Apical Prolapse Surgery Research Articles

Surgical Decision-Making: Who Should Be Offered Sacrocolpopexy?

Women undergoing surgery for apical pelvic organ prolapse have several medically sound options for specific surgical approaches. We review the principles of shared decision-making as they pertain to surgery for prolapse. We review the literature supporting the superior sacrocolpopexy as a durable treatment for prolapse and the factors that may differentiate it from other repairs in risk and benefit. We emphasize the importance of collaboration between patients and surgeons in surgical decision-making. All medically appropriate patients who desire reconstructive surgery for prolapse should be offered sacrocolpopexy.

Effect of Body Mass Index on Complications After Vaginal and Laparoscopic Apical Prolapse Surgery.

Obesity is increasing worldwide, and data are limited on how body mass index (BMI) affects surgical risk in pelvic organ prolapse. This study is aimed at evaluating the impact of obesity on outcomes after apical pelvic organ prolapse surgery. We hypothesize that obese patients have higher rates of postoperative complications. This is a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2014 to 2018. Current Procedural Terminology codes identified subjects aged 18-89 who underwent apical prolapse repair, including vaginal colpopexy and laparoscopic or robotic sacrocolpopexy. Minor and major complications were analyzed using the World Health Organization BMI category. Regression analysis was performed to adjust for confounders. The total cohort was 24,718 with 15,137 vaginal colpopexy and 9,581 laparoscopic/robotic sacrocolpopexy. The average age was 60.1, 76.5% were white, 24.2% were American Society of Anesthesiologists (ASA) class 3 or 4, and 44.7% had a major medical comorbidity. Eight hundred and eighty-five patients (5.4%) experienced a minor complication, 324 (2.0%) a major complication, and 1,167 (7.2%) any complication. There was no difference in any, major, or minor complication by BMI and this persisted after adjusting for age, race, ASA class, smoking, and surgical approach. There is no difference in complication rates after apical prolapse surgery by BMI regardless of age, race, ASA class, smoking use, and surgical approach. Patients and surgeons should be reassured that minimally invasive apical prolapse surgery is safe, with low complication rates. Randomized controlled trials are needed to verify these findings.

Patient perspectives in adverse event reporting after vaginal apical prolapse surgery

BackgroundMany clinical trials use systematic methodology to monitor adverse events (AE) and determine grade (severity), expectedness, and relatedness to treatments as determined by clinicians. However, patient perspective in the process remains lacking. ObjectivesTo compare clinician versus patient grading of AE severity in a urogynecologic surgical trial. Secondary objectives were to estimate the association between patient grading of AEs with decision-making and quality of life outcomes and to determine if patient perspective changes over time. Study DesignThis was a planned supplementary study, “Patient-Perspectives in Adverse Event Reporting” (PPAR), to a randomized trial comparing 3 surgical approaches to vaginal apical prolapse. In the parent trial, AEs experienced by patients were collected per a standardized protocol every 6 months where clinicians graded AE severity (mild, moderate, severe/life threatening). In this sub-study, we obtained additional longitudinal patient perspectives for 19 predetermined “PPAR AEs”. Patients provided their own severity grading (mild, moderate, severe/very severe/ life threatening) at initial assessment and at 12 and 36 months postoperatively. Clinicians and patients were masked to each other’s reporting. The primary outcome was the interrater agreement (kappa statistic, κ) for AE severity between the initial clinician and patient assessment, combining patient grades of mild and moderate. Association between AE severity and the Decision-Regret Scale (DRS), Satisfaction with Decision Scale (SDS), the Short-Form Health Survey-12 (SF-12), and Patient-Global Impression of Improvement (PGI-I) scores were assessed utilizing Spearman’s correlation coefficient (ρ) for continuous scales, Mantel-Haenszel chi-squared test for PGI-I, and T-tests or chi-squared tests comparing assessments of severe vs other grades. To describe patient perspective changes over time, the intra-observer agreement was estimated for AE severity grade over time using weighted kappa-coefficients. ResultsOf 360 patients randomized, 219 (61%) experienced a total of 527 PPAR AEs (91% moderate and 9% severe/life threatening by clinician grading). Mean patient age was 67 years, 87% were White, and 12% Hispanic. Of patients reporting any PPAR event, the most common were urinary tract infection (61%), de novo urgency urinary incontinence (35%), stress urinary incontinence (22%), and fecal incontinence (13%).Overall agreement between clinician and participant grading of severity was poor (κ=0.24 (95%CI 0.14, 0.34). Of 414 AEs clinicians graded as moderate, patients graded 120 (29%) mild, and 80 (19%) severe. Of 39 AEs graded severe by clinicians, patients graded 15 (38%) mild or moderate. Initial patient grading of the most severe reported AE was mildly correlated with worse DRS (ρ=0.2, p=0.01), SF-12 (ρ=-0.24, p<0.01) and PGI-I (p<0.01). There was no association between AE severity and SDS. Patients with an initial grading of “severe” had more regret, lower quality of life, and poorer global impressions of health than those whose worst severity grade was mild (p<0.05). Agreement between the patients’ initial severity and later timepoints was fair at 12 months (κ=0.48 (95% CI 0.39, 0.58)) and 36 months (κ=0.45 (95% CI 0.37, 0.53)). ConclusionsClinician and patient perceptions of AE severity are discordant. Worse severity from the patient perspective was associated with patient-centered outcomes. Including the patient perspective provides additional information for evaluating surgical procedures.

