Transvaginal Reconstructive Surgery Research Articles

Effect of mesh anchoring technique in uterine prolapse repair surgery: A finite element analysis

The female pelvic cavity involves muscles, ligaments, endopelvic fasciae and multiple organs where different pathologies may occur, namely the pelvic organ prolapse (POP). The synthetic implants are used for the reconstructive surgery of POP, but severe complications associated with their use have been reported, mainly related to their mechanical properties (e.g., implant stiffness) and microstructure.In this study, we mimicked a transvaginal reconstructive surgery to repair the apical ligaments (uterosacral ligaments (USLs) and cardinal ligaments (CLs)), by modeling, their impairment (90% and 50%) and/or total rupture. The implants to reinforce/replace these ligaments were built based on literature specifications and their mechanical properties were obtained through uniaxial tensile tests. The main aim of this study was to simulate the effect of mesh anchoring technique (simple stich and continuous stitch), and compare the displacement magnitude of the pelvic tissues, during Valsalva maneuver.The absence/presence of the synthetic implant was simulated when total rupture of the CLs and USLs occurs, causing a variation of the vaginal displacement (9% for the CLs and 27% for the USLs). Additionally, the simulations showed that there was a variation of the supero-inferior displacement of the vaginal wall between different anchoring techniques (simple stich and continuous stitch) being approximately of 10% for the simulation USLs and CLs implant.The computational simulation was able to mimic the biomechanical behavior of the USLs and CLs, in response to different anchoring techniques, which can be help improving the outcomes of the prolapse surgery.

Transvaginal reconstructive surgery for POP: Innovative approach to graft augmentation in the post-mesh era

Transvaginal reconstructive surgery for POP: Innovative approach to graft augmentation in the post-mesh era

Risk factors for the failure of iliococcygeus suspension for uterine prolapse

ObjectivesThe objective of this study was to evaluate the risk factors for the failure of iliococcygeus suspension (ICG) for uterine prolapse and estimate its long-term success rates using a clinically relevant criterion. Study designThis retrospective cohort study included 144 women who underwent transvaginal reconstructive surgery including ICG for symptomatic pelvic organ prolapse. Surgical failure was defined as anatomic recurrence (descent of the vaginal apex beyond the halfway point of the vagina or descent of the anterior or posterior vaginal wall beyond the hymen), symptomatic recurrence (vaginal bulge symptoms), or retreatment for prolapse. ResultsDuring the median 4-year follow-up period, surgical failure was observed in 20 women (13.9%). Multivariate analysis with the Cox proportional hazard model showed that advanced prolapse (preoperative pelvic organ prolapse quantification [POP-Q] stage >II and point C >0) and uterus-saving techniques were independent risk factors for failure. When the ICG was performed as a vault suspension procedure together with hysterectomy, the estimated 4-year success rates were 100% for mild prolapse (POP-Q stage II or point C ≤0) and 91.2% for advanced prolapse. When the procedure was done as a hysteropexy, the corresponding success rates decreased to 75.3% and 48.0%, respectively. ConclusionsThis study indicates that the severity of prolapse and the uterus-saving technique affect the prognosis after ICG. The ICG provides a durable apical vaginal support when performed together with hysterectomy, irrespective of the severity of the prolapse. In addition, it appears to be an acceptable hysteropexy option for mild uterine prolapse.

Perioperative Behavioral Therapy and Pelvic Muscle Strengthening Do Not Enhance Quality of Life After Pelvic Surgery: Secondary Report of a Randomized Controlled Trial.

There is significant need for trials evaluating the long-term effectiveness of a rigorous program of perioperative behavioral therapy with pelvic floor muscle training (BPMT) in women undergoing transvaginal reconstructive surgery for prolapse. The purpose of this study was to evaluate the effect of perioperative BPMT on health-related quality of life (HRQOL) and sexual function following vaginal surgery for pelvic organ prolapse (POP) and stress urinary incontinence (SUI). This study is a secondary report of a 2 × 2 factorial randomized controlled trial. This study was a multicenter trial. Participants were adult women with stage 2-4 POP and SUI. Perioperative BPMT versus usual care and sacrospinous ligament fixation (SSLF) versus uterosacral ligament suspension (ULS) were provided. Participants undergoing transvaginal surgery (SSLF or ULS for POP and a midurethral sling for SUI) received usual care or five perioperative BPMT visits. The primary outcome was change in body image and in Pelvic Floor Impact Questionnaire (PFIQ) short-form subscale, 36-item Short-Form Health Survey (SF-36), Pelvic Organ Prolapse-Urinary Incontinence Sexual Questionnaire short form (PISQ-12), Patient Global Impression of Improvement (PGII), and Brink scores. The 374 participants were randomized to BPMT (n=186) and usual care (n=188). Outcomes were available for 137 (74%) of BPMT participants and 146 (78%) of the usual care participants at 24 months. There were no statistically significant differences between groups in PFIQ, SF-36, PGII, PISQ-12, or body image scale measures. The clinicians providing BPMT had variable expertise. Findings might not apply to vaginal prolapse procedures without slings or abdominal apical prolapse procedures. Perioperative BPMT performed as an adjunct to vaginal surgery for POP and SUI provided no additional improvement in QOL or sexual function compared with usual care.

