Treatment Of Pelvic Organ Prolapse Research Articles

Long-term pelvic organ prolapse recurrence and mesh exposure following sacrocolpopexy.

Large, long-term studies are needed to compare pelvic organ prolapse (POP) recurrence and mesh exposure following all modes of sacrocolpopexy (open, robotic, and laparoscopic). We hypothesized that the prevalence of recurrent POP and mesh exposure does not differ between modes of sacrocolpopexy. This is a retrospective cohort study with a cross-sectional, prospective survey. Participants were surveyed regarding complications, retreatments, and symptoms following sacrocolpopexy. Baseline characteristics, POP recurrence, mesh exposure, and survey responses were compared. A total of 709 participants met the criteria. Median time from sacrocolpopexy to last follow-up for all participants was 0.5years (2days to 13.4years). 15.0% experienced recurrent stage 2 or greater POP or underwent retreatment (open 11.7% [95% CI 7.8-17.2%]; robotic 21.1% [95% CI 15.6-27.9%]; laparoscopic 13.8% [95% CI 10.6-17.9%]; p = 0.03). After adjusting for baseline differences there was no significant difference among groups (p = 0.30). 5.3% experienced mesh and/or suture exposure (mesh n = 19, suture n = 10, mesh and suture n = 8) with no significant difference among groups (open 7.7% [95% CI 4.6-12.5%]; robotic 3.6% [95% CI 1.7-7.6%]; laparoscopic 4.9% [95% CI 3.1-7.7%]; p = 0.20). Median time from sacrocolpopexy to survey completion was 6.5 (1.6-13.4) years. 9.2% reported evaluation or treatment for recurrent POP (open 6.3% [95% CI 2.1-16.8%]; robotic 12.5% [95% CI 6.9-21.5%]; laparoscopic 8.5% [5.1-13.8%]; p = 0.44). 6.9% reported evaluation or treatment for mesh exposure (open 6.0% [95% CI 2.1-16.2%]; robotic 3.9% [95% CI 1.3-10.7%]; laparoscopic 8.6% [5.2-13.9%]; p = 0.38). Objective and patient-reported long-term prevalence of POP recurrence and mesh exposure are low following all modes of sacrocolpopexy.

Timing of Office-Based Pessary Care: A Randomized Controlled Trial

(Abstracted from Obstet Gynecol 2020;135:100–105) Vaginal pessaries are recommended often as first-line treatment of pelvic organ prolapse and stress urinary incontinence, especially for women who do not desire surgery or who are poor surgical candidates. Several studies have shown that pessaries improve symptoms of prolapse, bowel symptoms, body image perception, and overall quality of life.

V13-02 ROBOTIC ASSISTED SACROCOLPOPEXY WITH AND WITHOUT HYSTERECTOMY: TIPS FOR EFFICIENCY

You have accessJournal of UrologyFemale Pelvic Surgery (V13)1 Apr 2020V13-02 ROBOTIC ASSISTED SACROCOLPOPEXY WITH AND WITHOUT HYSTERECTOMY: TIPS FOR EFFICIENCY Siri Drangsholt*, Daniel Lieberman, and Patrick Culligan Siri Drangsholt*Siri Drangsholt* More articles by this author , Daniel LiebermanDaniel Lieberman More articles by this author , and Patrick CulliganPatrick Culligan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000970.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic Assisted Sacrocolpopexy is a commonly performed surgery and is considered the gold standard for pelvic organ prolapse treatment. Here we present our tips for efficiency for the novice and experienced surgeons. METHODS: We present two cases of robotic sacrocolpopexy. RESULTS: Video CONCLUSIONS: Robotic Assisted Sacrocolpopexy can be performed efficiently and successfully with our detailed steps. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1211-e1211 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Siri Drangsholt* More articles by this author Daniel Lieberman More articles by this author Patrick Culligan More articles by this author Expand All Advertisement PDF downloadLoading ...

