähernd gleicher Erfolgsrate aus. Das Problem von Kombinationseingriffen bei simultaner oder larvierter Belastungsharninkontinenz lässt sich bislang nicht endgültig mit der vorhandenen Literatur beantworten. Die Verwendung alloplastischer Materialien konfrontiert uns zudem mit einem neuen Komplikationsspektrum, das ein entsprechend angepasstes Management erfordert. Angesichts überwiegend kleiner Studienzahlen mit kurzer Nachbeobachtungszeit sind die Mesh-Verfahren noch nicht abschließend beurteilbar und noch als experimentell anzusehen. Vorläufig ist den etablierten Standardverfahren in der Primärbehandlung der Vorzug zu geben. In speziellen, insbesondere Rezidiv-Situationen bieten die neuartigen Operationsverfahren mit alloplastischen Materialien vielversprechende Alternativen.

Selective embolization of the superior vesical artery for the treatment of a severe retroperitoneal pelvic haemorrhage following Endo-Stitch sacrospinous colpopexy

Pelvic haemorrhage is a rare but important complication that may follow sacrospinous fixation of the vaginal vault. When such complication occurs, packing and clipping of the involved artery is often suggested as the first-line treatment, while arterial embolization is considered only after failure of surgery. In this report, we describe the successful super-selective embolization of a variant of the superior vesical artery in a patient who underwent Endo-Stitch sacrospinous colpopexy. Based on our experience, we suggest that when a well-trained radiological staff is available, endovascular embolization is an effective and less invasive option.

Surgical management of pelvic organ prolapse in women: A short version Cochrane review

Pelvic organ prolapse may occur in up to 50% of parous women. A variety of urinary, bowel and sexual symptoms may be associated with prolapse. To determine the effects of the many different surgeries in the management of pelvic organ prolapse. We searched the Cochrane Incontinence Group Specialised Trials Register (searched 3 May 2006) and reference lists of relevant articles. We also contacted researchers in the field. Randomised or quasi-randomised controlled trials that included surgical operations for pelvic organ prolapse. Trials were assessed and data extracted independently by two reviewers. Six investigators were contacted for additional information with five responding. Twenty two randomised controlled trials were identified evaluating 2368 women. Abdominal sacral colpopexy was better than vaginal sacrospinous colpopexy in terms of a lower rate of recurrent vault prolapse (RR 0.23, 95% CI 0.07 to 0.77) and less dyspareunia (RR 0.39, 95% CI 0.18 to 0.86), but the trend towards a lower re-operation rate for prolapse following abdominal sacrocolpopexy was not statistically significant (RR 0.46, 95% CI 0.19 to 1.11). However, the vaginal sacrospinous colpopexy was quicker and cheaper to perform and women had an earlier return to activities of daily living. The data were too few to evaluate other clinical outcomes and adverse events. The three trials contributing to this comparison were clinically heterogeneous. For the anterior vaginal wall prolapse, standard anterior repair was associated with more recurrent cystoceles than when supplemented by polyglactin mesh inlay (RR 1.39, 95% CI 1.02 to 1.90) or porcine dermis mesh inlay (RR 2.72, 95% CI 1.20 to 6.14), but data on morbidity, other clinical outcomes and for other mesh or graft materials were too few for reliable comparisons. For posterior vaginal wall prolapse, the vaginal approach was associated with a lower rate of recurrent rectocele and/or enterocele than the transanal approach (RR 0.24, 95% CI 0.09 to 0.64), although there was a higher blood loss and postoperative narcotic use. However, data on the effect of surgery on bowel symptoms and the use of polyglactin mesh inlay or porcine small intestine graft inlay on the risk of recurrent rectocele were insufficient for meta-analysis.Meta-analysis on the impact of pelvic organ prolapse surgery on continence issues was limited and inconclusive, although about 10% of women developed new urinary symptoms after surgery. Although the addition of tension-free vaginal tape to endopelvic fascia plication (RR 5.5, 95% CI 1.36 to 22.32) and Burch colposuspension to abdominal sacrocolpopexy (RR 2.13, 95% CI 1.39 to 3.24) were followed by a lower risk of women developing new postoperative stress incontinence, but other outcomes, particularly economic, remain to be evaluated. Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed.