Hyperbaric Oxygen Therapy to Promote Vaginal Wall Healing after Salvage Surgery for Mesh-related Complication

Patients with multiple failed vaginal surgeries utilizing synthetic mesh present a therapeutic challenge. We present a case of a 75-year-old woman with severe stress urinary incontinence and mesh extrusion after two failed synthetic sling surgeries. Surgical reconstruction consisted of mesh excision, urethral reconstruction with vaginal tubularization, autologous rectus fascia sling placement. The patient developed a vaginal hematoma and wound dehiscence post-operatively, which was treated with surgical debridement and hyperbaric oxygen (HBO). The patient’s wound healed well, and she regained full continence, which was sustained at 10 months postoperatively. HBO therapy promotes wound healing after complex transvaginal reconstructive surgery.

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Urethro-vaginal fistulae (UVF) occur usually as infrequent complications of a variety of gynecological surgical procedures. The aim of this study was to present an interesting case of a complicated UVF diagnosed after gynaecological surgery. A 61-year-old gravida-2, para-2, post-menopausal woman was referred with a complaint of urine loss through the vagina. She had undergone anterior and posterior vaginal wall repair due to cystocele and stress urinary incontinence (SUI). Transvaginal repair was performed 20 weeks after primary surgery. However, a second transvaginal reconstructive surgery using Martius-flap originating from the bulbocavernosus muscle was necessary due to persistent urine leakage in the vagina. Thirty-two months after successful urethro-vaginal treatment, the patient self-referred for persistent SUI. Burch colposuspension was performed and at 16 months follow-up the patient remains continent. Surgical repair of complicated UVF seems to be more successful with Martius flap interposition than with no interposition.

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse

The objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery. The charts of 142 patients who underwent transvaginal reconstructive surgery with mesh were included in the analysis. Primary outcome was the incidence of PUR following surgery with mesh. Patients were grouped according to discharge from the hospital with or without a catheter based on a standardized voiding trial. Forty-eight patients (34%) developed PUR after surgery. Of those, 30 patients (62.5%) had a combined anterior and posterior repair (p = 0.033). Mean preoperative anterior stage prolapse for patients with PUR compared with no PUR was 2.31 vs. 1.80 (p = 0.002). There was a greater association of PUR among patients with concomitant retropubic slings compared with transobturator slings (OR = 3.6, 95% confidence interval = 1.3-9.8). A higher preoperative anterior stage prolapse, combined anterior and posterior compartment repairs, and retropubic sling procedures appear to be associated with PUR.

Anatomical conditions for pelvic floor reconstruction with polypropylene implant and its application for the treatment of vaginal prolapse

Objective The purpose of the surgical treatment of vaginal prolapse is not only the restoration of the anatomy but also of the visceral functioning. To maintain the quality of life for patients with recurrent vaginal prolapse, to reduce the failure rates of operations and to avoid a colpectomy or a colpocleisis at the same time, synthetic materials have been introduced in transvaginal reconstructive surgery of the pelvic floor. The TVM Group from France described the reconstruction of the pelvic floor with polypropylene implants in 2004. The aim of this study is to determine the anatomical position of the polypropylene implants after reconstruction of each compartment of the pelvic floor and to determine the relation of the implants to the major neighbouring neurovascular structures on the basis of corpse dissections. Study design Following the technique of the TVM Group from France we present the pelvic floor reconstruction using Gynecare Prolift* (Ethicon, Sommerville, NJ, USA). To reach the aims of the study, anatomical dissections of the pelvic floor on three specially preserved anatomical specimens are performed after the placement of the implants. Results The anatomical dissections show that every defect in all three compartments of the pelvic floor can be repaired by using polypropylene implants. Between the implants and the major neighbouring neurovascular structures a safe distance exists with slight individual differences. Conclusion The pelvic floor reconstruction using polypropylene implants is a treatment option especially for the surgical correction of the recurrent vaginal prolapse. If the surgeon has thorough anatomical knowledge and performs the surgical technique in the recommended manner, injuries of the major neighbouring neurovascular structures will be avoided. Clinical studies will analyze the long-term results after pelvic floor reconstruction using polypropylene implants.