Electrospun Nanofiber Meshes With Endometrial MSCs Modulate Foreign Body Response by Increased Angiogenesis, Matrix Synthesis, and Anti-Inflammatory Gene Expression in Mice: Implication in Pelvic Floor.

PurposeTransvaginal meshes for the treatment of Pelvic Organ Prolapse (POP) have been associated with severe adverse events and have been banned for clinical use in many countries. We recently reported the design of degradable poly L-lactic acid-co-poly ε-caprolactone nanofibrous mesh (P nanomesh) bioengineered with endometrial mesenchymal stem/stromal cells (eMSC) for POP repair. We showed that such bioengineered meshes had high tissue integration as well as immunomodulatory effects in vivo. This study aimed to determine the key molecular players enabling eMSC-based foreign body response modulation.MethodsSUSD2+ eMSC were purified from single cell suspensions obtained from endometrial biopsies from cycling women by magnetic bead sorting. Electrospun P nanomeshes with and without eMSC were implanted in a NSG mouse skin wound repair model for 1 and 6 weeks. Quantitative PCR was used to assess the expression of extracellular matrix (ECM), cell adhesion, angiogenesis and inflammation genes as log2 fold changes compared to sham controls. Histology and immunostaining were used to visualize the ECM, blood vessels, and multinucleated foreign body giant cells around implants.ResultsBioengineered P nanomesh/eMSC constructs explanted after 6 weeks showed significant increase in 35 genes associated with ECM, ECM regulation, cell adhesion angiogenesis, and immune response in comparison to P nanomesh alone. In the absence of eMSC, acute inflammatory genes were significantly elevated at 1 week. However, in the presence of eMSC, there was an increased expression of anti-inflammatory genes including Mrc1 and Arg1 by 6 weeks. There was formation of multinucleated foreign body giant cells around both implants at 6 weeks that expressed CD206, a M2 macrophage marker.ConclusionThis study reveals that eMSC modulate the foreign body response to degradable P nanomeshes in vivo by altering the expression profile of mouse genes. eMSC reduce acute inflammatory and increase ECM synthesis, angiogenesis and anti-inflammatory gene expression at 6 weeks while forming newly synthesized collagen within the nanomeshes and neo-vasculature in close proximity. From a tissue engineering perspective, this is a hallmark of a highly successful implant, suggesting significant potential as alternative surgical constructs for the treatment of POP.

Evaluation of the effect of abdominal sacrocolpopexy (ASC) on urethral anatomy and continence mechanism using dynamic MRI.

Treatment of pelvic organ prolapse (POP) associated with stress urinary incontinence (SUI) is a surgical challenge. Surgeons may perform combined prolapse and incontinence surgery or may correct prolapse first and evaluate incontinence afterwards. We present a prospective study to evaluate the effect of abdominal sacrocolpopexy (ASC) on urethral anatomy and continence using dynamic magnetic resonance imaging (MRI). Twenty females with concomitant apical prolapse and SUI due to urethral hypermobility were included. Patients with intrinsic sphincteric deficiency (ISD) were excluded. All patients underwent ASC operation as a sole treatment without anti-incontinence procedure. Patients were informed they may need anti-incontinence procedure afterwards. Symptom-specific questionnaires assessing prolapse, incontinence, sexual function and quality of life (QoL), dynamic MRI and pressure flow urodynamic study were administered before and after surgery. Mean age was 53years. All patients had apical prolapse; four with cystocele, and five with rectocele. Urethral hypermobility was positive in all patients. After performing ASC, all patients reported significant improvement of all prolapse and incontinence questionnaires as well as QoL and sexual function. Significant improvement of incontinence parameters on dynamic MRI (bladder neck descent, posterior urethrovesical angle and urethral inclination angle) was observed after ASC. Similarly, significant change in the position of the leading edge of prolapse and anorectal junction was observed. In patients with prolapse and urethral hypermobility, ASC may return bladder neck and urethral anatomy towards normal as proved by dynamic MRI. However, further studies on larger number of patients with longer follow-up period are required.