Surgery for Apical Prolapse: A Whiteboard Animation Patient Education Video

Surgery for Apical Prolapse: A Whiteboard Animation Patient Education Video

Should sacrouterine plication be added to lateral suspension surgery? A prospective study.

Laparoscopic lateral suspension is a novel approach for repairing anterior and apical pelvic organ prolapse (POP). According to integral theory, urinary symptoms and pelvic pain are believed to originate from suspensory ligaments. We aimed to investigate the objective and subjective outcomes of adding sacroterine plication to apical prolapse surgery. Sixty patients with Grade 2 or higher symptomatic apical POP were included in the study. The study sample was categorized into two groups: Group 1 underwent lateral suspension and Group 2 underwent lateral suspension and sacroterine plication. Anatomical cure was defined separately for the apical and anterior compartments as POP-Q scores for sites C and Ba of less than -1 cm for each compartment. A subjective cure was defined as the absence of bulge symptoms. Patient satisfaction, sexual function, prolapse-related quality of life, voiding dysfunction, nocturia, and constipation were assessed. In Group 1, anatomical cure rates for apical and anterior prolapse were 100% and 70%, respectively (p <0.001). In Group 2, these rates were 100% for apical prolapse and 73.3% for anterior prolapse (p <0.001). The subjective cure was 96.6% in both groups. Furthermore, improvement in sexual and urinary symptoms was more significant in the group that underwent sacroterine plication (p <0.001). The additional sacroterine plication (shortening) procedure with lateral suspension proved to be an effective and successful surgical approach for apical prolapse. Its routine addition to existing lateral suspension surgery can contribute significantly to the improvement of urinary and prolapse symptoms.

Specialty-Specific Trends in Surgery for Apical Pelvic Organ Prolapse Post Vaginal Mesh.

