Vaginal Prolapse Repair Research Articles

Trocar-Guided Mesh Compared With Conventional Vaginal Repair in Recurrent Prolapse

To compare efficacy and safety of trocar-guided tension-free vaginal mesh insertion with conventional vaginal prolapse repair in patients with recurrent pelvic organ prolapse. Patients with recurrent pelvic organ prolapse stage II or higher were randomly assigned to either conventional vaginal prolapse surgery or polypropylene mesh insertion. Primary outcome was anatomic failure (pelvic organ prolapse stage II or higher) in the treated vaginal compartments. Secondary outcomes were subjective improvement, effects on bother, quality of life, and adverse events. Questionnaires such as the Incontinence Impact Questionnaire and Urogenital Distress Inventory were administered at baseline, 6 months, and 12 months. Anatomic outcomes were assessed by an unblinded surgeon. Power calculation with α=0.05 and β=0.80 indicated that 194 patients were needed. Ninety-seven women underwent conventional repair and 93 mesh repair. The follow-up rate after 12 months was 186 of 190 patients (98%). Twelve months postsurgery, anatomic failure in the treated compartment was observed in 38 of 84 patients (45.2%) in the conventional group and in eight of 83 patients (9.6%) in the mesh group (P<.001; odds ratio, 7.7; 95% confidence interval, 3.3-18). Patients in either group reported less bulge and overactive bladder symptoms. Subjective improvement was reported by 64 of 80 patients (80%) in the conventional group compared with 63 of 78 patients (81%) in the mesh group. Mesh exposure was detected in 14 of 83 patients (16.9%). At 12 months, the number of anatomic failures observed after tension-free vaginal mesh insertion was less than after conventional vaginal prolapse repair. Symptom decrease and improvement of quality of life were equal in both groups. ClinicalTrials.gov, www.clinicaltrials.gov, NCT00372190. I.

Long-term outcomes of robotic-assisted laparoscopic sacrocolpopexy with a minimum of three years follow-up.

We describe efficacy and safety of robotic-assisted laparoscopic vaginal vault prolapse repair with long-term follow-up. We reviewed the records of 40 consecutive patients with posthysterectomy vaginal vault prolapse who underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution between September 2002 and September 2006. Patient analysis focused on complications, patient satisfaction, and morbidity, with a minimum of 36months' follow-up. Median follow-up was 62months (range 36-84) and mean age was 67 (43-83)years. Mean operating time was 3.1 (2.15-5)h with a median operating time of 2.9h. All but four were discharged home on postoperative day one; three patients left on postoperative day two and one left on postoperative day seven. Three developed recurrent grade 3-4 rectoceles and two vaginal extrusion of mesh. Thirty-eight of the 40 patients (95%) were satisfied with their outcome. Robotic-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a short hospital stay, low complication rates, and high patient satisfaction with a minimum of 3years' follow-up.

Trocar-guided mesh repair of vaginal prolapse using partially absorbable mesh: 1year outcomes

Trocar-guided mesh repair of vaginal prolapse using partially absorbable mesh: 1year outcomes

Robotic Surgery for Pelvic Organ Prolapse: More Time, More Pain, Higher Cost

Sacrocolpopexy is the gold standard for surgical repair of vaginal prolapse, and it can be performed laparoscopically with lower morbidity and shorter hospital stays than can open abdominal surgery. The laparoscopic approach, however, requires suturing and knot-tying skills that can be difficult to master. Many experts advocate robotic-assisted laparoscopy despite limited comparative data. Now, investigators at a single U.S. center have conducted a randomized trial to compare conventional laparoscopic and robotic-assisted …