AB266. A review of mesh excisions over a four-year period in Cork University Maternity Hospital (CUMH)

Background: Synthetic mesh has been widely used in the surgical treatment of stress urinary incontinence and pelvic organ prolapse. Due to controversy regarding the safety of mesh devices, the use of mesh in urogynaecological procedures is currently on hold in Ireland.

13: The art of peritoneal closure during sacrocolpopexy

To demonstrate an efficient surgical technique for peritoneal closure at the time of laparoscopic sacrocolpopexy. Laparoscopic sacrocolpopexy is a common surgical treatment for pelvic organ prolapse. Closure of the peritoneum over the mesh has historically been recommended by both expert surgeons and mesh manufacturers to decrease the risk of bowel obstruction, adhesion formation, and mesh erosion. Case reports of these complications have been published in the urogynecology and general surgery literature. However, controversy remains as the benefits of re-peritonealization have been difficult to demonstrate, even in studies of up to 400 patients. In addition, many surgeons find this step time-consuming and difficult to perform as the peritoneum is delicate and tears can result in gaps over the mesh or bowel obstruction. In light of the seriousness of bowel obstruction or mesh erosion and the litigious environment in which most gynecologists practice, many surgeons continue to perform peritoneal closure in the absence of further safety data. We present a video demonstrating one surgeon’s technique for efficient peritoneal closure at the time of laparoscopic sacrocolpopexy. Key steps include retraction of the sigmoid epiploica using a stitch pulled through the anterior abdominal wall, creation of a retroperitoneal tunnel from the sacral peritoneal window to the rectovaginal dissection, and use of a monofilament suture for the remaining re-peritonealization. With the appropriate techniques, peritoneal closures over mesh at the time of laparoscopic sacrocolpopexy can be performed with relative ease and efficiency.

Age-associated differences in macrophage response in a vaginal wound healing rat model.

Surgical treatment of pelvic organ prolapse often includes the use of patients' vaginal connective tissue. Wound healing appears to play an important part in the success of such procedures. The aim of this study was to describe the effect of age on inflammatory processes, specifically macrophage response, involved in vaginal wound healing. Twenty-five young (12weeks old) and 25 old (12months old) virgin female Fischer rats underwent a standardized 9-mm posterior midline vaginal incision. Tissue samples were taken for histological analysis on days 1, 3, 7, 14 and 30 post-injury. Parameters evaluated included wound area, macrophage number and expression of inflammatory markers including tumor necrosis factor alpha (TNFa), inducible nitric oxide synthase (iNOS), CCR7/CD197, arginase I and CD163/M130. Microscopic examination of the vaginal wounds over time demonstrated a clear difference between young and old rats in spontaneous healing capacity. The average wound area in young rats 1 day after injury was significantly smaller than in old rats (16.5 ± 1.7 vs. 23.8 ± 1.5mm2, P < 0.05). At 3days post-injury, wounds were closed in young rats but still open in old rats (wound area: 13.5 ± 1.5 mm2). Old rats demonstrated a more excessive and sustained macrophage response compared with young rats. They also demonstrated a disordered pattern of macrophage expression over time, with a prolonged expression of TNFa and iNOS in the tissue and a disordered M2 macrophage response. Excessive and prolonged macrophage response in older rats may contribute to poor wound healing in the vagina.

Self-cut titanium-coated polypropylene mesh versus pre-cut mesh-kit for transvaginal treatment of severe pelvic organ prolapse: study protocol for a multicenter non-inferiority trial

