Clinical efficacy of a trocar-guided mesh kit for repairing lateral defects

Introduction and hypothesis

The optimal surgery for lateral defects is not well defined. Our objective was to assess the effects of anterior trocar-guided transvaginal mesh repair versus anterior colporrhaphy in women with lateral defects.

Methods

This subanalysis from a randomized controlled trial of mesh kit versus anterior colporrhaphy assessed 99 patient diagnosed at baseline with lateral defects in the anterior vaginal wall. Thirty-nine patients underwent anterior colporrhaphy and 60 anterior trocar-guided transvaginal mesh surgery.

Results

One year after surgery, a persistent lateral defect was significantly more common after colporrhaphy compared with transvaginal mesh [11/32 (34.4 %) vs 1/42 (2.4 %), risk ratio (RR) 14.4, 95 % confidence interval (CI) 2.0–106.1; P?<?0.001)] However, there were no significant differences between treatment groups with regard to subjective symptoms as reflected by the overall Urogenital Distress Inventory scores, with mean difference from baseline 37.3?±?50.6 in the colporrhaphy group vs 39.0?±?45.8 in the mesh group (p?=?0.61).

Conclusions

Use of a transvaginal mesh kit increases the odds for anatomical correction of lateral defects compared with anterior colporrhaphy but does not necessarily improve lower urinary tract symptoms.     

A randomized controlled trial comparing anatomical and functional outcome between vaginal colposuspension and transvaginal mesh

Introduction and hypothesis

Our aim was to compare anatomical and functional outcome between vaginal colposuspension and transvaginal mesh.

Methods

This was a prospective randomized controlled trial in a teaching hospital. Sixty-eight women with stage ≥3 anterior vaginal wall prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system were assessed, randomized, and analyzed. Patients were randomized to anterior colporrhaphy with vaginal colposuspension (n?=?35) or transvaginal mesh (n?=?33). Primary outcome was objective cure rate of the anterior vaginal wall, defined as POP-Q ≤1 at 2 years. Secondary outcomes were functional results, quality-of-life (QoL) scores, mesh-related morbidity, and onset of urinary incontinence.

Results

The anatomical result for point Ba was significantly better at 2 years in the mesh group (?2.8 cm) than in the colposuspension group (?2.4 cm) (p?=?0.02). Concerning POP-Q stages, the anatomical success rate at 2 years was 84.4 % for colposuspension and 100 % for mesh (p?=?0.05). There were 5 anatomic recurrences (15.6 %) in the colposuspension group. The erosion rate was 6 % (n?=?2). No significant difference was noted regarding minor complications. Analysis of QoL questionnaires showed overall improvement in both groups, with no significant difference between them.

Conclusions

The vaginal colposuspension technique of anterior vaginal wall prolapse repair gave good anatomical and functional results at 2 years. Transobturator vaginal mesh gave better 2-year anatomical results than vaginal colposuspension, with overall improvement in QoL in both groups.     

Comparison between trans-obturator trans-vaginal mesh and traditional anterior colporrhaphy in the treatment of anterior vaginal wall prolapse: results of a French RCT

Introduction and hypothesis

To compare the efficacy of a collagen-coated polypropylene mesh and anterior colporrhaphy in the treatment of stage 2 or more anterior vaginal wall prolapse.

Methods

Prospective, randomized, multicenter study conducted between April 2005 and December 2009. The principal endpoint was the recurrence rate of stage 2 or more anterior vaginal wall prolapse 12 months after surgery. Secondary endpoints consisted of functional results and mesh-related morbidity.

Results

One hundred and forty-seven patients were included, randomized and analyzed: 72 in the anterior colporrhaphy group and 75 in the mesh group. The anatomical success rate was significantly higher in the mesh group (89 %) than in the colporrhaphy group (64 %) (p?=?0.0006). Anatomical and functional recurrence was also less frequent in the mesh group (31.3 % vs 52.2 %, p?=?0.007). Two patients (2.8 %) were reoperated on in the colporrhaphy group for anterior vaginal wall prolapse recurrence. No significant difference was noted regarding minor complications. An erosion rate of 9.5 % was noted. De novo dyspareunia occurred in 1/14 patients in the colporrhaphy group and in 3/13 patients in the mesh group. An analysis of the quality of life questionnaires showed an overall improvement in both groups, with no statistical difference between them. Satisfaction rates were high in both groups (92 % in the colporrhaphy group and 96 % in the mesh group).