Society of Gynecologic Surgeons' Survey

: To evaluate the practice patterns of the Society of Gynecologic Surgeons (SGS) members and guests regarding the use of synthetic mesh in vaginal prolapse repair. : A 26-item questionnaire regarding synthetic mesh use in vaginal prolapse repair was placed on the desks of those SGS attendees present at the fourth scientific session of the 2008 annual scientific meeting. Voluntary participation was requested and the survey questionnaires were retrieved at the session's conclusion. Descriptive statistics and cross-tabulation using χ tests were performed with SPSS. : One hundred twenty-eight of the 180 scientific session attendees completed the surveys. Sixty-nine percent (88/128) of the respondents identified themselves as urogynecologists and 45% (83/128) were male. Forty-five percent (58/128) were SGS members. Sixty-six percent (84/128) described their practice setting as academic, 28% (36/128) as community-based, and 6% (8/128) as other. The majority of the urogynecologists, 65% (64/88), used mesh at the time of survey completion versus 40% (8/18) of the obstetrician/gynecologists (P < 0.001). Fifty-nine percent (74/125) respondents were currently using mesh and 11% (14/125) reported using mesh at one time. Fifty-six percent (48/86) used mesh in both primary and recurrent repairs. For anterior repair, 97% (82/86) used mesh; of these, 31% (26/86) used only mesh kits, 33% (28/86) used only free mesh and 33% (28/86) reported using both. For posterior repair, 70% (62/88) used mesh; of these 18% (16/88) used only mesh kits, 26% (23/88) used only free mesh and 26% (23/88) used both. For anterior repair, 84% (71/85) dissected full-thickness and 43% (35/85) plicated connective tissue prior to inserting the mesh. The respondents had excised mesh for indications including: persistent drainage (59%), persistent pain (21%), hispareunia (21%), dyspareunia (16%), and asymptomatic exposure (11%). Fifty percent (44/88) initially managed mesh erosion with estrogen cream whereas 29% (26/88) started with mesh excision. : This survey suggests that the majority of urogynecologists attending the 34th SGS annual scientific meeting have used vaginal mesh for prolapse repair, and they more commonly used it in the anterior as compared to the posterior compartment. This has occurred in the absence of prospective, controlled, high-quality studies supporting its efficacy and safety. Research is clearly needed in this area.

Trocar-guided mesh repair of vaginal prolapse using partially absorbable mesh: 1 year outcomes

To evaluate anatomic and functional outcomes at 1-year following trocar-guided transvaginal prolapse repair using a partially absorbable mesh. Prospective multicentre cohort study at 11 international sites. One hundred twenty-seven patients with pelvic organ prolapse stage ≥ III had surgery and were evaluated at 3 months and 1-year postsurgery compared with baseline. Instruments of measurements: Pelvic Organ Prolapse Quantification, Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire-7, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire-12, and Patients Global Impression of Change. Anatomic success, defined as prolapse stage ≤ I in the treated vaginal compartments, was 77.4% (95% confidence interval, 69.0-84.4%). Significant improvements in bother, quality of life, and sexual function were detected at 3 months and 1 year compared with baseline. At 1-year after surgery, 86.2% of patients indicated their prolapse situation to be "much better." Mesh exposure rate was 10.2% and rate of de novo dyspareunia 2% at 1 year. These results demonstrate improved anatomic support, associated with excellent functional improvements, without apparent safety concerns.

Mesh kits for anterior vaginal prolapse are not cost effective

To analyze the cost-effectiveness of traditional anterior colporrhaphy (AC), hand-cut mesh, and mesh kit anterior vaginal prolapse (AVP) repair. A decision analysis model was built using mean operating room (OR) times, mesh extrusion rates, and recurrence rates obtained from a meta-analysis along with Medicare reimbursement for surgeon fees and office visits, and hospital costs of supplies, OR time, and room and board. Non-kit mesh repair was $3,380, AC $3,461, and mesh kit $4,678. One-way sensitivity analyses demonstrated recurrence rate of AC would need to be 28% to be equally cost effective. Mesh kit repair did not reach cost equivalence even at 0 min OR time. Two-way sensitivity analysis comparing mesh extrusion and AC recurrence demonstrated AC is more cost effective if recurrence is <20% or extrusion >25%. Mesh kits for AVP repair are not cost effective, regardless of the OR time saved.