BackgroundPelvic organ prolapse (POP) is a common health problem and has significant negative effects on a woman’s quality of life. The transvaginal mesh procedure is a durable reconstructive surgery, but the mesh kits are expensive for underdeveloped countries. Our previous case-series study showed that the use of self-cut mesh had a good success rate (91.8% at 1-year follow-up) and low complication rate. This trial is designed to compare a self-cut titanium-coated polypropylene mesh procedure with a mesh kit for the treatment of symptomatic stage III–IV anterior or apical prolapse in terms of efficacy, safety and cost-effectiveness.MethodsThe trial is a randomized controlled multicenter non-inferiority trial. The primary outcome measure is the composite success rate at 1-year follow-up. The secondary outcomes are anatomic outcomes of each vaginal segment (anterior, posterior and apical) using the POP-Q score, subjective improvement of quality of life according to questionnaires, intraoperative parameters, complications and costs. Analysis will be performed according to the intention-to-treat principle. Based on a comparable success rate of 90% and 10% as the margin (β = 0.2 and one-sided α = 0.025), about 312 patients in total from 11 centers will be recruited including 10% dropout. The aims of the research are to demonstrate whether the self-cut mesh procedure is non-inferior to the mesh-kit procedure and to investigate the performance of titanium-coated mesh for vaginal prolapse repair.DiscussionThis multicenter non-inferiority trial will evaluate whether the efficacy and safety of self-cut mesh is non-inferior to mesh kits in women with severe symptomatic stage III–IV anterior or apical prolapse. If we are able to show that the self-cut mesh procedure is non-inferior to the mesh-kit procedure in success rates, then the self-cut mesh procedure may be more cost-effective.Trial registrationClinicalTrials.gov, NCT03283124. Registered on 17 January 2018.

Is it safe and effective to maintain the vaginal pessary without removing it for 2consecutive years?

The study was aimed at evaluating the safety and efficacy of ring pessaries without support under continuous use without periodic removal or replacement for the treatment of advanced pelvic organ prolapse (POP) in women for 2consecutive years. This study was a prospective observational study. A total of 123 women were recruited in a tertiary hospital from January 2013 to January 2016. The primary objective was the percentage of patients maintaining the use of the pessary after 24months. The secondary objectives were the reasons for discontinuation and the adverse events in patients with successful fittings. A total of 115 patients (93.5%) had a successful fitting. Four patients died of non-pessary-related causes during the study and, one patient dropped out the follow-up so that finally, 110 patients were included in the efficacy analysis. Pessary use was maintained by 91.8% of the women at the end of the study. The adverse events rate was low (27.0%). The two main factors of interruption in the pessary use were: age (OR 0.93; 95% CI 0.87-0.99) and history of urinary urge incontinence (OR 0.33; 95% CI 0.11-0.96]). A high success rate and low adverse events rate were achieved in patients with advanced-stage POP with continuous pessary use for 24months, indicating that a ring pessary could also be used without periodic removal for at least the first 2years. This practice could reduce the number of control visits.

Evaluation of single-incision apical vaginal suspension for treatment of pelvic organ prolapse

ObjectiveTo present a comprehensive evaluation of anterior/apical and/or posterior prolapse repair systems with a focus on safety and surgical efficacy. MethodsTwo hundred and twenty women with pelvic organ prolapse (POP) stage II–IV were referred for single-incision transvaginal mesh procedures in a single institution. Pre- and postoperative assessments included pelvic examination, urodynamic studies, and personal interviews about patients’ quality of life and urinary symptoms. ResultsThe anatomical success rate was 92.3 % (203/220), regardless of primary or de-novo POP, at 12–38 month follow-up. The POP quantification parameters, except total vaginal length, improved significantly after surgery (p < 0.05). Complications included bladder injury (one case), mesh exposure (six cases) and urinary retention that required intermittent catheterization (five cases). There were no cases of bowel injury during surgery. The results indicated that 29 % of patients had de-novo stress urinary incontinence and 7.7 % of patients had de-novo POP after surgery. ConclusionThe apical vaginal suspension system is a safe and effective procedure, creating good anatomical restoration and significant improvement in quality of life. However, the rate of de-novo POP in the anterior compartment of the vagina (31.8 %) seems high after treatment with apical and posterior prolapse repair systems.

Withdrawal: Implementation of specially designed enhanced recovery after surgery protocols versus conventional protocol in total pelvic floor reconstructive surgery.