Conclusion

Trans-obturator Ugytex® mesh used to treat anterior vaginal wall prolapse gives better 1-year anatomical results than traditional anterior colporrhaphy, but with small a increase in morbidity in the mesh group.     

Mesh retraction correlates with vaginal pain and overactive bladder symptoms after anterior vaginal mesh repair

Introduction and hypothesis

The aim of the present study was to determine possible correlations between mesh retraction after anterior vaginal mesh repair and de novo stress urinary incontinence (SUI), overactive bladder (OAB), and vaginal pain symptoms.

Methods

One hundred and three women with symptomatic prolapse of the anterior vaginal wall, stages 3 and 4 based on the Pelvic Organ Prolapse Quantification (POP-Q) system, underwent Prolift anterior? implantation. At a 6-month follow-up, the patients were interviewed for de novo SUI, OAB, and vaginal pain, and underwent an introital/transvaginal ultrasound examination to measure the mesh length in the midsagittal plane.

Results

Mesh retraction was significantly larger in a subgroup of patients (n?=?20; 19.4 %) presenting de novo OAB symptoms on the follow-up assessment compared with those without this complication (5.0 cm vs. 4.3 cm; p?<?0.05). Mesh retraction was also significantly larger in a subgroup of patients (n?=?23; 22.3 %) reporting postoperative vaginal pain compared with the women who did not report any postoperative vaginal pain (5.3 cm vs. 4.2 cm; p?<?0.01). A significant correlation was found between mesh retraction and the severity of vaginal pain (R?=?0.4, p?<?0.01). Mesh retraction did not differ between patients with de novo SUI symptoms and those without this complication.

Conclusions

Mesh retraction assessed on ultrasound examination after anterior vaginal mesh repair may correlate with de novo OAB symptoms and vaginal pain.     

Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse after failed transvaginal polypropylene mesh surgery

Introduction and hypothesis

A prospective case series to assess the safety and efficacy of laparoscopic sacrocolpopexy for the surgical management of recurrent pelvic organ prolapse (POP) after transvaginal polypropylene mesh prolapse surgery.

Methods

Between January and December 2010, women with post-hysterectomy recurrent prolapse (≥ stage 2 POP-Q) after transvaginal polypropylene mesh prolapse surgery were included. Perioperative morbidity and short-term complications were recorded and evaluated. Surgical outcomes were objectively assessed utilising the Pelvic Organ Prolapse Quantification system (POP-Q), the validated, condition-specific Australian Pelvic Floor Questionnaire (APFQ) and the Patient Global Impression of Improvement (PGI-I) at 12 months.

Results

All 16 women in this study had undergone surgery with trocar-guided transvaginal polypropylene mesh kits. In 75% the recurrent prolapse affected the compartment of prior mesh surgery with the anterior (81%) and apical (75%) compartment prolapse predominating. At a mean follow-up of 12 months, all women had resolution of awareness of prolapse, had < stage 2 POP-Q on examination and high levels of satisfaction on PGI-I post surgery. There were no serious peri- or postoperative complications.

Conclusions

This preliminary study suggests that laparoscopic sacrocolpopexy for recurrent prolapse after failed transvaginal mesh surgery is feasible and safe. Further widespread evaluation is required.     

Long-term outcomes of vaginal mesh versus native tissue repair for anterior vaginal wall prolapse

Introduction and hypothesis

To estimate the risk of repeat surgery for recurrent prolapse or mesh removal after vaginal mesh versus native tissue repair for anterior vaginal wall prolapse.

Methods

We utilized longitudinal, adjudicated, healthcare claims from 2005 to 2010 to identify women ≥18 years who underwent an anterior colporrhaphy (CPT 57420) with or without concurrent vaginal mesh (CPT 57267). The primary outcome was repeat surgery for anterior or apical prolapse or for mesh removal/revision; these outcomes were also analyzed separately. We utilized Kaplan–Meier curves to estimate the cumulative risk of each outcome after vaginal mesh versus native tissue repair. Cox proportional hazards models were used to estimate the hazard ratio (HR) for vaginal mesh versus native tissue repair, adjusted for age, concurrent hysterectomy, and concurrent or recent sling.

