Uterovaginal Prolapse Research Articles

Magnetic resonance defecography: Post-defecation straining detects more and maximal prolapse in the anterior and middle compartments

ObjectiveTo compare pre-defecation straining without rectal gel and post-defecation straining with the defecation phase, and to investigate their roles in evaluating pelvic organ prolapse (POP). Material & methodsMagnetic Resonance Defecography (MRD) images of 65 patients with a clinical diagnosis of POP were retrospectively reviewed by two independent readers. Measurements were taken at rest, pre-defecation straining without rectal gel, defecation, and post-defecation straining. The presence, sizes, and/or grades of cystocele, uterovaginal prolapse, widened levator hiatus, perineal descent, cul-de-sac hernia, rectocele, and rectal intussusception were evaluated and compared across the four phases. ResultsCompared to pre-defecation straining, both defecation and post-defecation straining detected more cases, larger sizes, and higher grades of prolapse in all compartments. When comparing defecation and post-defecation straining, the latter diagnosed four more cases of cystocele (80 % vs 73.9 %, p = 0.2) with larger size (−34.1 vs −29.0, p < 0.01) and higher grade (p = 0.19). Post-defecation straining also identified eight more cases of uterovaginal prolapse (89.2 % vs 73.9 %, p < 0.01) with larger size (−32.9 vs −26.4, p < 0.01) and higher grade (p < 0.01) compared to defecation. Conversely, defecation detected eight more cases of rectocele (46.2 % vs 33.9 %, p < 0.01) with larger size (9.2 vs 6.2 cm, p < 0.01) and higher grade (p = 0.26). ConclusionPost-defecation straining effectively depicts the maximal extent of prolapse in the anterior and middle compartments, and should be performed whenever there is a clinical need for a comprehensive assessment of prolapse in these compartments.

Laparoscopic Sacrohysteropexy for the Management of Uterovaginal Prolapse: a Pilot, Single-Center Experience from Saudi Arabia.

Laparoscopic sacrohysteropexy is an emerging uterine-preserving strategy for management of uterovaginal prolapse (UVP). The literature on laparoscopic sacrohysteropexy for management of UVP is very scarce from Saudi Arabia. This research examined the feasibility, clinical utility, and safety of laparoscopic sacrohysteropexy in a Saudi setting. A retrospective study was conducted, including all patients who met the inclusion criteria. The laparoscopic sacrohysteropexy technique was adapted with modifications from the "Oxford hysteropexy". The primary endpoint was overall success, defined as anatomical success in all vaginal compartments (UVP grade 0 or 1 postoperatively). The secondary endpoint was the mean change in point C. Descriptive data were summarized with numbers and percentages, while numerical data used means ± standard deviations. Fisher's exact and Student's t tests were used for univariate analyses. Significant surgical outcome predictors were identified via logistic regression, with p <0.05 considered statistically significant. Overall, 21 patients met the inclusion criteria. The most frequent indication for laparoscopic sacrohysteropexy was UVP without anterior or posterior wall prolapse (n = 15, 71.4%), whereas the most frequent grade of UVP was grade III (n = 13, 61.9%). One patient (4.8%) required switch to laparotomy due to severe adhesions. No perioperative complications were recorded. The mean change in point C and hospital stay were 5.8 ± 2.1 (range: 0-8) and 1.4 ± 0.6 days (range: 1-3), respectively. Surgical success was achieved in 18 patients (85.7%). Only three patients experienced recurrences (one, two, and six months postoperatively). The mean change in point C was significantly higher in successful cases contrasted with the failed cases (6.5 versus 1.3). Laparoscopic sacrohysteropexy for management of uterovaginal prolapse revealed technical feasibility, safety, and beneficial utility of the procedure. Further large-sized and multicentric investigations are important to gather additional pertinent information on laparoscopic sacrohysteropexy.

Robotic versus Mini-Laparoscopic Colposacropexy to Treat Pelvic Organ Prolapse: A Retrospective Observational Cohort Study and a Medicolegal Perspective.

