Time Of Pelvic Organ Prolapse Repair Research Articles

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

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

PD32-03 ROBOTIC SACROCOLPOPEXY WITH UTERUS PRESERVATION FOR WOMEN WITH COMPLETE VAGINAL VAULT EVERSION. SURGICAL TECHNIQUE WITH 10 YEAR EXPERIENCE

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Pelvic Prolapse (PD32)1 Sep 2021PD32-03 ROBOTIC SACROCOLPOPEXY WITH UTERUS PRESERVATION FOR WOMEN WITH COMPLETE VAGINAL VAULT EVERSION. SURGICAL TECHNIQUE WITH 10 YEAR EXPERIENCE Cassandra Schuster, and Robert Carey Cassandra SchusterCassandra Schuster More articles by this author , and Robert CareyRobert Carey More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002033.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic sacrocolpopexy with uterus preservation (RASCP-UP) is a transabdominal approach to repair of pelvic organ prolapse (POP) that avoids placement of transvaginal mesh and preserves female sexual organs. Although hysterectomy may be performed at the time of POP repair, many women choose to preserve their uterus for reasons of sexuality, female identity, religion, maintenance of maximal vaginal length, and resistance to removal of a normal organ. METHODS: Data is collected from an IRB approved prospectively maintained database of robotic POP repair in an 836 bed tertiary care hospital. The surgery is performed with a da Vinci Si or Xi system with 4 robotic ports and 1 assistant port. Commercially available 4 x 24 cm Y-shaped wide pore polypropylene mesh is modified to accommodate >10 cm anterior and posterior dissections of the vaginal walls. The anterior vaginal wall component is brought through the broad ligament and joined with the posteriorly placed component for attachment to the Anterior Longitudinal Ligament with GoreTex sutures. The mesh is then completely covered by peritoneum. All patients for RASCP-UP had Stage 4 prolapse with maximal anterior, posterior and apical descent with the cervix at the apex of the descent. All patients had normal PAP smears and pelvic ultrasounds. RESULTS: Between 2010 and 2021 a total of 351 patients underwent RASCP at the same institution. Of these, 54 presented with complete vaginal vault eversion requesting RASCP-UP. Mean age was 67.5 years and mean BMI 26.8. Cases were completed with robotic console time between 61 and 121 minutes and all patients discharged within 24-48 hours. At mean 60 month (12–124 month) follow-up, there were no mesh erosions, hernias, or reoperations for prolapse. There was one reoperation for hysterectomy at 6 year follow up for suspected endometrial carcinoma and one reoperation for small bowel obstruction in a patient with extensive lysis of adhesions. Mid-urethral slings were placed at the time of sacrocolpopexy to prevent de novo stress incontinence CONCLUSIONS: RASCP-UP is a reproducible, reliable procedure for patients with severe POP who desire uterus preservation. The surgery restores normal vaginal axis and length without placement of mesh material through vaginal mucosa. Long-term results show durable functional repair. Is the “unnecessary” removal of an otherwise normal uterus “necessary” for repair of POP? For a number of female patients, the answer appears to be no. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e545-e545 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Cassandra Schuster More articles by this author Robert Carey More articles by this author Expand All Advertisement Loading ...

08 The influence of race on pelvic organ prolapse surgery repair and complications

Studies indicate variations exist in surgical route and outcomes for treatment of gynecologic conditions among different races. The aim of this study was to investigate the difference in route of pelvic organ prolapse (POP) surgery and subsequent complications among women of different races and ethnicity in the United States. Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was used to estimate surgical route and complication rates. A total of 48,712 patients underwent a POP repair between 2014 and 2018, based on CPT codes. Based on the NSQIP database, patients were grouped by race and Hispanic ethnicity, and the route of POP repair was assessed. Primary outcome was the difference in surgical route (vaginal, laparoscopic, and abdominal) between groups. Secondary outcomes were differences in concomitant procedures and post-operative complications between groups. Descriptive statistics were used to analyze the data. All confidence intervals were computed using the normal approximation method. Statistical significance was P < 0.05. While a vaginal approach was the most common route across all groups, there was a significant difference in the route of POP repair among women of different races and ethnicities (P < 0.001; Table 1). Analysis revealed significantly more Black women undergoing laparoscopic procedures (P < 0.001), and more Hispanic women undergoing an abdominal approach (P < 0.001) than other groups. Black, Asian, and Hispanic women were more likely to undergo a hysterectomy than White women at the time of POP repair (P < 0.001). Black women were less likely to receive a concomitant sling than all other groups (P < 0.001). While readmission rates were not statistically different (P = 0.06; Table 2), the occurrence of one or more adverse event was significantly different between races (P < 0.0001), as was reoperation rate (P = 0.04). Black and Hispanic women were transfused 2-fold more often than White women, although the rates of transfusion overlapped with other non-White races (P < 0.001). Surgical approach to and outcomes of POP surgery differed significantly between races and Hispanic ethnicity. While more is needed to assess the impact of pre-existing co-morbidities on routes of surgery, reasons for why differences exist may not be fully elucidated from this dataset. Findings may reflect variations in prevalence of concurrent disorders among racial/ethnic groups, provider biases, patient preferences, and access to subspecialty-trained surgeons.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Balancing the possibility of needing a future incontinence procedure versus a future urethral sling revision surgery: a tradeoff analysis for continent women undergoing pelvic organ prolapse surgery.