Editorial comment Re: Surgical management of pelvic organ prolapse in women: A short version Cochrane review

Around 1 in 10 women will need a surgical vaginal prolapse repair in their lifetime, and 50% of parous women will have prolapse with symptoms. With our ageing population, this is set to increase. On pages 3 to 12 we publish a precised version of a recently updated Cochrane review on surgery for vaginal prolapse. This shows that despite the prevalence of the problem, and an estimated failure rate for primary surgery of 30%, there is a disappointing lack of evidence about the best surgical techniques. The authors of the Cochrane systematic review, using exhaustive search techniques, found only 22 randomised or quasi-randomised trials on 2368 women undergoing prolapse repair. Most of the trials were small or of poor quality, and addressed disparate operations or types of prolapse, resulting in limited and diffuse evidence. Important take home messages include: abdominal sacrocolpopexy results in a better anatomical outcome than the vaginal sacrospinous colpopexy in women with upper vaginal prolapse, but at higher cost; mesh inlays might improve the objective success rate for anterior repair, but there was no long term evidence of effect on quality of life or failure; and traditional posterior repair is superior to transanal repair for posterior vaginal wall prolapse. In particular, the trials were short on subjective, patient-determined outcomes, which are what matter to women having the surgery. The authors illustrated how limited the current evidence base is for prolapse surgery. This is a particular concern at a time when new procedures, particularly involving mesh or grafts, with or without intro- ducer kits, and laparoscopic approaches, are being promoted without any rigorous evidence about their effectiveness or safety. This raises questions about how well the interests of women are being safeguarded. In particular, the plethora of mesh or graft material, ranging from absorbable (synthetic and biological) to non-absorbable materials, indicates how uncertain we are about the best management. If these were new drugs they would require much more stringent evalua- tion before widespread use. What should we do? One attitude is to just say that there is nothing that can be done, as any research started now will be outdated by the time it is completed. The alternative is to get together as a community, identify the fundamental differ- ences in approaches and to mount collaborative randomised trials to find out which are the most effective, cost-effective and safe. We could also lobby the regulatory authorities to consider introducing safeguards over the introduction of new devices at least until basic safety and efficacy is established. Current impediments at the moment are: lack of stand- ardised, validated outcomes; lack of collaborative clinical networks; a perception that it is not possible to evaluate new surgical procedures (for cost reasons, the long time scale until evidence is available, learning and skill issues, and the introduction of newer procedures before the older ones have been evaluated); and as a result of all these factors, no international track record in mounting such trials.

Vaginal sacrospinous colpopexy and laparoscopic sacral colpopexy for vaginal vault prolapse

Vaginal sacrospinous colpopexy (VSC) and laparoscopic sacral colpopexy (LSC) both correct vault prolapse. The present study compares the perioperative course and long-term results of VSC and LSC. This retrospective study of post-hysterectomy vault prolapse involved 111 patients operated with either VSC (n=51) or LSC (n=60). The median time for the postoperative follow-up visit was 33.6 (range: 13-60) months for the LSC group and 38.4 (range: 7-108) months for the VSC group. Prolapse grade as well as the patient's satisfaction was recorded at the follow-up visit. Operation time was significantly shorter in the VSC group (median: 62 min) compared to the LSC group (median: 129 min). The rate of perioperative complications was low in both groups. There were 3 laparotomies in the LSC group, due to perioperative complications. The inpatients days were similar, with 3.7 days (1-18) and 4.0 days (2-21) in the VSC and the LSC group, respectively. Surgery for the recurrence of vault prolapse at any time before the follow-up visit did not occur in the VSC group, but occurred in 7 patients in the LSC group. At the follow-up visit, there was no recurrence of vault prolapse in either group. The subjective success rate was 82% in the VSC and 78% in the LSC group. This study indicates that VSC and LSC are two equally effective surgical procedures to correct vaginal vault prolapse, but the LSC technique requires a longer operating time.

PD-03.09: Long term outcome of laparoscopic promontofixation for vaginal prolapse

Genito-urinary prolapse is a common benign problem in women. In a prospective randomized study, abdominal sacral colpopexy was superior to the vaginal sacrospinous colpopexy in the treatment of pelvic organ prolapse. Laparoscopic surgery allows a better visualisation than the abdominal approach. We hereby describe our long term outcome of our initial series treated with laparoscopic colpo-sacropexy.