Background: POP (pelvic organ prolapse) involves the descent of one or more pelvic organs downwards with or without protrusion from the vaginal opening, caused by the relaxation and weakening of ligaments, connective tissue, and pelvic muscles. Such an outcome negatively impacts the quality of life. The gold standard procedure for repairing apical compartment prolapse is colposacropexy (CS) to secure the anterior and posterior walls of the vagina to the anterior longitudinal sacral ligament, located anteriorly to the sacral promontory, using a mesh. Several surgical approaches are feasible. Laparotomic or minimally invasive methods, including laparoscopic or robotic ones, can restore the horizontal axis of the vagina and typically involve concomitant hysterectomy. Methods: This study is based on 80 patients who underwent CS at Palermo's Ospedali Riuniti Villa Sofia-Cervello from 2019 to 2023. Women aged 35-85 at the time of surgery were divided into two groups: 40 patients underwent mini-laparoscopic surgery, and 40 patients underwent robotic surgery. The following parameters were accounted for: demographic data (initials of name and surname, age), preoperative clinical diagnosis, date of surgery, surgical procedure performed, estimated intraoperative blood loss, duration of surgical intervention, length of hospital stay, postoperative pain assessed at 24 h using the VAS scale, and any complications occurring in the postoperative period. Mini-laparoscopic CS (Minilap) and robotic CS (Rob) were then compared in terms of outcomes. Results: In the Minilap group, 11 patients out of 40 had a preoperative diagnosis of vaginal vault prolapse. The average age in this group was 61.6. Five of these patients had isolated cystocele, while the rest presented vaginal stump prolapse linked to cystocele, rectocele, or both. The remaining 29 patients in the Minilap group had a preoperative diagnosis of uterovaginal prolapse, also associated with cystocele, rectocele, or both, or isolated in nine cases. In the Rob group (average age: 60.1), 13 patients were diagnosed with vaginal prolapse (isolated or associated with cystocele), while the remaining 27 had a diagnosis of uterovaginal prolapse. In the Minilap group, the average procedure duration was 123.3 min, shorter than the Rob group (160.1 min). Conclusions: The data collected throughout this prospective study point to the mini-laparoscopic approach as being preferable over the robotic one in terms of surgical procedure length, intraoperative blood loss, postoperative pain, and aesthetic outcome. Hospital stay duration and post operative complication rates were similar for both groups. The innovative and ever-progressing nature of such procedures calls for novel standards prioritizing patient care as well as medicolegal viability.

Outcomes of uterosacral ligaments suspension for uterovaginal prolapse native-tissue repair: Over 1000-patient single-center study

Introduction and hypothesisSurgical repair is the mainstay of genital prolapse management. Among native-tissue apical procedures, high uterosacral ligaments suspension is considered a valid and effective option for central compartment repair. In this study, we aimed to evaluate the effectiveness, complications rate, and functional results of high USL suspension as a primary prolapse repair technique in a large cohort of patients. MethodsPatients who underwent vaginal hysterectomy followed by high uterosacral ligaments suspension for POP between January 2008 and December 2020 were retrospectively analyzed. Questionnaires and clinical interviews were preoperatively performed to assess symptoms and severity of urinary, bowel, and sexual dysfunctions. After surgical procedure, diagnostic cystoscopy was performed to evaluate ureteral patency. Postoperative data, objective, and subjective cure rate were then noted at the follow-up evaluation. ResultsA total of 1099 patients underwent high uterosacral ligaments suspension. The total complication rate was 3.4 % and recurrence in any of the vaginal compartments was 12.4 %. Reoperation for symptomatic prolapse recurrence or pessary treatment was required in 9 women (0.9 %). In the evaluation of postoperative questionnaires, functional outcomes analysis revealed a significant improvement (p < 0.05) in terms of stress urinary incontinence, urge urinary incontinence, voiding symptoms, constipation, and dyspareunia after prolapse repair. ConclusionUterosacral ligament suspension is a safe and effective procedure for primary surgical treatment of pelvic organ prolapse. Anatomical, functional, and subjective outcomes were very satisfactory, and the reoperation rate for recurrence was below 1%.