To evaluate outcomes of perioperative recovery indices and the application value of specially designed enhanced recovery after surgery (ERAS) protocols in total pelvic floor reconstructive surgery. Data of 300 womenwith stage III or IV pelvic organ prolapse undergoing total pelvic floor reconstructive surgerybetweenMarch 2013 and August 2016 at a single institute were studied retrospectively. Women were divided intotwo groupsaccording tobeforeorafter implementation of ERASprotocols.The ERAS group received ERAS protocols (149 cases) andthe pre-ERAS group received conventional treatment (151 cases).Indices of postoperative recoveryand incidence of complications were statistically analyzed. The ERAS group versus the pre-ERAS group differ in first flatus time (37.75±9.26vs.41.92±13.19 h), hospitalization days (4.98±1.25vs.6.93±1.24 days), cost of hospitalization (47 132.93±7297.02vs.49 069.54±6340.25 CNY),and first mobilization out of bed time(29.19±8.05 vs.49.86±9.87 h). The differences were statistically significant.Compared with the pre-ERAS group,fewer patientsin the ERASgroup had pain and urinary retention after surgery. ERAS protocols for the perioperative period of total pelvic floor reconstructive surgery is safe, economical, and reliable, and has a great role in promoting the standardized treatment of pelvic organ prolapse.

Functional supramolecular bioactivated electrospun mesh improves tissue ingrowth in experimental abdominal wall reconstruction in rats

Development of biomaterials for hernia and pelvic organ prolapse (POP) repair is encouraged because of high local complication rates with current materials. Therefore, we aimed to develop a functionalized electrospun mesh that promotes tissue ingrowth and provides adequate mechanical strength and compliance during degradation. We describe the in vivo function of a new supramolecular bioactivated polycarbonate (PC) material based on fourfold hydrogen bonding ureidopyrimidinone (UPy) units (UPy-PC). The UPy-PC material was functionalized with UPy-modified cyclic arginine-glycine-aspartic acid (cRGD) peptide additives. Morphometric analysis of the musculofascial content during wound healing showed that cRGD functionalization promotes myogenesis with inhibition of collagen deposition at 14 days. It also prevents muscle atrophy at 90 days and exerts an immunomodulatory effect on infiltrating macrophages at 14 days and foreign body giant cell formation at 14 and 90 days. Additionally, the bioactivated material promotes neovascularization and connective tissue ingrowth. Supramolecular cRGD-bioactivation of UPy-PC-meshes promotes integration of the implant, accelerates tissue ingrowth and reduces scar formation, resulting in physiological neotissue formation when used for abdominal wall reconstruction in the rat hernia model. Moreover, cRGD-bioactivation prevents muscle atrophy and modulates the inflammatory response. Our results provide a promising outlook towards a new type of biomaterial for the treatment of hernia and POP. Statement of SignificanceDevelopment of biomaterials for hernia and pelvic organ prolapse (POP) repair is encouraged because of high local complication rates with current materials. Ureidopyrimidinone-polycarbonate is a elastomeric and biodegradable electrospun mesh, which could mimic physiological compliance. The UPy-PC material was functionalized with UPy-modified cyclic arginine-glycine-aspartic acid (cRGD) peptide additives. Supramolecular cRGD-bioactivation of UPy-PC-meshes promotes integration of the implant, accelerates tissue ingrowth and reduces scar formation, resulting in physiological neotissue formation when used for abdominal wall reconstruction in rat hernia model. Moreover, cRGD-bioactivation prevents muscle atrophy and modulates the inflammatory response. These data provide a promising outlook towards a new type of biomaterial for the treatment of hernia and POP.