Use of Bovine Pericardium in Pelvic Reconstructive Surgery

Hypothesis / aims of study With an estimated 30% of women needing additional surgery for pelvic organ prolapse recurrence, there has been a significant increase in the use of synthetic and biologic grafts. Our aim was to evaluate our experience with bovine pericardium (Veritas®, Synovis Surgical Innovations, Minneapolis, MN) in pelvic reconstructive surgery. Veritas® is a non-cross linked bovine pericardium implant that acts as a temporary scaffolding to allow ingrowth of deficient fascia by surrounding host tissues. Study design, materials and methods All patients at our institution who had urogynecologic surgery utilizing bovine pericardium graft were reviewed. The decision to use bovine pericardium was based on the surgeon’s intraoperative assessment of endopelvic fascial quality. For anterior repairs the graft was secured from apex to bladder neck and from arcus to arcus as an overlay to reinforce traditional midline plication. In vaginal enterocele repairs, a 4x7 piece of graft was utilized when the rectovaginal septum could not be successfully reattached to the vaginal apex. Data analyzed included demographics, prior urogynecologic surgery, postoperative POP-Q values, prolapse recurrence rates, complications, and healing abnormalities. The primary outcome was prolapse recurrence in the same compartment defined as POP-Q values ≥-1. Results From 2003 – 2009, 135 urogynecology procedures incorporated a bovine pericardium graft. Mean patient age was 62.2 ± 11.7. There were 53 anterior repairs reinforced with a bovine pericardium graft. Preoperative POP-Q values Aa and Ba were 1.21 and 1.77 cm respectively. At a median follow-up of 54 weeks (24-142.5), anatomical results were satisfactory with measurements of Aa and Ba at -2.33 and -2.28 cm respectively (p<0.0001). For patients with previous anterior repairs (6/53) there was also a statistically significant improvement in postoperative POP-Q values Aa and Ba. 10 patients had cystocele recurrence. None of these patients were symptomatic or required repeat surgery. There were 77 posterior enterocele repairs utilizing a bovine pericardium graft. Preoperative POP-Q values Ap and Bp were -0.18 and 0.31 cm respectively. At a median follow-up of 56 weeks (41-105), anatomical results were satisfactory with measurements of Ap and Bp at -2.66 and -2.68 cm respectively (p<0.0001). For patients with previous posterior repairs (13/77) there was also a statistically significant improvement in postoperative POP-Q values Ap and Bp. 5 patients had posterior wall recurrence. There were no significant differences between preoperative and postoperative rates of dyspareunia or bowel complaints. 5 patients underwent urethral diverticulum excision with reinforcement with bovine pericardium. All patients had concomitant suburethral sling and Veritas® was used for tissue reinforcement prior to placement of the sling. Postoperatively, all patients reported themselves as “cured/greatly improved” with no diverticula recurrence or graft erosion. Overall, patients were satisfied with surgical outcomes with 76% reporting themselves as either “cured” or “greatly improved”. Alterations in healing were evaluated by presence of granulation tissue at 6 weeks postoperatively and beyond. At 6 weeks, granulation tissue was present in 18.5% of anterior repairs and 16.9% of posterior repairs. The majority of these healing abnormalities were related to suture sites and resolved by 12 weeks postoperatively. There were no graft exposures/erosions and no patients required repeat surgery for graft related complications. Interpretation of results At one year follow up, bovine pericardium used in vaginal prolapse repair results in acceptable anatomical and functional outcomes without significant graft related complications. Concluding message Bovine pericardium is useful for tissue augmentation in pelvic organ prolapse surgery.

Exposition prothétique vaginale tardive après cure de prolapsus

Mesh exposure is the major complication of vaginal prolapse repair. Incidence rates are variable according to the series. Mesh exposure usually occurs during the year following the intervention. We report here the first case of a patient with a late exposure of an anterior vaginal mesh 4 years after a surgical cystocele repair. The mesh has been easily removed at the operative theatre by vaginal approach.

UP-2.09: Consideration on surgical results and quality of life in the surgical repair of anterior vaginal prolapse

UP-2.09: Consideration on surgical results and quality of life in the surgical repair of anterior vaginal prolapse

The use of mesh in vaginal prolapse repair: do the benefits justify the risks?

Due to the desire for improved outcomes, the use of synthetic materials in vaginal prolapse repair has been increasing despite the lack of sound evidence of their efficacy and safety. Given the limited number of randomized controlled trials evaluating repair of vaginal prolapse with the use of mesh and a paucity of data on long-term outcomes and complications, there is no clear evidence to suggest mesh should or should not be used. However, complications of mesh can range from minor to major but may lead to chronic, potentially debilitating conditions. Tailoring surgical decision-making for the individual patient must take into account and balance the patient's anatomy, symptoms, and functional status. Repairing anatomy alone is not the only important factor. The use of synthetic materials in prolapse repair demands critical examination, given the devastating complications that can occur.