Prevalence of and risk factors for endometrial polyps among asymptomatic postmenopausal women with uterovaginal prolapse

The prevalence of endometrial polyps among asymptomatic, postmenopausal women is not well defined. There is no clear clinical consensus on how to manage endometrial polyps in this population and whether these polyps truly are cause for clinical concern. To estimate the prevalence of endometrial polyps among asymptomatic (without bleeding), postmenopausal women, and evaluate risk factors associated with their presence. This cross-sectional study assessed the prevalence of endometrial polyps among asymptomatic, postmenopausal women undergoing hysterectomy for uterovaginal prolapse. Patients were excluded if undergoing hysterectomy for other indications including postmenopausal bleeding. Chart review included eligible patients who received care at a single-site in Washington state from 2009 to 2018. The primary outcome was presence of endometrial polyps on pathology. Risk factors associated with polyp prevalence were subsequently assessed using univariate analysis and multivariate regression. Of the 317 eligible women identified, endometrial polyps were identified in 106 women (33.4%). The average polyp size and endometrial thickness was 13 +/- 10mm and 1.4 +/- 1.5mm. Most cases, 78%, had solitary polyps. Premalignant and malignant lesions were found in 2 cases (1.89%); one had endometrial carcinoma and one had endometrial intraepithelial neoplasia. Baseline clinical and demographic characteristics were similar between patients with and without endometrial polyps, including the presence of fibroids, endometriosis and adenomyosis. Multivariate logistic regression showed that presence of polyps was independently associated with high body mass index (OR 1.06, 95%-CI 1.01-1.12, p-value 0.02) and use of menopausal hormone therapy (OR 1.67, 95%-CI 1.02 - 2.72, p-value 0.04). Asymptomatic postmenopausal women undergoing hysterectomy for uterovaginal prolapse exhibit a high prevalence of endometrial polyps. Those with use of menopausal hormone therapy and high body mass index are at a higher risk of developing endometrial polyps. While the malignant risk seems to be low, more investigation is warranted to truly quantify the lifetime risk. For now, expectant management may be a reasonable approach for incidentally found, asymptomatic polyps.

Minimally Invasive Sacrocolpopexy: Impact on Sexual Function.

Sacrocolpopexy (SCP) is the gold standard surgical management of apical pelvic organ prolapse (POP), and increasingly, minimally invasive SCP is being adopted as a primary treatment for advanced uterovaginal prolapse. Patients undergoing surgery for POP consider postoperative improvement in sexual function to be a highly important outcome, and sexual dysfunction and dyspareunia severe adverse events. Therefore, it is crucial to understand the impact of minimally invasive SCP on postoperative sexual function. We aimed to analyze the current literature available to discuss the impact of minimally invasive SCP on postoperative sexual function. We performed a narrative review of minimally invasive SCP and its impact on sexual function. PubMed and EMBASE were searched from inception through 28 January 2024 for studies that reported sexual function following surgery for POP. Baseline and postoperative sexual activity, dyspareunia, and validated questionnaire scores for sexual function were documented. Minimally invasive SCP is associated with improved postoperative sexual function, increased rates of postoperative sexual activity, and low rates of dyspareunia. Dyspareunia was not associated with mesh related complications. Patients with baseline dyspareunia or pain were more likely to experience persistent dyspareunia after surgery. The rates of POP are increasing in our aging population, and sexual function is very important to patients undergoing surgery for POP. Clinicians should consider all factors related to sexual function when planning surgery for POP and address dyspareunia prior to surgery. Sexual function appears to improve overall after minimally invasive SCP and de novo dyspareunia rates are low.

Novel Vaginal Cerclage Assisted Laparoscopic Cervico-Sacropexy Technique for Uterovaginal Prolapse.

Laparoscopic hysteropexy is a complicated procedure that requires specialized surgical skills, including precise dissection and suturing. The aim is to describe the technical considerations for performing a new, feasible, and minimally invasive technique to correct apical and concurrent apical and anterior vaginal wall defects. A retrospective analysis was conducted on 70 consecutive women who underwent surgery for stage ≥3 uterovaginal prolapse. As a part of the technique, an anterior 2-cm long transverse incision was made at the anterior cervicovaginal junction, and the bladder was dissected through blunt and sharp dissection to the level of the isthmus. A posterior colpotomy was performed. A polypropylene tape was inserted into the cervical connective tissue, and the free arms of the tape were inserted into the peritoneum via the posterior colpotomy. Two arms of the tape were passed from the tunnel parallel and medial to a right sacrouterine fold, then fixed to the anterior longitudinal ligament via the laparoscopic route. The tape can be inserted into the cervix in a median of 15min, and the laparoscopy procedure can be completed in 24min. No mesh erosion or long-term complications occurred. At a 1-year control, there were no cases of recurrence. This novel cervico-sacrocolpopexy technique is a feasible and safe, minimally invasive way to correct apical or multicompartment defects, with a short operation time and an anatomical result that mimics the normal sacrouterine ligament.