Technical considerations and mid-term follow-up after vaginal hysterocolpectomy with colpocleisis for pelvic organ prolapse

ObjectivesAt the time of controversies on surgical treatment of pelvic organ prolapse, our aim was to describe an effective technique of hysterocolpectomy with colpocleisis for elderly patients not wishing to maintain vaginal sexual activity and present mid-term results including pelvic floor symptoms and quality of life, patient satisfaction and surgical complications using validated scores. Study designWe conducted a retrospective study of all patients having undergone this surgery between June 2006 and June 2016. Women were examined using POP-Q classification and completed validated questionnaires concerning symptoms and quality of life before and after the surgery. Patient satisfaction was assessed using the PGI-I. Complications were described according to the Clavien-Dindo classification. ResultsDuring the 10-year period, 37 women underwent the surgery with a mean age at surgery of 81.2 years (range: 61–93 years). One per-operative complication occurred (a rectal wound that was sutured) and five Clavien-Dindo grade 3b postoperative complications. Three repeat operations were necessary within 15 days; one suburethral sling had to be lowered because of urinary retention; one tension-free vaginal tape had to be unilaterally sectioned for acute urinary retention; and one woman presented a pararectal abscess requiring surgical drainage. The mean duration of hospitalization was 5.5 (+/-4.2) days. The mean follow-up time was 44.1 (±30.1) months. All symptoms and quality of life scores decreased significantly after the surgery and patient satisfaction was good (PGI-I score = 1.55 +/-0.8). ConclusionsHysterocolpectomy with colpocleisis appears to be an effective treatment with a high level of patient satisfaction among the elderly.

Quality of life and sexuality after bilateral sacrospinous fixation with vaginal hysterectomy for treatment of primary pelvic organ prolapse.

To investigate the quality of life (QoL) and sexuality in women affected by pelvic organ prolapse (POP) and treated by bilateral sacrospinous ligament fixation (SSLF) with vaginal hysterectomy. This is a prospective observational study carried out at Isparta City Hospital from July 2017 to December 2018. A total of 26 sexually active women with symptomatic uterine prolapse POP-Q (Pelvic Organ Prolapse Quantification) stage II or higher requiring surgery were included in the study. Short Form Health Survey (SF-36) was used preoperatively and at 6 months to examine the impacts of vaginal reconstruction on QoL. To assess sexual functioning, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) was used preoperatively and at 6 months. A significant improvement of POP-Q landmarks was found between pre- and posttreatment at 6 months of follow-up. The patients reported QoL improvement at the follow-up for all the categories of physical functioning, bodily pain, physical health, general health, vitality, social activity, emotional state, and mental health with respect to the baseline values (P < .001). The results of PISQ-12 demonstrated a significant improvement for all the three fields: behavioral emotive factor, physical factor, and partner-related factor, and the total score at 6 months after surgery (P < .001). This study clearly demonstrates that bilateral SSLF is able to significantly improve both QoL and sexual function in patients with POP. Improvement in sexuality and QoL after surgery may be explained by correction of avoidance of sexual intercourse due to prolapse and physical recovery.

Characteristics of opioid users undergoing surgery for pelvic organ prolapse.

Understanding demographic and opioid utilization patterns of preoperative opioid users compared with opioid-naïve patients undergoing surgical treatment for pelvic organ prolapse (POP) better informs opioid prescribing. A cohort of preoperative opioid users undergoing surgery for POP from 1 January 2012 through 30 May 2017 was identified. Electronic medical records were utilized to obtain pain scores and prescription data. The cohort was organized by surgical approach, number of concomitant procedures, and patient age. These factors were then matched to pain scores, opioid quantity prescribed at discharge, and subsequent refills. Pain scores and opioid use were evaluated for correlation. Results were then compared with similar data previously published for opioid-naïve patients undergoing surgical treatment of POP. Preoperative opioid users were younger (55.5 [14.7] vs 59.5 [12.7]; p= 0.002), of higher body mass index (BMI; 29.2 [5.4] vs 28.6 [10.3]; p= 0.04), and less likely Caucasian (90.3% vs 95.9%; p= 0.002) than opioid-naïve patients. After matching for these differences, opioid users reported higher pain scores (3.5 [2.2] vs 2.6 [1.8]; p = <0.0001), but received similar opioid quantities (324.4 [395] vs 296 [158] oral morphine equivalents [OME]; p= 0.27; 16.8% vs 10.4% refill rates; p= 0.07). In preoperative opioid users, neither surgical approach nor the number of concomitant procedures influenced pain scores. Increasing mean pain scores (1.8 [2.0] to 4.2 [2.4]; p< 0.002) and OME prescribed (226 [170.2] to 541 [902.5] p= 0.056; 0% to 22.2% refill rates; p= 0.02), were seen with decreasing patient age. Pain scores correlated directly with the opioid amount prescribed. Patient age and preoperative opioid utilization should be factored into urogynecological postoperative opioid-prescribing protocols.