V176 ROBOTIC-ASSISTED LAPAROSCOPIC EXCISION OF SACROCOLPOPEXY MESH WITH EROSION INTO BLADDER: A NOVEL APPROACH

You have accessJournal of UrologyFemale Voiding Dysfunction (Pelvic Reconstruction & Incontinence)1 Apr 2010V176 ROBOTIC-ASSISTED LAPAROSCOPIC EXCISION OF SACROCOLPOPEXY MESH WITH EROSION INTO BLADDER: A NOVEL APPROACH Ornob Roy and William Steers Ornob RoyOrnob Roy More articles by this author and William SteersWilliam Steers More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.231AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Abdominal sacrocolpopexy is a standard approach for surgical repair of vaginal vault prolapse. Despite advances in mesh materials, erosion into the vagina occurs at a rate of 0-9%, occasionally eroding into the bladder. Current techniques for excision of artificial mesh eroded into the bladder include open abdominal and vaginal exploration, as well as combined vaginal and endoscopic excision. We demonstrate a novel approach to excise polypropylene mesh eroded into the bladder using a robotic-assisted laparoscopic approach. METHODS The patient was positioned in low lithotomy and cystoscopy was used to place bilateral ureteral catheters prior to incision. The DaVinci surgical system was docked in-between the legs of the patient, similar to the position used for robotic-assisted laparoscopic radical prostatectomy (RALRP). Five ports were placed in a semilunar orientation centered around the pelvis similar to RALRP. The peritoneum was incised at the junction of the posterior bladder and vaginal cuff and a midline cystotomy was used to expose the eroded mesh within the bladder. After mesh removal, the bladder was closed in two layers with absorbable suture, and a suprapubic tube was placed for bladder drainage. RESULTS Total anesthesia time was 300 minutes, while robotic console time was 190 minutes. The mesh was densely adherent to the bladder, vaginal cuff, and small bowel; however, it was completely excised without evidence of entry into the vaginal vault. One small enterotomy was made during sharp dissection. This was immediately recognized and primarily repaired robotically. Preoperatively, the patient had exhibited signs and symptoms of irritative voiding, hematuria, infection, and bladder pain typical of mesh erosion into the bladder. The patient recovered well with no complications and the suprapubic catheter was removed after a negative cystogram two weeks postoperatively. CONCLUSIONS Robotic-assisted laparoscopic excision of mesh erosion into the bladder after sacroclpopexy is a viable alternative to open surgery. As a minimally-invasive technique, it may offer advantages of decreased postoperative hospital length of stay and decreased postoperative pain over open abdominal surgery. It also offers the potential for complete removal of the mesh which is not possible in endoscopic management. Further prospective study is required to determine its place in surgical management of this difficult problem. Charlottesville, VA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e70-e71 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ornob Roy More articles by this author William Steers More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1675 IMPACT OF TRANSLABIAL ULTRASOUND ON DIAGNOSIS AND TREATMENT OF MESH RELATED COMPLICATIONS