Secondary Amenorrhea from Long Forgotten Intracervical Herbal Concoction Pessary: A Case Report and Review of Literature

Vaginal pessaries are used in gynaecology to treat utero-vaginal prolapse or urinary incontinence (pelvic floor disorders). However, self-administered or provider-administered per vagina insertion of herbal materials and concoctions is a practice prevalent amongst the low socioeconomic class of developing nations with poor access to good comprehensive health care. These oftentimes unhygienic and toxic materials may present with symptoms of immediate and or long-term complications. Asymptomatic cases may be forgotten only to be discovered incidentally. This study reports the case of a 47-year-old nullipara with amenorrhoea and infertility with an incidental finding of long forgotten intracervical herbal packing. The prolonged herbal pessary caused chemical vaginitis, scarring and subsequent cervical stenosis and amenorrhoea.

Concomitant rectal and uterovaginal prolapse in the community

Concomitant rectal and uterovaginal prolapse in the community

Same-day Discharge Following Vaginal Hysterectomy and Native-tissue Apical Repair for Uterovaginal Prolapse: A Prospective Cohort Study.

The safety and feasibility of same-day discharge (SDD) has been consistently reported across the benign and gynecologic oncology literature. However, outcomes of SDD in the urogynecology population are sparse. The objectives of this study were to describe the success of SDD following vaginal hysterectomy and native-tissue colpopexy, and to compare the incidence of postoperative adverse events in patients discharged same-day versus postoperative day 1 (POD1). Further objectives were to compare pain, quality of recovery (QoR), and satisfaction between the groups. This was a single-center, prospective cohort study of patients with planned SDD. A standardized ERAS protocol was utilized. The QoR-40 questionnaire was administered at baseline, POD2, and the 6-week postoperative visit. Pain scores were captured similarly, and a satisfaction survey was administered at 6 weeks. The primary outcome was composite adverse events defined as any postoperative adverse event and/or health care utilization, excluding telephone calls, and urinary tract infection. A total of 101 patients were enrolled in the study; the primary outcome was available for 99. SDD was achieved for 76 patients (77.0%); 23 patients stayed overnight (23.2%). The overall incidence of composite adverse events was 20.2% (95% CI, 13.5-29.2), and was not different between the groups (26.1% vs 18.4%, p = 0.42). Additionally, there were no differences in the QoR-40 or pain scores on POD2 and at 6 weeks. Patient satisfaction was high and similar between the groups. Successful SDD was achieved in 77.0% of the patients. SDD following vaginal hysterectomy and native-tissue colpopexy appears to be safe, feasible, and associated with good QoR and a high degree of patient satisfaction.

An Unpropitious Surprise Post Vaginal Hysterectomy – A Case of Incidentally Discovered Extra-Gastrointestinal Stromal Tumour

Extra-gastrointestinal stromal tumours (EGIST) are rare mesenchymal tumours that arise outside the gastrointestinal tract and mainly affect the omentum, mesentery, and retroperitoneum. We report a case of EGIST in an elderly female patient at an unusual location. The patient was referred to our centre with hemoperitoneum post vaginal hysterectomy for the treatment of third-degree utero-vaginal prolapse. Ultrasonography (USG) of abdomen and pelvis was done which revealed a heterogenous tumour in the upper abdomen. The tumour mass measured 23x18x8.5cms and was abutting the greater curvature of stomach without infiltration. A diagnosis of extra-gastrointestinal stromal tumour, spindle cell type, high grade, with pseudo signet ring appearance was rendered based on the morphology and immunohistochemistry with CD117(c-kit) and DOG1. Rupture of cancerous mass in the abdomen is one of the causes to be kept in mind in hemoperitoneum and EGIST should be considered in the differential diagnosis of large, multi-nodular, primary lesions of the abdomen. A high degree of suspicion is needed as these patients present late and are often diagnosed incidentally during investigations for unrelated medical conditions. 10% of EGISTs are primarily disseminated and the site of origin cannot be established with certainty, emphasizing the enigma of its origin as encountered in the present case.International Journal of Human and Health Sciences Vol. 08 No. 02 Apr’24 Page: 207-211

Abnormal Pathology Following Vaginal Hysterectomy for Pelvic Organ Prolapse Repair.