Risk of pelvic organ prolapse treatment based on extended family history

Family history of pelvic organ prolapse among first-degree relatives is an established risk factor for pelvic organ prolapse; however, consideration of the constellation of family history that extends to distant relationships allows for more accurate determination of risk and may improve pelvic organ prolapse risk prediction estimates. The purpose of this study was to assess risk for pelvic organ prolapse treatment based on varying family histories of pelvic organ prolapse and included number and types of affected relatives, ages of relatives at pelvic organ prolapse treatment, and whether the family history is of maternal or paternal origin. This was a retrospective, population-based study that involved the Utah Population Database, which is a population resource that includes extensive genealogy information linked to medical records. The study population included 453,522 total women: 4628 women with a diagnosis of treated (surgical or pessary) pelvic organ prolapse and their 15,530 first-degree relatives; 33,782 second-degree relatives, and 66,469 third-degree relatives. We estimated relative risk of treated pelvic organ prolapse based on specific family history constellations. Relative risk estimates increased with a family history of increasing numbers of treated first-degree relatives with pelvic organ prolapse (first-degree relatives, ≥1 [relative risk, 2.36; 95% confidence interval, 2.15-2.58], first-degree relatives, ≥2 [relative risk, 3.79; 95% confidence interval, 2.65-5.24], and first-degree relatives, ≥3 [relative risk, 6.26; 95% confidence interval, 1.29-18.30]). Having a family history of ≥3 affected third-degree relatives (eg, first cousins) and no affected first- or second-degree relatives was similar in risk to having 1 affected first-degree relative. Relative risk estimates decreased with increasing age of treatment for first-degree family members. Risks in individuals with a positive maternal family history for pelvic organ prolapse were consistently higher than risks in individuals with equivalent paternal family history, but paternal inheritance still played a role. Approximately 4% of the total studied female population was found to have a >2-fold risk of being treated for pelvic organ prolapse and is considered high-risk based on their family history. We provide estimates for treated pelvic organ prolapse based on an extensive family history of pelvic organ prolapse using a large population-based sample. Risk for treated pelvic organ prolapse increased with increasing numbers of affected close and distant female relatives, earlier age of pelvic organ prolapse treatment in relatives, and maternal inheritance. These risk estimates may be useful for genetic studies and investigation of risk reduction strategies in those at highest risk for pelvic organ prolapse.

Anchorless implant for the treatment of advanced anterior and apical vaginal prolapse – Medium term follow up