Although urinary incontinence surgery has potential benefits such as preventing de novo stress urinary incontinence in women undergoing pelvic organ prolapse (POP) surgery, it comes with the potential cost of overtreatment and complications. We compared future surgery rates in a population cohort of women undergoing vaginal pelvic organ prolapse surgery. All women undergoing POP repair in California from 2005 to 2011 were identified from the Office of Statewide Health Planning and Development databases. Rates of repeat surgery in those with and without concomitant urethral sling procedures were compared. To control for confounding effects, multivariate mixed effects logistic regression models were constructed to compare each woman's individualized risk of undergoing either sling revision surgery or future incontinence surgery. In the cohort, 38,456 underwent a sling procedure at the time of POP repair and 42,858 did not. The future surgery rate was higher for sling-related complications in the POP + sling cohort compared with future incontinence surgery in the POP alone cohort (3.5% versus 3.0% respectively, p< 0.001). The difference persisted in multivariate modeling, where most women (60%) are at a higher risk of requiring sling revision surgery compared with needing a future primary incontinence procedure (40%). Women who undergo vaginal prolapse repair without an incontinence procedure are at a low risk of future incontinence surgery. Women without urinary incontinence who are considering vaginal POP surgery should be informed of the risks and benefits of including a sling procedure.

Rates and Risk Factors for Future Stress Urinary Incontinence Surgery after Pelvic Organ Prolapse Repair in a Large Population-based Cohort in California

ObjectivesTo determine the rate and risk factors for future stress urinary incontinence (SUI) surgery in a large population-based cohort of previously continent women following pelvic organ prolapse (POP) repair without concomitant SUI treatment. MethodsData from the Office of Statewide Health Planning and Development were used to identify all women who underwent anterior, apical, or combined anteroapical POP repair without concomitant SUI procedures in the state of California between 2005 and 2011 with at least 1-year follow-up. Patient and surgical characteristics were explored for associations with subsequent SUI procedures. ResultsOf 41,689 women undergoing anterior or apical POP surgery, 1,504 (3.6%) underwent subsequent SUI surgery with a mean follow-up time of 4.1 years. Age (odds ratio [OR] 1.01), obesity (OR 1.98), use of mesh at the time of POP repair (OR 2.04), diabetes mellitus (OR 1.19), white race, and combined anteroapical repair (OR 1.30) were associated with increased odds of future SUI surgery. ConclusionThe rate of subsequent surgery for de novo SUI following POP repair on a population level is low. Patient and surgical characteristics may alter a woman's individual risk and should be considered in surgical planning.

Incidence and Management of De Novo Lower Urinary Tract Symptoms After Pelvic Organ Prolapse Repair.

Pelvic organ prolapse (POP) is a significant problem with many options for surgical correction. Following prolapse surgery, de novo lower urinary tract symptoms (LUTS) are not uncommon. We review the current literature on de novo lower urinary tract symptoms following POP repair and discuss the role of urodynamics in the evaluation of the prolapse patient. Patients with occult stress urinary incontinence (SUI) appear to be at higher risk of developing de novo SUI after POP repair. Prolapse reduction in patients undergoing urodynamic evaluation is important. Different types of POP repair influence rates of de novo SUI. Also, prophylactic anti-incontinence procedures at time of POP repair appear to lower the incidence of de novo SUI, but at the cost of increased risk of complications and morbidity. Pre-existing overactive bladder (OAB) symptoms may either improve or persist, and de novo OAB can develop. The specific role of urodynamic study testing for POP is still being determined. Increasingly, women are seeking surgical treatment for POP. Aside from complications related to surgery in general, proper patient counseling is important regarding the risk of development of de novo voiding problems following surgery. Despite a growing body of literature looking at de novo voiding symptoms after prolapse repair, more studies are still needed.