Objective: Uterine-sparing surgery for pelvic organ prolapse (POP) repair has shown good results, but the potential negative implications of leaving the uterus in place are yet to be fully defined. We aimed to assess the risk of unanticipated abnormal gynecological pathology at the time of reconstructive pelvic surgery. Methods: A retrospective consecutive case series including women who underwent vaginal hysterectomy for POP repair at a tertiary medical center in 2006-2020. All patients were offered a free Pap smear test at the age of 65 years as part of a national screening program. Transvaginal ultrasound was routinely performed preoperatively. Standard 3 pedicle hysterectomy was performed with/without bilateral salpingo-oophorectomy (BSO). Results: The study comprised 462 women of mean age 63 ± 9.3 years without previous known malignant or premalignant pathology. Benign pathology was observed in 286 patients (61.9%). Endometrial malignancy was found in three patients (0.7%) and significant premalignant pathology in 15 patients (3.2%), including cervical intraepithelial neoplasia stage 2-3 in seven patients (1.5%) and complex hyperplasia with atypia in eight patients (1.7%). All these pathologies were found in postmenopausal women. None had preoperative clinical symptoms or endometrial thickness of ≥5 mm on preoperative ultrasound. In the 35 patients after BSO, adnexal findings were normal (77.2%) or benign (22.8%). Conclusions: Premenopausal women with uterovaginal prolapse and normal preoperative evaluation have a minimal risk of significant abnormal uterine pathology. In postmenopausal women, the risk of unanticipated malignant uterine pathology is 0.7% and 3.2% for significant premalignancy.

Long-Term Costs of Minimally Invasive Sacral Colpopexy Compared to Native Tissue Vaginal Repair With Concomitant Hysterectomy

Study ObjectiveTo determine the long-term costs of hysterectomy with minimally invasive sacrocolpopexy (MISCP) versus uterosacral ligament suspension (USLS) for primary uterovaginal prolapse repair. DesignA hospital-based decision analysis model was built using TreeAge Pro (TreeAge Software Inc, Williamstown, MA). Those with prolapse were modeled to undergo either vaginal hysterectomy with USLS or minimally invasive total hysterectomy with sacrocolpopexy (MISCP). We modeled the chance of complications of the index procedure, prolapse recurrence with the option for surgical retreatment, complications of the salvage procedure, and possible second prolapse recurrence. The primary outcome was cost of the surgical strategy. The proportion of patients living with prolapse after treatment was the secondary outcome. SettingTertiary center for urogynecology. PatientsFemale patients undergoing surgical repair by the same team for primary uterovaginal prolapse. InterventionsComparison analysis of estimated long-term costs was performed. Measurements and Main ResultsOur primary outcome showed that a strategy of undergoing MISCP as the primary index procedure cost $19 935 and that undergoing USLS as the primary index procedure cost $15 457, a difference of $4478. Furthermore, 21.1% of women in the USLS group will be living with recurrent prolapse compared to 6.2% of MISCP patients. Switching from USLS to MISCP to minimize recurrence risk would cost $30 054 per case of prolapse prevented. Additionally, a surgeon would have to perform 6.7 cases by MISCP instead of USLS in order to prevent 1 patient from having recurrent prolapse. ConclusionThe higher initial costs of MISCP compared to USLS persist in the long term after factoring in recurrence and complication rates, though more patients who undergo USLS live with prolapse recurrence.