Since transvaginal mesh (VM) kits for apical pelvic organ prolapse (APOP) were labeled "high-risk" in 2016 and subsequently banned in 2019 by the U.S. Food and Drug Administration, the most common remaining surgical options include abdominal mesh-augmented sacrocolpopexy (AS) and transvaginal native tissue suspension (VN). The objective of this study was to determine temporal trends in APOP procedures for urologists and gynecologists. Between 2011 and 2020, the American College of Surgeons National Surgical Quality Improvement Program database was queried for AS, VM, and VN. There were 26,477 cases of APOP repair (32% AS, 6% VM, 62% VN) included, 9% by urologists. Urologists operated on older (65 vs 61 years) patients with more medical comorbidities. Urologists performed significantly higher proportion of AS (65% vs 29%) and VM (8% vs 6%) relative to VN (27% vs 65%) than gynecologists ( P < 0.0001). Transvaginal mesh utilization has decreased over time for both specialties ( P < 0.05); nonsignificant trends toward increasing AS ( P = 0.1646) in urologists and VN ( P = 0.0913) in gynecologists concurrently occurred. Significant independent predictors of the operating surgeon being a urologist were surgery being performed in the latter half of the cohort (2016-2020; odds ratio [OR], 1.22), non-White patient race (OR < 1 for all), a concomitant sling being placed (OR = 0.89), the surgery being VM (OR = 2.95) or AS (OR = 4.36), the patient being older (OR > 1 for each age range), and having a higher frailty index score (OR = 1.16). Significant differences in APOP repair choices exist between specialties. Urologists operate on older, more medically complex patients while demonstrating a strong preference for mesh-augmented compared with transvaginal native tissue repairs.

Patient perspectives in adverse event reporting after apical prolapse surgery

Patient perspectives in adverse event reporting after apical prolapse surgery

Longitudinal Reoperation Risk After Apical Prolapse Procedures in Women Aged 65 Years and Older.

To describe longitudinal reoperation risk among older women undergoing surgery for apical pelvic organ prolapse (POP) and to compare risk of reoperation for prolapse and complications among different surgical approaches. This nationwide, retrospective cohort study evaluated older adult women (aged 65 years and older) within the Centers for Medicare & Medicaid Services' (CMS) 5% LDS (Limited Data Set) who underwent sacrocolpopexy, uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF), or colpocleisis, or their uterine-preserving equivalents, from January 1, 2011, to December 31, 2018, with follow-up through 2019. The primary outcome was overall reoperation, and secondary outcomes included reoperation for POP and for complications. Rates were compared using χ 2 tests for categorical variables, Wilcoxon rank-sum for continuous variables and Kaplan Meier estimates of cumulative incidence. Death and exit from CMS insurance were considered as censoring events. We used cumulative incidence to calculate reoperation risk as a function of time at 1 year or more, 3 years or more, and 7 years or more. This cohort included 4,089 women who underwent surgery to treat apical POP from 2011 to 2018: 1,034 underwent sacrocolpopexy, 717 underwent USLS, 1,529 underwent SSLF, and 809 underwent colpocleisis. Demographics varied among patients for each POP surgery. Patients who underwent the different surgeries had differences in age ( P <.01), Charlson Comorbidity Index score ( P <.01), diabetes ( P <.01), chronic obstructive pulmonary disease ( P <.01), hypertension ( P <.01), chronic pain ( P =.01), congestive heart failure ( P <.01), and concomitant hysterectomy ( P <.01). Reoperation rates were low and increased over time. The overall reoperation risk through 7 years was 7.3% for colpocleisis, 10.4% for USLS, 12.5% for sacrocolpopexy, and 15.0% for SSLF ( P <.01). Reoperation for recurrent POP through 7 years was 2.9% for colpocleisis, 7.3% for sacrocolpopexy, 7.7% for USLS, and 9.9% for SSLF ( P <.01). Reoperation for complications through 7 years was 5.3% for colpocleisis, 8.2% for sacrocolpopexy, 6.4% for USLS, and 8.2% for SSLF ( P <.01). The type of surgical repair is significantly associated with long-term risk of reoperation. Colpocleisis offers the least likelihood of reoperation for prolapse, followed by sacrocolpopexy; colpocleisis followed by USLS has the least risk of long-term reoperation for complication.