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology II1 Apr 20101675 IMPACT OF TRANSLABIAL ULTRASOUND ON DIAGNOSIS AND TREATMENT OF MESH RELATED COMPLICATIONS Andrea Staack, Chad Z. Baxter, Una Lee, Shelby Morrisroe, Ja-Hong Kim, Larissa Rodriguez, and Shlomo Raz Andrea StaackAndrea Staack More articles by this author , Chad Z. BaxterChad Z. Baxter More articles by this author , Una LeeUna Lee More articles by this author , Shelby MorrisroeShelby Morrisroe More articles by this author , Ja-Hong KimJa-Hong Kim More articles by this author , Larissa RodriguezLarissa Rodriguez More articles by this author , and Shlomo RazShlomo Raz More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1499AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The prevalence of patients presenting with mesh related complications at our tertiary center is increasing. Symptom assessment, clinical examination and cystoscopy help to elucidate mesh complications, however, there are diagnostic limits. Surgical reports on patient's history of previous prolapse or incontinence repair utilizing mesh are often missing. The purpose of the study was to evaluate ultrasound (US) as a diagnostic method to locate the mesh, to evaluate underlying symptoms, and to guide the surgical approach of removal. METHODS Between 01/09 and 09/09 15 consecutive patients came to our tertiary referral center with mesh related complications. In a prospective observational study all patients were evaluated for clinical symptoms and findings on 2-D translabial US. Coronal, sagittal, and axial views were obtained with a curved transducer and evaluated. RESULTS Mean age was 56.2 years (range 38-82). Out of 15 patients of the total patient population seven had undergone a periurethral sling procedure only, two a sling and concomitant anterior vaginal wall prolapse (AVW) repair, one an isolated posterior wall (PVW) repair, two a sling and concomitant AVW and PVW repair, one an isolated AVW repair, and two an AVW and concomitant PVW repair. Patients main complains were dyspareunia (n=10), LUTS (n=13), pelvic pain (n=10), recurrent UTI (n=4), recurrent SUI (n=5), vaginal fullness (n=4), and autoimmune reaction requiring immunosuppressive therapy (n=1). All patients underwent translabial US. Mesh dislocation, folding, shrinkage, or disruptions were seen in 12 patients (80%). Of 10 patients, who had undergone a suburethral sling procedure, 8 patients presented sonographically with misplaced or folded mesh and 2 with a cystic lesion or foreign body granuloma periurethrally. All AVW patients (n=8) presented sonographically with mesh dislocation, folding, and shrinkages. A recurrent cystocele was found in 6 patients. Five patients underwent a posterior repair. Translabial US detected mesh dislocation on all patients and a recurrent rectocele in 4 patients. CONCLUSIONS US is the only diagnostic method to evaluate mesh, to detect dislocation, folding, misplacement, or shrinkage. Translabial US can differentiate between symptoms related or unrelated to mesh complications. It is a useful cost-efficient and non-invasive tool to localize misplacement and to determine the best surgical approach for mesh removal. Los Angeles, CA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e647 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrea Staack More articles by this author Chad Z. Baxter More articles by this author Una Lee More articles by this author Shelby Morrisroe More articles by this author Ja-Hong Kim More articles by this author Larissa Rodriguez More articles by this author Shlomo Raz More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Perioperative course and medium-term outcome of the transobturator and infracoccygeal hammock for posthysterectomy vaginal vault prolapse

Objective To describe the perioperative course and medium-term anatomic and functional outcomes of the transobturator–infracoccygeal hammock for posthysterectomy vaginal vault prolapse repair. Methods A prospective consecutive series of 52 women with a stage 2 vaginal vault prolapse or higher that occurred after total hysterectomy who underwent surgery between 2003 and 2007. Principal outcome measures were anatomic cure (stage 1 or lower) and impact on quality of life measured using the pelvic floor distress inventory (PFDI) and pelvic floor impact self-reported questionnaire (PFIQ). Anatomical results were analyzed using χ 2 and Fisher exact tests, and PFDI and PFIQ scores were analyzed using the Wilcoxon test. Results With a median follow-up of 36 months, the anatomic cure rate was 96%. Significant improvements were noted in POPQ-S scores after surgery ( P < 0.05). Stress urinary incontinence was cured in 73% of patients and improved in 15% of patients. The PFDI and PFIQ scores were improved ( P < 0.05). One mesh extrusion was observed. The rates of mesh contraction and new cases of dyspareunia were 31% and 13%, respectively. Conclusion The transvaginal mesh hammock represents a useful treatment for recurrent and major vaginal vault prolapse, and has few complications.

Efficacy and Safety of "Tension-free" Placement of Gynemesh PS for the Treatment of Anterior Vaginal Wall Prolapse

To evaluate the efficacy and safety of the tension-free placement of a monofilament polypropylene mesh for the repair of an anterior vaginal wall prolapse (AVWP). Women aged ≥ 30 years with an AVWP stage of II or greater were included. Forty-nine women underwent trans-vaginal repair using a Gynemesh™ PS. Forty-six women who had symptomatic stress urinary incontinence received a midurethral sling (MUS). At the 12-month follow-up, evaluations were made for changes in the Pelvic Organ Prolapse Quantification (POP-Q) stage and Pelvic Floor Distress Inventory. Cure was defined as a POP-Q stage of 0 and improvement as a stage of I. Complications were also evaluated. The cure rate was 71.4%, and the improvement rate was 18.4%. Obstructive/discomfort, irritative, and stress subscale scores of the Urinary Distress Inventory anterior and posterior subscale scores of the POP Distress Inventory and the obstructive subscale score of the Colo-Rectal-Anal Distress Inventory were significantly improved. Thirty-two of the 46 women (69.6%) who received MUS procedures reported no leakage after surgery. Complications were 2 cases of increased intraoperative bleeding and 1 case of vaginal erosion. Trans-vaginal repair using a Gynemesh™ PS is a feasible and effective procedure for the treatment of AVWP with no significant complications.