Objectiveto evaluate the mid-term safety and efficacy of a surgical technique using an anchorless implant. Study designThis is a prospective study. Women with symptomatic POP were recruited. The technique involved placement of an open trapezoid-shaped frame which retains a polypropylene mesh stretched within its parameter. No fixation techniques used. Demographic data and pre-operative quality of life (QoL) questionnaires were collected. Peri-operative data were documented. Patients were followed at 2, 6, 12, 24 and 36 months. Follow-up included repeated QoL questionnaires, Pelvic Organ Prolapse- Quantification (POP-Q) measurements and assessment for possible complications. ResultsSeventy women were recruited. Mean age was 63.1 years, mean parity was 4.6 deliveries. Mean pre-operative POP-Q were Ba = 3.1 (-1 to 6) cm and C = 0.4 (-8 to 6) cm. No intra-operative complications were observed. Surgical time averaged 24.7 min. Estimated blood loss averaged 155 cc. Mean follow up at last visit was 27.7 months. Two patients (2.8 %) underwent partial frame resection and two patients (2.8 %) underwent a TVT-O for de-novo stress urinary incontinence (SUI). At follow-up, the mean POP-Q were Ba= -2.8 (-3 to -1) cm and C = -6.8 (-10 to 1) cm. Two patients (2.8 %) had recurrent prolapse. One was symptomatic and received treatment. No mesh erosion or chronic pelvic pain were documented. Pelvic Function Distress Inventory (PFDI20) scores showed significant improvement. Thirty-eight (54 %) patients completed the Pelvic organ prolapse/Urinary Incontinence Sexual Questionnaire (PISQ12) showing no chronic dyspareunia. ConclusionThe Self Retaining Support (SRS) implant provides 97 % subjective and 94.3 % objective cure. Two patients (2.8 %) had the implant’s frame removed surgically. The SRS is a safe and effective treatment for pelvic organ prolapse.

Feasibility of vaginal mesh for anterior vaginal wall prolapse in an ambulatory setting: A retrospective case series

IntroductionVaginal mesh has been proven to be an effective aid in the treatment of cystocele. Could an ambulatory approach be feasible for the Uphold Lite®-mesh? HypothesisWe investigate the feasibility of an ambulatory approach of Uphold Lite® insertion in a well-selected population. Risk factors for a non-successful ambulatory approach are identified. MethodologyWe conducted a retrospective case series of 236 women who underwent Uphold Lite® vaginal mesh insertion for the treatment of pelvic organ prolapse at our center. Indications for surgery were symptomatic anterior and/or apical prolapse, stages POPQ≥2. We compared women having an ambulatory approach, to those having a one day hospitalization planned but needed to stay. Comparisons between percentages were calculated using the chi-square or Fisher’s exact test, depending on the number of women in each group. The mean comparisons were performed using the Student t-test, and the median test comparisons by the Kruskal-Wallis test. A difference was considered significant if p<0.05. ResultsThe most common reason for staying (85.7% of all ambulatory failures) after Uphold® surgery is the presence of an elevated post void residual. This complication was more found in the following: surgery in the afternoon, use of high-dose morphinics in general anesthesia, and in women with a higher parity. ConclusionsOur study shows that Uphold® surgery in a one-day setting is feasible and safe. Women desiring this approach should be counselled on the 42.6% risk of one-day failure though, mostly due to non-validation of a post void residual. General anesthesia with high-dose morphinics, a higher parity, and surgery in the afternoon are risk factors for failure of an ambulatory protocol.

Colpocleisis for Advanced Pelvic Organ Prolapse

The purpose of this review is to consolidate and present the most recent literature on colpocleisis in the treatment of pelvic organ prolapse. Since its origin in the 1800s, the techniques for colpocleisis have remain largely unchanged. We will review the peri-operative considerations for a patient undergoing an obliterative procedure, specifically focusing on the potential concern for uterine pathology. There are no universally accepted guidelines for endometrial evaluation in the asymptomatic post-menopausal patient, yet the majority of providers prefer to perform some type of pre-operative endometrial evaluation. Colpocleisis can be performed with hysterectomy as a part of the procedure, as a uterine-sparing procedure, or in a patient who has already had a hysterectomy. Performing a hysterectomy at the time of colpocleisis is associated with longer operating times and higher estimated blood loss, but removal of the uterus negates the concern for future uterine pathology. Anti-incontinence procedures are commonly performed concomitantly. Complications following colpocleisis are not common. As the life expectancy in the USA and medical comorbidities increase, future studies are needed to evaluate long-term outcomes. Colpocleisis is a minimally invasive and safe procedure which demonstrates consistently high rates of patient satisfaction. Female pelvic reconstructive surgeons should be comfortable with offering obliterative procedures as an option for patients desiring definitive treatment.