Operating room variables: Endoscopic vs. vaginal surgery in postmenopausal women with apical prolapse. An analysis of retrospective data

Objective:Pelvic organ prolapse is a common condition with an increasing prevalence among elderly women. Currently, an efficient surgery to treat such a condition requires both cost-efficiency and time efficiency, since operating rooms also serve as the financial center of modern hospitals. This study is aimed at comparing different approaches to treating an apical prolapse based on perioperative variables, including operating room times and their efficiency. Materials and MethodsWe reviewed and compared the perioperative data of postmenopausal women over 60 who had undergone POP surgery for an apical prolapse via laparoscopic approach between 2012 and 2022 with women who underwent surgery via vaginal approach between 2018 and 2022. The groups were divided into subdivisions based on concomitant hysterectomy. The operating room time, perioperative complications, blood loss, and the time of hospital stay were compared under different groups. Results:A total of 199 patients were included in this study, out of which 66 underwent laparoscopic surgery and 133 underwent vaginal surgery for apical pelvic organ prolapse (POP). The vaginal approach showed significantly shorter operating room times when it came to the duration of anesthesia induction, case preparation, and the surgery. The blood loss did not significantly differ between the groups. The length of hospital stay was significantly longer in the groups with a laparoscopic approach. Conclusion:The advantage of traditional vaginal surgery is the significant time efficiency with better perioperative variables compared to the laparoscopic approach.

Patient Satisfaction with Same-Day Discharge after Urogynecologic Surgery during the COVID-19 Pandemic

Background Patient satisfaction with same-day discharge after apical prolapse surgery has not been studied in the setting of the COVID-19 pandemic. Widespread implementation of same-day discharge for urogynecologic procedures has the potential to decrease hospital crowding, cost to patients, and the potential risks of in-patient stays, which are especially important to consider amid an ongoing pandemic. This study aims to investigate patient satisfaction with same-day discharge after minimally invasive urogynecologic surgery for apical vaginal prolapse during the COVID-19 pandemic. Patients and Methods All patients undergoing apical prolapse surgery at a single academic institution during the COVID-19 pandemic from March 2020 to December 2021 were queried using applicable CPT codes. In this observational cohort study, each participant was surveyed by phone. The validated Surgical Satisfaction Questionnaire (SSQ-8) was used to assess general satisfaction with the surgical experience, and additional questions were asked to assess the impact of the COVID-19 pandemic on patient satisfaction. Results One hundred and twenty-six patients met inclusion criteria and 60 patients (47.6%) chose to participate in the study. SSQ-8 scores revealed high overall satisfaction with the surgical experience (34.7 ± 5.7 out of 40). The majority of patients, 43 (71.7%), found that the ongoing COVID-19 pandemic had “no impact” on their surgical satisfaction. Conclusions Same-day discharge after surgery for apical vaginal prolapse is regarded as highly satisfactory and safe by the majority of patients. Overall, the COVID-19 pandemic had no impact on patient satisfaction with same-day discharge after urogynecologic surgery at our institution.