Vaginal Cuff Self-Suspension Technique: A Novel Apical Suspension Technique for Patients With Uterovaginal Prolapse and Poor Tissue Integrity [ID 2683606

INTRODUCTION: Of all surgical approaches to correct apical prolapse, transvaginal native tissue repair (TNTR) accounts for 80–90% of cases. Conditions such as uncontrolled diabetes lead to poor tissue integrity, often rendering the anatomical structures necessary insufficient, resulting in recurrent prolapse or immediate procedure failure. We present a novel TNTR technique, called “vaginal cuff self-suspension technique” (VCST) that can be used in such cases to provide a potentially more reliable and efficient means of apical suspension. METHODS: We conducted a prospective observational study from July 2022 to July 2023 and followed all patients who underwent a total hysterectomy and subsequent TNTR for advanced uterovaginal prolapse and concurrent stage IV endometriosis or uncontrolled diabetes. Advanced uterovaginal prolapse was defined as either a POP-Q score of 3 or 4 or Baden-Walker Grade 3 or 4. Patients receiving VCST were compared with matched controls receiving other TNTR methods. The primary outcomes were recurrent apical prolapse at 6 months or failure at initial surgery, as discrete events. All appropriate IRB approvals were obtained. RESULTS: The study included 88 patients with 33 receiving VCST and 55 controls. Of the 55 controls, 42 utilized uterosacral ligament suspensions (USLS) and 13 utilized sacrospinous ligament fixations. Demographic factors were not significantly different. Patients receiving VCST had lower rates of initial failed suspension (6% versus 23%; P=.002) as well as a 37% decreased risk in confounder-adjusted models (risk ratio [RR] 0.63; 95% CI, 0.36–0.81; P=.003). Among patients with poorly controlled diabetes, the VCST had lower rates of recurrent prolapse (9% versus 47%) and a 81% decreased risk in confounder-adjusted models (RR 0.19; 95% CI, 0.08–0.31; P&lt;.001). CONCLUSION: Vaginal cuff self-suspension technique offers a simple and effective way to potentially prevent recurrent apical prolapse and/or immediate procedure failure for patients with advanced uterovaginal prolapse and concurrent stage IV endometriosis or poorly controlled diabetes.

Preoperative prolapse phenotype is predictive of surgical outcome with minimally invasive sacrocolpopexy

The gold-standard treatment for advanced pelvic organ prolapse is sacrocolpopexy. However, the preoperative features of prolapse that predict optimal outcomes are unknown. This study aimed to develop a clinical prediction model that uses preoperative scores on the Pelvic Organ Prolapse Quantification examination to predict outcomes after minimally invasive sacrocolpopexy for stages 2, 3, and 4 uterovaginal prolapse and vaginal vault prolapse. A 2-institution database of pre- and postoperative variables from 881 cases of minimally invasive sacrocolpopexy was analyzed. Data from patients were analyzed in the following 4 groups: stage 2 uterovaginal prolapse, stage 3 to 4 uterovaginal prolapse, stage 2 vaginal vault prolapse, and stage 3 to 4 vaginal vault prolapse. Unsupervised machine learning was used to identify clusters and investigate associations between clusters and outcome. The k-means clustering analysis was performed with preoperative Pelvic Organ Prolapse Quantification points and stratified by previous hysterectomy status. The "optimal" surgical outcome was defined as postoperative Pelvic Organ Prolapse Quantification stage <2. Demographic variables were compared by cluster with Student t and chi-square tests. Odds ratios were calculated to determine whether clusters could predict the outcome. Age at surgery, body mass index, and previous prolapse surgery were used for adjusted odds ratios. Five statistically distinct prolapse clusters (phenotypes C, A, A>P, P, and P>A) were found. These phenotypes reflected the predominant region of prolapse (apical, anterior, or posterior) and whether support was preserved in the nonpredominant region. Phenotype A (anterior compartment prolapse predominant, posterior support preserved) was found in all 4 groups of patients and was considered the reference in the analysis. In 111 patients with stage 2 uterovaginal prolapse, phenotypes A and A>P (greater anterior prolapse than posterior prolapse) were found, and patients with phenotype A were more likely than those with phenotype A>P to have an optimal surgical outcome. In 401 patients with stage 3 to 4 uterovaginal prolapse, phenotypes C (apical compartment predominant, prolapse in all compartments), A, and A>P were found, and patients with phenotype A>P were more likely than those with phenotype A to have ideal surgical outcome. In 72 patients with stage 2 vaginal vault prolapse, phenotypes A, A>P, and P (posterior compartment predominant, anterior support preserved) were found, and those with phenotype A>P were less likely to have an ideal outcome than patients with phenotype A. In 297 patients with stage 3 to 4 vaginal vault prolapse, phenotypes C, A, and P>A (prolapse greater in posterior than in anterior compartment) were found, but there were no significant differences in rate of ideal outcome between phenotypes. Five anatomic phenotypes based on preoperative Pelvic Organ Prolapse Quantification scores were present in patients with stages 2 and 3 to 4 uterovaginal prolapse and vaginal vault prolapse. These phenotypes are predictive of surgical outcome after minimally invasive sacrocolpopexy. Further work needs to confirm the presence and predictive nature of these phenotypes. In addition, whether the phenotypes represent a progression of prolapse or discrete prolapse presentations resulting from different anatomic and life course risk profiles is unknown. These phenotypes may be useful in surgical counseling and planning.