腟管上部下垂（脱出）に対する腟式修復術

腟管上部下垂（脱出）に対する腟式修復術

A Transvaginal Approach to Repair of Apical and Other Associated Sites of Pelvic Organ Prolapse With Uterosacral Ligaments

Abstract Objective: The objectives of this study were (1) to describe a group of women with pelvic organ prolapse associated with apical loss of support through grading with the Baden-Walker halfway system before, during, and after the corrective operation, (2) to describe the operative repair of the support defects, (3) to report the morbidity associated with the operative repair, and (4) to assess the durability of the repair at each site. Study Design: Between January 1, 1994, and December 31, 1998, a total of 302 consecutive women with apical and associated other support defects were evaluated before, during, and after the corrective operation by the senior author (Bob L. Shull). All patients underwent transvaginal reconstructive surgery with native tissue. Two hundred eighty-nine patients (96%) returned for at least one postoperative visit, and they constitute the group used for the follow-up data. Perioperative morbidity was considered to include hemorrhage necessitating homologous blood transfusion, visceral injury, neurologic impairment, or death. Durability was assessed by means of life-table analysis for each of 5 sites in the vagina. Results: All patients had preoperative or intraoperative evidence of grade 1 or greater apical loss of support of and at least one other site of pelvic organ prolapse. Two hundred eighty-nine patients (96%) returned for at least one postoperative visit. Two hundred fifty-one patients (group 1, 87%) had optimal anatomic outcomes, with no persistent or recurrent support defects at any site. Thirty-eight patients (group 2, 13%) had one or more sites with at least grade 1 loss of support during the follow-up interval. Twenty-four of these 38 patients had grade 1 defects that were detectable only on careful pelvic examination. Fourteen of these patients (5%) had grade 2 or greater persistent or recurrent support defects. The anterior segment (bladder) was the site with the most persistent or recurrent support defects, which means that it was the site of the least durable repair. The urethra and cuff had the most durable repairs. Morbidity included a 1% transfusion rate, a 1% ureteral injury or ureteral kinking rate, and a 0.3% postoperative death rate. Conclusion: Careful preoperative and intraoperative evaluation of pelvic support defects and the use of native connective tissue and uterosacral ligaments are associated with excellent anatomic outcomes. The durability of the surgical correction varies according to the individual site of repair and the duration of postoperative follow-up. (Am J Obstet Gynecol 2000;183:1365-74.)

A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments

Objective: The objectives of this study were (1) to describe a group of women with pelvic organ prolapse associated with apical loss of support through grading with the Baden-Walker halfway system before, during, and after the corrective operation, (2) to describe the operative repair of the support defects, (3) to report the morbidity associated with the operative repair, and (4) to assess the durability of the repair at each site. Study Design: Between January 1, 1994, and December 31, 1998, a total of 302 consecutive women with apical and associated other support defects were evaluated before, during, and after the corrective operation by the senior author (Bob L. Shull). All patients underwent transvaginal reconstructive surgery with native tissue. Two hundred eighty-nine patients (96%) returned for at least one postoperative visit, and they constitute the group used for the follow-up data. Perioperative morbidity was considered to include hemorrhage necessitating homologous blood transfusion, visceral injury, neurologic impairment, or death. Durability was assessed by means of life-table analysis for each of 5 sites in the vagina. Results: All patients had preoperative or intraoperative evidence of grade 1 or greater apical loss of support of and at least one other site of pelvic organ prolapse. Two hundred eighty-nine patients (96%) returned for at least one postoperative visit. Two hundred fifty-one patients (group 1, 87%) had optimal anatomic outcomes, with no persistent or recurrent support defects at any site. Thirty-eight patients (group 2, 13%) had one or more sites with at least grade 1 loss of support during the follow-up interval. Twenty-four of these 38 patients had grade 1 defects that were detectable only on careful pelvic examination. Fourteen of these patients (5%) had grade 2 or greater persistent or recurrent support defects. The anterior segment (bladder) was the site with the most persistent or recurrent support defects, which means that it was the site of the least durable repair. The urethra and cuff had the most durable repairs. Morbidity included a 1% transfusion rate, a 1% ureteral injury or ureteral kinking rate, and a 0.3% postoperative death rate. Conclusion: Careful preoperative and intraoperative evaluation of pelvic support defects and the use of native connective tissue and uterosacral ligaments are associated with excellent anatomic outcomes. The durability of the surgical correction varies according to the individual site of repair and the duration of postoperative follow-up. (Am J Obstet Gynecol 2000;183:1365-74.)