Genital hiatus measurements predict cuff prolapse risk in prolapse surgery

Background/Aim: Recognition and assessment of apical vaginal support defects remains a significant challenge in the evaluation and management of prolapse because there are no consensus or guidelines address the degree of apical support loss at which an apical support procedure should routinely be performed. The aim of this study was to evaluate whether preoperative genital hiatus (GH), perineal body (PB), and total vaginal length (TVL) are associated with prolapse recurrence after apical prolapse surgery. Methods: Our cohort study included 98 patients who underwent vaginal hysterectomy apical suspension due to uterovaginal prolapse of grade 2 or higher according to Pelvic Organ Prolapse Quantification (POP-Q) staging between 2020 and 2021. Patients with a history of gynecologic malignancy, those who could not tolerate surgery or anesthesia, those who had previously undergone pelvic organ prolapse surgery, those with concomitant stress urinary incontinence, and those with abnormal cervical smear results were excluded. Patients were followed for 2 years at intervals of 3 months in the first year after the surgery. The last POP-Q was performed 24 months after surgical intervention. Surgical failure or recurrence was defined as apical descent greater than one third of the total vaginal length, anterior or posterior vaginal wall past the hymen, subsequent surgery, or bothersome vaginal bulge. Patients were given the Pelvic Organ Prolapse Symptom Score (POP-SS) questionnaire before surgery and 6 months postoperatively, and the severity of symptoms was compared between the groups with and without postoperative recurrence. Logistic regression (LR) analysis was performed to determine the factors affecting recurrence. Areas under the ROC curve were calculated as a differential diagnosis for the presence of recurrence, and the predictive value (cut-off) of variables was determined using sensitivity, specificity, positive predictive value, negative predictive value, and LR (+) values. Results: While surgery was successful in 80 patients, genital relapse was seen in 18 patients. The mean preoperative perineal body was 3.05 (0.28) cm, mean preoperative GH was 3.9 (0.39) cm, and mean preoperative TVL was 8.54 (1.33) cm. The mean GH of the group with recurrence was significantly higher than the group without recurrence (P=0.004). The mean preoperative POP-SS score was 15.14 (1.86), and the postoperative POP-SS score was 4.01 (3.74). The postoperative POP-SS score mean of the recurrence (+) group was significantly higher than the group without recurrence (P&lt;0.001). For the genital hiatus, the cut-off &gt;4 cm had a sensitivity of 61.11%, specificity of 76.25%, positive predictive value of 36.70%, negative predictive value of 89.70%, and LR (+) value of 2.57. For POP-SS Preop-Postop Change %, the cut-off &lt;60 had a sensitivity of 94.44%, specificity of 98.75%, positive predictive value of 94.40%, negative predictive value of 98.80%, and LR (+) value of 75.56. Conclusion: Apical vaginal support loss is highly associated with genital hiatus size. In particular, according to all study definitions, a Pelvic Organ Prolapse-Quantification measurement genital hiatus of &gt;4 cm is a strong predictor of apical support loss. This simple measurement can be used to screen for apical support loss and further evaluate apical vaginal support before planning a hysterectomy or prolapse surgery.

Healthcare Resource Utilization After Apical Prolapse Surgery in Women Who Received In-Office Versus Telephone-Only Preoperative Teaching

Despite increasing use of telehealth, no studies have evaluated telehealth use for preoperative teaching and its impact on healthcare resource utilization (HRU) after gynecologic surgery. This study aimed to compare HRU after apical prolapse surgery in women receiving in-office versus telephone-only preoperative teaching and identify factors associated with postoperative HRU. A retrospective cohort study of women who underwent apical prolapse surgery from 2017 to 2020 at a tertiary referral center was conducted. Women were grouped based on the preoperative teaching type they received. Healthcare resource utilization was defined as a composite of patient-initiated calls, unscheduled outpatient visits, emergency department visits, and readmissions before the scheduled 6-week postoperative visit. Healthcare resource utilization was compared between in-office and telephone-only groups. Multivariable regression analysis was performed to identify factors associated with HRU. A total of 1,168 women underwent in-office teaching, and 181 had telephone-only teaching. Of the 1,349 women, 980 (72.6%) had ≥1 HRU encounter and 222 (16.5%) had ≥5 HRU encounters within 6 weeks after surgery. There was no difference between telephone and office groups for composite outcomes of ≥1 HRU (78.5% vs 71.7%, P = 0.06) and ≥5 HRU (13.3% vs 17.0%, P = 0.21) encounters. A failed voiding trial was associated with a 4.4-fold increased risk of ≥5 encounters. Increasing age and body mass index, concomitant hysterectomy, and abdominal route were associated with a decreased likelihood of ≥5 encounters. Three of 4 women had at least 1 unanticipated HRU encounter within 6 weeks after apical prolapse surgery. Preoperative teaching type was not associated with postoperative HRU. Telephone visits may be considered as an alternative to in-office visits for preoperative teaching.

Healthcare resource utilization following apical prolapse surgery in women who received in-office versus phone-only preoperative teaching

Healthcare resource utilization following apical prolapse surgery in women who received in-office versus phone-only preoperative teaching

Long-term safety and efficacy of non-absorbable abdominal mesh for apical prolapse surgery: A 10-year experience at Tertiary Care Hospital.