Transvaginal Mesh for Cystocele Repair

No AccessJournal of UrologyOpposing Views1 Feb 2010Transvaginal Mesh for Cystocele Repair Howard B. Goldman and Mary P. FitzGerald Howard B. GoldmanHoward B. Goldman Center for Female Pelvic Medicine and Reconstructive Surgery, Glickman Urologic and Kidney Institute, The Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio Financial and/or other relationship with Pfizer, Novartis, Astellas, Johnson and Johnson, American Medical Systems, Endogun Medical Systems and Allergan. More articles by this author and Mary P. FitzGeraldMary P. FitzGerald Department of Obstetrics and Gynecology, Department of Urology, Loyola University Medical Center, Maywood, Illinois More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2009.11.074AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail References 1 : Outcome after anterior vaginal prolapse repair: a randomized controlled trial. Obstet Gynecol2008; 111: 891. Google Scholar 2 : Low-weight polypropylene mesh for anterior vaginal wall prolapse: a randomized controlled trial. Obstet Gynecol2007; 110: 455. Google Scholar 3 : Efficacy and safety of using mesh or grafts in surgery for anterior and/or posterior vaginal wall prolapse: systematic review and meta-analysis. BJOG2008; 115: 1350. Google Scholar 4 : Sexual dysfunction after trocar-guided transvaginal mesh repair of pelvic organ prolapse. Obstet Gynecol2009; 113: 127. Google Scholar 5 : Identification of risk factors for genital prolapse recurrence. Neurourol Urodynam2009; 28: 301. Google Scholar 6 : Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol1997; 89: 501. Google Scholar © 2010 by American Urological AssociationFiguresReferencesRelatedDetails Volume 183Issue 2February 2010Page: 430-432 Advertisement Copyright & Permissions© 2010 by American Urological AssociationMetricsAuthor Information Howard B. Goldman Center for Female Pelvic Medicine and Reconstructive Surgery, Glickman Urologic and Kidney Institute, The Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio Financial and/or other relationship with Pfizer, Novartis, Astellas, Johnson and Johnson, American Medical Systems, Endogun Medical Systems and Allergan. More articles by this author Mary P. FitzGerald Department of Obstetrics and Gynecology, Department of Urology, Loyola University Medical Center, Maywood, Illinois More articles by this author Expand All Advertisement PDF downloadLoading ...

Combined Abdominal and Vaginal Prolapse Repair: Is Order Important?

Study Objective: The objective of this study was to compare anatomic outcomes of abdominal sacrocolpopexy with vaginal prolapse repair when the vaginal portion of the surgery was performed first versus performing the abdominal portion of the surgery first. Design: This was a retrospective chart review of 42 patients who underwent abdominal sacrocolpopexy combined with vaginal prolapse repair. Setting: Academic urogynecology division in the Northeastern United States. Patients: Forty-two adult women who underwent abdominal sacrocolpopexy combined with vaginal prolapse repair. Intervention: Twenty-one of the women had the colpopexy performed prior to the vaginal prolapse repair and twenty-one of the women had the vaginal prolapse repair performed prior to the colpopexy. Measurements and Main Results: Patients were included in the analysis if they had at least one vaginal segment repaired at the time of abdominal sacrocolpopexy. Patients were excluded if they did not have Pelvic Organ Quantification (POP-Q) measurements on follow up exam. Anatomic failure was defined as POP-Q stage 2 or greater. At 3-6 month follow up, there were no apical or posterior compartment failures. The rate of anterior compartment failure was equal in both groups (57.89% versus 52.63%, p value 0.744). Conclusion: At 3-6 month follow up, failure rates were similar for combined abdominal and vaginal prolapse repair regardless of the order of the repair. Larger sample size is needed to confirm our results.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

O137 The safety and success of early discharge or day case surgery for the repair of vaginal wall prolapse

O137 The safety and success of early discharge or day case surgery for the repair of vaginal wall prolapse

Comments on Wall and Brown: “Commercial pressures and professional ethics: troubling revisions to the recent ACOG Practice Bulletins on surgery for pelvic organ prolapse”