Enhanced recovery after surgery (ERAS) in prolapse repair: A prospective study on pre-emptive uterosacral/cervical block.

Enhanced recovery after surgery (ERAS) protocols have been introduced in gynecology. Postoperative pain management after vaginal procedures remains a relevant issue. In the present study we aimed to evaluate the effectiveness of pre-emptive uterosacral/cervical block (PUCB) for postoperative pain control in patients with uterovaginal prolapse undergoing vaginal hysterectomy and pelvic floor repair. We also evaluated the impact on the length of recovery. This was a pilot study analyzing 40 women who underwent pelvic organ prolapse repair through uterosacral ligament suspension. Patients who chose to undergo PUCB were considered as cases, otherwise as controls. After general or spinal anesthesia induction, the treatment group received the PUCB with ropivacaine plus clonidine injections at 2, 4, 8, and 10 o'clock of the cervix. The control group did not receive additional treatment. Pain intensity was measured at rest and after forceful cough at 1, 4, 8, 12, 24, and 48 h postoperatively. We found a significant reduction in pain values at 1 h (rest and forceful cough) and 24 h (forceful cough) in the PUCB group. The incidence of moderate/severe pain was inferior in the PUCB group at 1 h (rest) and 24 h (rest and forceful cough). There were no differences in terms of the use of rescue opioids (0% vs. 5%; P = 0.311) and length of hospital stay (2.5 ± 0.6 vs. 2.3 ± 0.6; P = 0.180). For the first time, we demonstrated the impact of pre-emptive uterosacral/cervical block on pain control up to 24 h after surgery. Clonidine as a sensory blockade extender appears promising in enhancing the efficacy of local anesthetics.

Obesity and Reconstructive Pelvic Surgery: An ACS NSQIP Study.

Obesity is steadily increasing in the United States and is a risk factor for many medical and surgical complications. Literature is limited regarding obesity as an independent risk factor for perioperative complications after reconstructive pelvic surgery (RPS). This study aimed to analyze the association of obesity on 30-day perioperative complications after RPS. This was a database study comparing perioperative complications after RPS of obese versus nonobese patients using the American College of Surgeons National Surgical Quality Improvement Program. Patients who underwent surgery for uterovaginal or vaginal vault prolapse were selected, and perioperative outcomes were compared between obese and nonobese patients. Obesity was defined as a body mass index ≥30 (calculated as weight in kilograms divided by height in meters squared). A total of 13,302 patients met the inclusion criteria and were included in this study; 4,815 patients were obese, whereas 8,487 were nonobese. The overall rate of any 30-day postoperative complication was 6.8%, and the rate of complications did not differ between groups. Superficial and organ space surgical site infections were significantly higher in the obese cohort, whereas nonobese patients were more likely to receive a blood transfusion. A multivariable logistic regression model was performed with variables that were statistically significant on bivariate analysis and deemed clinically significant. Variables included obesity, age, American Society of Anesthesiologists class, current smoker, diabetes, hypertension, operative time, colpopexy, and obliterative procedure. After controlling for potential confounding factors, obesity was not associated with any 30-day postoperative complications after pelvic organ prolapse surgery. Obesity was not associated with 30-day postoperative complications after RPS after controlling for possible confounding variables.