To evaluate the complications of apical prolapse correction with abdominally placed mesh and to assess the long-term efficacy of Sacrohysteropexy and Sacrocolpopexy. A retrospective cohort study was conducted at the Department of Gynecology and Obstetrics, Aga Khan University Hospital. All women who underwent apical prolapse surgery using abdominal mesh from January 2010 to December 2019 at AKUH were included. Patients with missing routine follow up visits and incomplete data up to one year post op were excluded. Patient notes were reviewed, and subjective and objective success and complications were analyzed. Safety was measured by incidence of intra, early and late postoperative complications and mesh-related complications of both procedures at two weeks, six months, twelve months, postoperatively. A total of 69 cases were retrieved from the database with a mean age of 46.97 ± 13.86 years. It was found that 14 (20.3%) patients had wound infection while six (8.7%) patients developed urinary tract infections. In a median follow-up of 12 months, three patients developed mesh erosion as a complication, with an incidence of 4.3%. Two required surgical excision of the mesh and the third was successfully managed conservatively with topical estrogen and oral antibiotics. Extremely significant improvements were observed in POPDI-six scores six months postoperatively (p=0.0001). The present study signifies the use of abdominally placed mesh in patients with pelvic organ prolapse indicating significant improvement in Pelvic Organ Prolapse-associated symptoms postoperatively.

Permanent Compared With Absorbable Suture in Apical Prolapse Surgery: A Systematic Review and Meta-analysis.

To explore how permanent compared with absorbable suture affects anatomic success in native tissue vaginal suspension (uterosacral ligament suspension and sacrospinous ligament suspension) and sacrocolpopexy with mesh. MEDLINE, EMBASE, and ClinicalTrials.gov were searched through March 29, 2022. Our population included women undergoing apical prolapse surgery (uterosacral ligament suspension and sacrospinous ligament suspension and abdominal sacrocolpopexy). Our intervention was permanent suture for apical prolapse surgery, and our comparator was absorbable suture. We determined a single anatomic success proportion per study. Adverse events collected included suture and mesh exposure, surgery for suture and mesh complication, dyspareunia, and granulation tissue. Abstracts were doubly screened, full-text articles were doubly screened, and accepted articles were doubly extracted. Quality of studies was assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. In single-arm studies using either permanent or absorbable suture, random effects meta-analyses of pooled proportions were used to assess anatomic success. In comparative studies investigating both suture types, random effects meta-analyses of pooled risk ratios were used. Of 4,658 abstracts screened, 398 full-text articles were assessed and 63 studies were included (24 vaginal suspension [13 uterosacral ligament suspension and 11 sacrospinous ligament suspension] and 39 sacrocolpopexy). At 2-year follow-up, there was no difference in permanent compared with absorbable suture in uterosacral ligament suspension and sacrospinous ligament suspension (proportional anatomic success rate 88% [95% CI 0.81-0.93] vs 88% [95% CI 0.82-0.92]). Similarly, at 18-month follow-up, there was no difference in permanent compared with absorbable suture in sacrocolpopexy (proportional anatomic success rate 92% [95% CI 0.88-0.95] vs 96% [95% CI 0.92-0.99]). On meta-analysis, there was no difference in relative risk (RR) of success for permanent compared with absorbable suture for uterosacral ligament suspension and sacrospinous ligament suspension (RR 1.11, 95% CI 0.93-1.33) or sacrocolpopexy (RR 1.00, 95% CI0.98-1.03). Success rates were similarly high for absorbable and permanent suture after uterosacral ligament suspension, sacrospinous ligament suspension, and sacrocolpopexy, with medium-term follow-up. PROSPERO, CRD42021265848.

Review of Vaginal Approaches to Apical Prolapse Repair.