Results

We identified 27,809 anterior prolapse surgeries with 49,658 person-years of follow-up. Of those, 6,871 (24.7%) included vaginal mesh. The 5-year cumulative risk of any repeat surgery was significantly higher for vaginal mesh versus native tissue (15.2 % vs 9.8 %, p?<0.0001) with a 5-year risk of mesh revision/removal of 5.9%. The 5-year risk of surgery for recurrent prolapse was similar between vaginal mesh and native tissue groups (10.4 % vs 9.3 %, p?=?0.70. The results of the adjusted Cox model were similar (HR 0.93, 95%CI: 0.83, 1.05).

Conclusions

The use of mesh for anterior prolapse was associated with an increased risk of any repeat surgery, which was driven by surgery for mesh removal. Native tissue and vaginal mesh surgery had similar 5-year risks for surgery for recurrent prolapse.     

Operation for recurrent cystocele with anterior colporrhaphy or non-absorbable mesh: patient reported outcomes

Introduction and hypothesis

The aim of this study was to compare patient reported outcomes and complications after repair of recurrent anterior vaginal wall prolapse in routine health care settings using standard anterior colporrhaphy or non-absorbable mesh.

Methods

The study is based on prospective data from the Swedish National Register for Gynaecological Surgery. 286 women were operated on for recurrent anterior vaginal wall prolapse in 2008–2010; 157 women had an anterior colporrhaphy and 129 were operated on with a non-absorbable mesh. Pre-, and perioperative data were collected from doctors and patients. Patient reported outcomes were evaluated 2 months and 12 months after the operation.

Results

After 12 months, the odds ratio (OR) of patient reported cure was 2.90 (1.34–6.31) after mesh implants compared with anterior colporrhaphy. Both patient- and doctor-reported complications were found more often in the mesh group. However, no differences in serious complications were found. Thus, an organ lesion was found in 2.3 % after mesh implant compared with 2.5 % after anterior colporrhaphy (p?=?0.58). Two patients in the mesh group (1.2 %) were re-operated compared with 1 patient (0.6 %) in the anterior colporrhaphy group (p?=?0.58). The infection rate was higher after mesh (8.5 %) than after anterior colporrhaphy (2.5 %; OR 3.19 ; 1.07–14.25).

Conclusion

Implantation of synthetic mesh during operation for recurrent cystocele more than doubled the cure rate, whereas no differences in serious complications were found between the groups. However, mesh increased the risk of infection.     

Reattachment of the endopelvic fascia to the apex during anterior colporrhaphy: does the type of suture matter?

Introduction and hypothesis

We aimed to determine if the use of permanent suture for the apical fixation during traditional anterior colporrhaphy results in improved outcomes compared to delayed absorbable suture.

Methods

A retrospective case-control study was performed in patients who underwent traditional non-grafted anterior colporrhaphy with reattachment of the anterior endopelvic fascia to the apex/cervix comparing permanent (group 1) or absorbable suture (group 2). Patients were matched based on age, body mass index, and presenting stage of prolapse. The primary outcome assessed was anterior wall vaginal prolapse recurrence defined as Pelvic Organ Prolapse Quantification (POP-Q) points Aa or Ba?≥??1 cm. Secondary outcome measures included overall prolapse stage, subjective reporting of satisfaction, and any healing abnormalities or complications resulting from suture type.

Results

A total of 230 patients were reviewed (80 in group 1 and 150 in group 2) and median follow-up was 52 (24–174) weeks. A statistically significant improvement in anterior wall anatomy was seen in group 1 compared to group 2 [(Aa ?2.70?±?0.6 cm vs ?2.5?±?0.75 cm, p?=?0.02) and Ba (?2.68?±?0.65 cm vs ?2.51?±?0.73 cm, p?=?0.03), respectively]. Comparing prolapse stage, there were no observed differences between the groups. Exposure of the permanent suture occurred in 12 patients (15 %) and 5 (6.5 %) required suture trimming to treat the exposure.

Conclusions

Reattachment of endopelvic fascia to the apex at the time of anterior colporrhaphy results in low recurrence rates. Use of permanent suture for apical fixation is associated with improved anatomic correction at the expense of increased suture exposures.     