Minimally Invasive Sacrohysteropexy Versus Vaginal Hysterectomy With Uterosacral Ligament Suspension for Pelvic Organ Prolapse: A Prospective Randomized Non-Inferiority Trial

Study ObjectiveTo investigate whether minimally invasive Sacrohysteropexy (SH) is non-inferior to Vaginal hysterectomy (VH) with uterosacral ligament suspension (USLS) in women with symptomatic uterovaginal prolapse. DesignProspective, randomized, non-inferiority study SettingTertiary university-based hospital. PatientsA total of 146 patients with uterovaginal prolapse between July 2016 and August 2019. InterventionsPatients were randomly assigned in a 1:1 ratio to either laparoscopic or robotic SH surgery or VH with USLS surgery. Measurements and Main ResultsThe primary outcome was prolapse recurrence at 1 year after surgery, defined as prolapse ≥ stage 2 evaluated using the pelvic organ prolapse quantification system, bothersome vaginal bulge symptoms, or retreatment for prolapse. The secondary outcomes included operation time, estimated blood loss, hospital stay, operation-related complications, pain intensity, quality of life, and activities of daily living. Of 146 women who underwent randomization, 73 in the SH group and 73 in the VH with USLS group were analyzed. SH was non-inferior for recurrence compared with VH with USLS (16.4% vs.15.8%, 95% confidence interval: -13.0%, 14.2%). Operating duration and transvaginal length were significantly longer in the SH group, while there were no significant differences in the estimated blood loss, length of hospital stay, or postoperative complication rates. Although perioperative pain intensity was greater from 1 week to 1 month in the SH group, the quality of life and activities of daily living did not differ between the groups throughout postoperative year 1. ConclusionLaparoscopic or robotic SH was non-inferior to VH with USLS for the recurrence of pelvic organ prolapse at the 1-year follow-up.

Vaginal hysterectomy at federal teaching hospital, Katsina: A five-year review.

Even though the vaginal route is said to be the gynaecologist route of surgery, abdominal hysterectomy remains the predominant method of uterine removal in most parts of the world, despite the evidence of the safety of vaginal hysterectomy. The study aims to determine the prevalence, socio-demographic variables, indications as well as outcome of vaginal hysterectomy at Federal Teaching Hospital (FTH) Katsina, during the 5-year study period. A five-year retrospective study on vaginal hysterectomy was conducted in Federal Teaching Hospital, Katsina from 1st January 2015 to 31st December 2019. The rate of hysterectomies (Abdominal & Vaginal) was 21.6% of the total major gynaecological surgeries performed during the study period. Vaginal hysterectomy accounted for 6.7%. The mean age and parity of the patients were 56.06+/- 9.55 years and 10.17+/- 4.57 respectively. The commonest indication was Utero-vaginal Prolapse (88.9%) and 80.5% (29) of the patients had no complications. Most of the patients (94.4%) were discharged within 7 days of surgery and there was no fatality. The rate of vaginal hysterectomy in our centre is low. Most of the patients were grand multiparous with the main indication being Uterovaginal prolapse. It is associated with favourable outcomes and very low complication rates.

A LARGE INTRAMURAL FIBROID WITH STAGE 3 UTERO VAGINAL PROLAPSE - A RARE CLINICAL PRESENTATION

Fibroid uterus are the benign tumors of the uterus comprising of smooth muscle fibres. There are 3 main types of fibroid uterus - submucosal, subserosal and intramural. Fibroid with the prolapse usually present as submucosal fibroid prolapsing into the vagina or intramural fibroid becoming submucosal and prolapsing out. A large intramural fibroid usually pulls up the uterus due to its growth and hence uterine prolapse is little rare scenario. In this case a perimenopausal women with mass descending per vaginum and pain abdomen for four years, on examination found to have a large intramural fibroid of size 20*10 cm and uterovaginal prolapse with cervix as leading point with cystocele, enterocoele and rectcoele. After routine pre operative work up, hysterectomy was planned by abdominovaginal route. Supracervical hysterectomy done abdominally followed by removal of cervical stump and anterior and posterior colpoperineoraphy by vaginal route.