To review recent literature and provide up-to-date knowledge on new and important findings in vaginal approaches to apical prolapse surgery. Overall prolapse recurrence rates following transvaginal apical prolapse repair range from 13.7 to 70.3% in medium- to long-term follow-up, while reoperation rates for prolapse recurrence are lower, ranging from 1 to 35%. Subjective prolapse symptoms remain improved despite increasing anatomic failure rates over time. The majority of studies demonstrated improvement in prolapse-related symptoms and quality of life in over 80% of patients 2-3years after transvaginal repair, with similar outcomes with and without uterine preservation. Contemporary studies continue to demonstrate the safety of transvaginal native tissue repair with most adverse events occurring within the first 2years. Transvaginal apical prolapse repair is safe and effective. It is associated with long-term improvement in prolapse-related symptoms and quality of life despite increasing rates of prolapse recurrence over time. Subjective outcomes do not correlate with anatomic outcomes.

Effect of BMI on Outcomes after Surgery for Apical Pelvic Organ Prolapse

<h3>Study Objective</h3> Evaluate the impact of obesity on outcomes after apical pelvic organ prolapse surgery. <h3>Design</h3> Retrospective cohort study using cases identified in the ACS-NSQIP database from 2014-2018. <h3>Setting</h3> Surgical cases from 722 hospitals nationally. <h3>Patients or Participants</h3> 26,898 females age 18-89 who underwent apical prolapse repair were identified by CPT codes. BMI categories are defined as: underweight (BMI <18.5, N=147), normal weight (BMI 18.5-24.9, N=7,374), overweight (BMI 25.0-29.9, N=10,268), class 1 obesity (BMI 30.0-34.9, N=5,810), class 2 obesity (BMI 35.0-39.9, N=2,240), and class 3 obesity (BMI ≥ 40.0, N=1,059). <h3>Interventions</h3> Participants underwent vaginal colpopexy (N=15,466), laparoscopic or robotic sacral colpopexy (N= 9,678), or abdominal sacrocolpopexy (N=1,754). <h3>Measurements and Main Results</h3> The average age of the cohort was 60 years, with 76.3% identifying as white race, 24.2% ASA class 3 or 4, 44.5% with a major medical comorbidity, and 9.0% smoking within one year. A total of 1,463 patients (5.4%) experienced a minor complication, 611 (2.3%) a major complication, and 1,993 (7.4%) any complication. Complication rates differed significantly by BMI class (minor p=0.005, major p<.001, any p<.001). Class 3 obesity had higher rates of any complication and minor complication compared to all classes except underweight and more major complication compared to normal, overweight and class 1 obesity. After adjusting for age, race, ASA class, smoking, and repair type, significant associations persisted between BMI and complications. <h3>Conclusion</h3> Based on national data from over 26,000 apical prolapse procedures, obesity is associated with post-operative complications. As obesity and average BMI in the US continue to increase, controlled studies are needed to confirm these findings. These results should be considered in preoperative planning and patient counseling.

Postoperative void trial failure and same-day discharge following apical pelvic organ prolapse surgery: a retrospective matched case-control study.

Robust data comparing the timing of voiding trials following prolapse surgery are lacking. Filling in these knowledge gaps would be helpful in counseling patients preoperatively about the concerns regarding same-day discharge. We aimed to compare the rate of a failed void trial after apical pelvic organ prolapse (POP) repair between patients who were discharged on the day of surgery versus those discharged on postoperative day 1. This was a retrospective matched case-control study of women who underwent either a laparoscopic/robotic or transvaginal apical POP surgery with or without concurrent hysterectomy. Patients who were discharged on postoperative day 0 (POD0) were identified as cases and matched to control patients discharged on postoperative day 1 (POD1). Patients were matched 1:1 based on age and surgical approach. A total of 59 patients in each group met the inclusion criteria. Of the entire cohort, 34 (28.8%) patients failed their void trial, with no statistically significant difference between those who were discharged on POD0 versus POD1 (33.9% vs 23.7%, p=0.47). Patients who were discharged on POD0 were more likely to be diagnosed with a urinary tract infection (22.0% vs 8.4%, p=0.041) during the postoperative period. In patients undergoing surgery for apical prolapse, there was no difference in the rate of void trial failure in those who had a catheter removal on the day of surgery compared with those who experienced removal the following day.