Using Veronikis ligature carrier to simplify transvaginal sacrospinous colpopexy

Pelvic organ prolapse is a common problem in women and often requires surgical management. Sacrospinous colpopexy (SSC) requires significant expertise, especially in placement of the suture into sacrospinous ligament (SSL). Veronikis ligature carrier (VLC) designed for SSC was used to facilitate suture placement and retrieval under direct visualization within the confines of the pararectal space. From December 2003 through March 2004, SSC was performed in 20 patients with VLC as part of their site-specific reconstructive pelvic surgery (group A). The historic control group (group B) included 15 patients who underwent SSC with a straight needle holder between March 1999 and March 2001. There was no significant difference in age, gravity, parity, body mass index, blood loss, and hospital stay in both groups with the diagnosis of uterovaginal prolapse or posthysterectomy vaginal vault prolapse. The median operation time for group A and group B was 35 min (range 25-40 min) and 75 min (range 45-128 min), respectively (P<0.001). It took less than 5 min to introduce two sutures through the SSL by VLC in group A but 20-40 min by straight needle holder in group B. There was no injury to the bladder, rectum, pudendal nerve, or major pelvic vessels. VLC allows rapid and safe introduction of the suspending suture through the SSL and makes SSC easy to perform.

Performance of the tension free vaginal tape procedure when combined with sacrospinous fixation for apical prolapse

SummaryReports of the tension-free vaginal tape (TVT) procedure performed in combination with reconstructive vaginal surgery have been published, but none of these has looked specifically at the sub-group of TVT in combination with sacrospinous colpopexy. This report describes a series of 15 cases where TVT was performed in combination with sacrospinous colpopexy. There were no major complications. Five patients (33.3%) had postoperative urine retention for more than 1 week. Mild incontinence was reported in five cases at 12 months. We conclude that the results of TVT in treating stress incontinence when combined with sacrospinous colpopexy are comparable with TVT alone. Patients should be warned of a higher rate of short-term urinary retention of up to 6 months, while the long-term urinary retention rate is comparable with the TVT procedure alone.

Long-term outcome of vaginal sacrospinous colpopexy for marked uterovaginal and vault prolapse

Background This study was carried out to evaluate the safety and long-term outcome of sacrospinous colpopexy in marked genital prolapse. Setting Gynaecology Department, Benenden Hospital, Kent, UK. Methods A prospective observational study was conducted between September 1993 and May 2000 on 305 women who underwent transvaginal sacrospinous colpopexy. The indications for surgery were marked vault prolapse in 43% and uterovaginal prolapse or enterocele in 57%. Patient follow up was at 6 weeks, 6 months, 1 year and then annually. Data was collected prospectively at the time of initial recruitment, during hospital stay and at the end of each follow up visit. Results Hysterectomy was performed in 117 patients and anterior colporrhaphy in 182. The mean operative time for the entire surgery was 65.6 min (S.D. 27.4, range 20–160 min) and estimated blood loss was 81.8 ml (S.D. 92, range 20–800 ml). After a mean follow up period of 57 months (range 24–84), vault support was maintained in 96%; recurrent vault prolapse occurred in 12 patients (4%) and the mean vaginal length at 1 and 5 years of follow up was 8 ± 0.9 and 7.8 ± 1.2 cm. Symptomatic cystocele occurred in 15 patients (5%). There were six recurrences of rectocele (2%) and there was no enterocele recurrence. Sexual function was maintained in all sexually active women and 43% reported improvement in sexual function. Out of 14 women who complained of fecal incontinence, 10 (71%) reported cure and 3 (21%) improved after surgery. Conclusions Vaginal sacrospinous colpopexy is associated with a high long-term success rate in correcting upper genital prolapse.

Surgical management of anterior vaginal wall prolapse: an evidencebased literature review

The aim of this review is to summarize the available literature on surgical management of anterior vaginal wall prolapse. A Medline search from 1966 to 2004 and a hand-search of conference proceedings of the International Continence Society and International Urogynecological Association from 2001 to 2004 were performed. The success rates for the anterior colporrhaphy vary widely between 37 and 100%. Augmentation with absorbable mesh (polyglactin) significantly increases the success rate for anterior vaginal wall prolapse. Abdominal sacrocolpopexy combined with paravaginal repair significantly reduced the risk for further cystocele surgery compared to anterior colporrhaphy and sacrospinous colpopexy. The abdominal and vaginal paravaginal repair have success rates between 76 and 100%, however, no randomized trials have been performed. There is currently no evidence to recommend the routine use of any graft in primary repairs, and possible improved anatomical out-comes have to be tempered againstcomplications including mesh erosions, infections and dyspareunia.