Synthetic graft use in vaginal prolapse surgery: objective and subjective outcomes

Introduction and hypothesis

This study reports 1-year outcomes in women who underwent transvaginal pelvic organ prolapse (POP) surgery with Prolift^® transvaginal mesh.

Methods

Pre- and postoperative objective vaginal Pelvic Organ Prolapse Quantification (POP-Q) and subjective symptom and impact assessments (Pelvic Floor Distress Inventory (PFDI)-20 and Pelvic Floor Impact Questionnaire (PFIQ)-7, respectively) were performed. Postoperative vaginal tenderness, stricture, and patient satisfaction were also obtained. Paired t tests were utilized for analysis.

Results

Mean age was 61.8?±?9.8 years; mean follow-up interval was 425.0?±?80.0 days (range, 237–717). POP-Q measurements of Ba, Bp, and C were significantly improved (all p values?p values?≤?0.004). Thirty-five of 48 (73%) were completely satisfied, and two (4%) were not satisfied. Complications (n (percent)) included graft exposure (1 (2%)), dyspareunia (2 (4%)), and granulation tissue (3 (6%)).

Conclusions

Women undergoing transvaginal repair of POP with the Prolift^® mesh system showed significant improvement in 1-year anatomic and subjective measures.     

Single-incision mesh repair versus traditional native tissue repair for pelvic organ prolapse: results of a cohort study

Introduction and hypothesis

To compare the efficacy and safety of the Elevate? anterior and posterior prolapse repair system and traditional vaginal native tissue repair in the treatment of stage 2 or higher pelvic organ prolapse.

Methods

A cohort study was conducted between January 2010 and July 2012. Patients who underwent transvaginal pelvic reconstruction surgery for prolapse were recruited. The primary outcome was anatomical success 1 year after surgery. The secondary outcome included changes in the quality of life and surgical complications. Recurrence of prolapse was defined as stage 2 or higher prolapse based upon the pelvic organ prolapse qQuantification system.

Results

Two hundred and one patients (100 in the Elevate? repair group and 101 in the traditional repair group) were recruited and analyzed. The anatomical success rate of the anterior compartment was significantly higher in the Elevate? repair group than in the traditional repair group (98 % vs 87 %, p?=?0.006), but not for the apical (99 % vs. 6 %, p?=?0.317) or posterior (100 % vs 97 %, p?=?0.367) compartments after a median 12 months of follow-up. Both groups showed significant improvements in the quality of life after surgery with no statistical difference. Mesh-related complications included extrusion (3 %) and the need for revision of the vaginal wound (1 %). Those in the mesh repair group had a longer hospital stay (p?=?0.04), operative time (p?<?0.001), and greater estimated blood loss (p?=?0.05). Other complications were comparable with no statistical difference.

Conclusions

The Elevate? prolapse repair system had a better 1-year anatomical cure rate of the anterior compartment than traditional repair, with slightly increased morbidity.     

Visualization of synthetic mesh utilizing optical coherence tomography

Introduction and hypothesis

Owing to the recent upsurge in adverse events reported after mesh-augmented pelvic organ prolapse (POP) repairs, our aim was to determine whether the location and depth of synthetic mesh can be measured postoperatively within the vaginal tissue microstructure using optical coherence tomography (OCT).

Methods

Seventeen patients with prior mesh-augmented repairs were recruited for participation. Patients were included if they had undergone an abdominal sacral colpopexy (ASC) or vaginal repair with mesh. Exclusion criteria were a postoperative period of <6 months, or the finding of mesh exposure on examination. OCT was used to image the vaginal wall at various POP-Q sites. If mesh was visualized, its location and depth was calculated and recorded.

Results

Ten patients underwent ASC and 7 patients had 8 transvaginal mesh repairs. Mesh was visualized in 16 of the 17 patients using OCT. In all ASC patients, mesh was imaged centrally at the posterior apex. In patients with transvaginal mesh in the anterior and/or posterior compartments, the mesh was visualized directly anterior and/or posterior to the apex respectively. Mean depth of the mesh in the ASC, anterior, and posterior groups was 60.9, 146.7, and 125.7 μm respectively. Mesh was visualized within the vaginal epithelial layer in all 16 patients despite the route of placement.