Outcomes following sacrocolpopexy using ultralight and lightweight mesh.

Introduction and hypothesisThis study reports the long-term anatomic and subjective outcomes following sacrocolpopexy based on mesh weight and provides device-specific data.MethodsThis cohort study compared ultra-lightweight (≤ 20 g/m2) with lightweight mesh (≥ 25 g/m2). The primary outcome was composite failure defined as at least one of ≥ stage 2 apical prolapse, anterior or posterior vaginal wall beyond hymen, complaint of bulge or retreatment. Effect measure estimates were calculated as the incidence rate ratio of composite failure comparing the use of ultra-light with lightweight mesh. Crude and adjusted incidence rate ratios (IRRs) were obtained using uni- and multivariable Poisson regression models.ResultsOf 358 women who met inclusion criteria, 220 (61%) agreed to attend for review; 95 (43%) had ultra-lightweight mesh and 125 (57%) had lightweight mesh including UpsylonTM. Median follow-up for ultra-light and lightweight mesh was 36 (IQR 22–42) and 63 (IQR 48–87) months, respectively (p < 0.001). Accounting for differences in follow-up time, there was no significant difference in composite failure between ultra-light and lightweight mesh groups (IRR 1.47, 95% CI 0.83–2.52, p = 0.15). This persisted after adjustment for age, body mass index, parity, smoking and presence of advanced prolapse prior to surgery (IRR 1.52, 95% CI 0.94–2.47, p = 0.087). Mesh exposure for both groups was mostly asymptomatic, and the rate was 7% for the ultra-light group and 8% in the lightweight group. Overall, repeat surgery for recurrent apical prolapse and mesh exposure occurred in 4% and 2%, respectively.ConclusionsUltra-lightweight mesh appears to have similar incidence rate of failure compared to lightweight mesh. UpsylonTM mesh has a similar low rate of recurrent apical prolapse and mesh exposure.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00192-022-05182-w.

Hysterectomy Versus Uterine Preservation at the Time of Pelvic Reconstructive Surgery.

To evaluate national trends in apical prolapse surgery with and without uterine preservation using the National Surgical Quality Improvement Program (NSQIP) database. Based on the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, patients diagnosed with uterovaginal prolapse who underwent apical suspensions between 2013 and 2018 were identified, and procedures involving uterine preservation were differentiated from those with concomitant hysterectomy. Patient characteristics and postoperative complications were analyzed. A total of 16 427 patients met inclusion criteria, with 2235 (13.6%) undergoing uterine-preservation procedures and 14 192 (86.4%) undergoing hysterectomy. Between 2013 and 2018, the rates of uterine preservation ranged from 12.8% to 15.3%, with the last 2 years having significantly lower rates. Patients in the uterine-preservation group were older (62.8 vs. 60.5 y; P < 0.001), had higher BMI (28.4 vs. 28.1 kg/m2; P= 0.018), and were more likely to have diabetes (12.4% vs. 10.5%; P= 0.006) and hypertension (43.4% vs. 38.0%; P < 0.001). These patients also had higher frailty index than hysterectomy patients. Patients in the uterine-preservation group were more likely to have vaginal mesh. There were no differences between the 2 groups in length of stay or postoperative complications. On multivariate logistic regression, older age (adjusted odds ratio [aoR] 1.02; P < 0.001), higher BMI (aOR 1.01; P= 0.009), and use of vaginal mesh (aOR 2.75; P<0.001) were associated with higher odds of uterine preservation. Uterine preservation decreased operative time by about 30 minutes after controlling for confounders. Patients with more comorbidities were more likely to undergo uterine-preserving surgeries, which offered reduced operative time and no differences in postoperative complications.