Dear Editor, As Vice President of Practice Activities at the American College of Obstetricians and Gynecologists, I read with interest Dr. Lewis Wall and Dr. Douglas Brown’s Current Opinion/Update article regarding ACOG Practice Bulletin #85 “Pelvic Organ Prolapse” [1]. The Practice Activities Division oversees development of the evidence-based Practice Bulletins series, which presents clinical management guidelines developed on the basis of the best available evidence, supplemented by consensus and expert opinion. And, while we recognize the right of individuals to express their opinions, I am concerned that Drs. Wall and Brown have misrepresented the intention behind the clarification of Practice Bulletin #79. The initial publication, Practice Bulletin #79 “Pelvic Organ Prolapse” (published in February 2007) used the term “experimental” in describing anterior and posterior vaginal prolapse repair surgeries. The Committee on Practice Bulletins–Gynecology, which oversaw development of this document, subsequently realized that the meaning of the term “experimental” was ambiguous and was being interpreted differently by different individuals. Therefore, in order to clarify the document, the Practice Bulletin was revised to reflect more clearly the original intention of the committee, in a way that would be more informative to clinicians and patients. It is important to note that the development and revision to this Practice Bulletin followed the same consistent process used for the development and revision of all Practice Bulletins. The ACOG document development process begins with a thorough review of the current peerreviewed scientific literature. A standing committee of obstetrician-gynecologists (in this case the Committee on Practice Bulletins–Gynecology), some with subspecialty training, develops an outline and oversees the drafting of the manuscript. Once the manuscript is developed, the committee reviews and revises the document until it meets the committee’s approval. Following approval by the committee, the document is reviewed by a Clinical Document Review Panel, which in this case comprised nine gynecologists including at least one urogynecologist. Lastly, the document is reviewed by certain ACOG senior staff and is submitted to the ACOG Executive Board for review and final approval. Shortly after Practice Bulletin 79 was published, the College received e-mails, letters, and phone calls from ACOG Fellows who objected to the use of the word “experimental” to describe the anterior and posterior vaginal prolapse surgeries. Their concerns centered on the ambiguity of the word “experimental” and their perception that “experimental” did not accurately reflect the wide acceptance of these surgeries. The College followed its routine procedure for handling such correspondence by putting the matter on the agenda for the next meeting of the Committee on Practice Bulletins–Gynecology. The Committee reviewed the correspondence from ACOG members as well as the opinions of four experts in prolapse repair who were not members of the Committee. The Committee concluded that the word “experimental” was ambiguous and revised the document to convey the Related correspondence can be found at doi:10.1007/s00192-0090984-9, doi:10.1007/s00192-009-0985-8, and doi:10.1007/s00192009-1003-x.

Sacrocolpopexy using xenogenic acellular collagen in patients at increased risk for graft‐related complications

We studied the long-term anatomical and functional outcome following sacrocolpopexy for apical vaginal prolapse using xenogenic grafts in a population at increased risk for graft-related complications (GRCs). Twenty-two consecutive patients with symptomatic apical prolapse were scheduled for laparoscopic sacrocolpopexy (LSC) with porcine grafts because they were presumed to be at risk for GRC, because of pre-existing vaginal ulcerations (n = 4), concomitant vaginal prolapse repair (n = 15), total hysterectomy (n = 1), or intra-operative abdominal contamination due to accidental laceration of the vagina, bowel perforation (n = 1) or the presence of infection (n = 1). Either small intestinal submucosa (n = 8) or dermal collagen (n = 14) was used. Outcome measures were GRCs, anatomical cure (<or=Stage I at any compartment), subjective cure, impact on bowel, bladder, and sexual function measured by a standardized interview. At study closure 20 (91%) patients were available for functional evaluation and 16 (73%) for anatomical evaluation at a mean follow-up period of 27.4 months. The GRC rate was 25% (n = 4) prompting reintervention in half, and including two patients with spondylodiscitis. The anatomical cure rate was 31.5%. Failures at the vault, anterior, and posterior compartments occurred in, respectively, 31%, 18.8%, and 50% of patients. The subjective cure rate was 60% and three patients (15%) underwent redo-LSC. The strategy of using xenografts in patients at risk for GRC, did not prevent these to occur and was associated with a high anatomical and functional failure rate as well as reoperation rate.