Conclusion

In this pilot study we found that OCT can be used to visualize polypropylene mesh within the vaginal wall following mesh-augmented prolapse repair. Regardless of abdominal versus vaginal placement, the mesh was identified within the vaginal epithelial layer.     

Evaluating the porcine dermis graft InteXen® in three-compartment transvaginal pelvic organ prolapse repair

Introduction and hypothesis

The aim was to assess the efficacy of three-compartment pelvic organ prolapse (POP) vaginal repair using the InteXen® biocompatible porcine dermal graft as compared to traditional colporrhaphy with sacrospinous ligament suspension.

Methods

Preoperative, operative, postoperative and follow-up data were collected retrospectively. Objective recurrence was defined as POP quantification ≥ stage II and subjective recurrence as a symptomatic bulge.

Results

Each group consisted of 63 patients. Surgery time was longer using InteXen® (72?±?24.5 vs 55?±?23.5 min, p?=?0.0002). Length of hospital stay (4.6?±?1.6 vs 4.9?±?2.1 days, p?=?0.34) as well as duration of follow-up (37.1 vs 35.7 months, p?=?0.45) were equivalent between the two groups. No case of mesh erosion or infection was noted. The objective (17% vs 8%, p?=?0.12) and subjective recurrence rates (13% vs 5%, p?=?0.12) between the two groups were not statistically different.

Conclusions

InteXen® was well tolerated but had similar efficacy to traditional colporrhaphy and sacrospinous ligament suspension.     

Post-reduction stress urinary incontinence rates in posterior versus anterior pelvic organ prolapse: a secondary analysis

Introduction/hypothesis

Stress incontinence with vaginal prolapse reduction is less common in women with posterior-predominant prolapse (rectocele) compared with those with anterior-predominant prolapse (cystocele).

Methods

This was a secondary analysis of a cohort of prospectively enrolled women with symptomatic pelvic organ prolapse at or beyond the hymen and prolapse-reduced stress urinary incontinence (SUI) testing. Subjects were included if they had anterior- or posterior-predominant prolapse with at least a 1 cm difference in pelvic organ prolapse quantification (POP-Q) points Ba and Bp (N?=?214). We evaluated the prevalence and risk factors of post-reduction SUI between the two groups.

Results

Comparing posterior (n?=?45) and anterior (n?=?169) prolapse groups, we identified similar rates of post-reduction SUI (posterior: 6/45, 13.3 %; anterior:18/169, 10.7 %; p?=?0.52) and SUI without reduction (posterior:4.4 %; anterior:11.2 %; p?=?0.26). Maximum prolapse size was slightly larger in anterior than in posterior patients (+3.1 vs +2.0 cm beyond the hymen, p?=?0.001), while a higher proportion of posterior subjects reported a prior hysterectomy (p?=?0.04). Among posterior subjects, lower maximum urethral closure pressure values (MUCP; p?=?0.02) were associated with post-reduction SUI. In contrast, among anterior-predominant prolapse, larger prolapse measured at POP-Q point Ba (p?=?0.003) and maximum POP-Q measurement (p?=?0.006) were each associated with higher rates of post-reduction SUI and were highly correlated with each other (R?=?0.90).

Conclusions

We observed similar rates of post-reduction SUI in women with anterior- and posterior-predominant pelvic organ prolapse. Factors affecting the anterior and posterior prolapse groups differed, suggesting different mechanisms of continence protection. These findings suggest that reduction incontinence testing for operative planning would be as relevant to posterior-predominant prolapses as it is to anterior prolapse.     

Changes in prolapse surgery trends relative to FDA notifications regarding vaginal mesh

Introduction and hypothesis

In 2008 and 2011, the US Food and Drug Administration (FDA) released notifications regarding vaginal mesh. In describing prolapse surgery trends over time, we predicted vaginal mesh use would decrease and native tissue repairs would increase.

Methods

Operative reports were reviewed for all prolapse repairs performed from 2008 to 2011 at our large regional hospital system. The number of each type of prolapse repair was determined per quarter year and expressed as a percentage of all repairs. Surgical trends were examined focusing on changes with respect to the release of two FDA notifications. We used linear regression to analyze surgical trends and chi-square for demographic comparisons.

Results

One thousand two hundred and eleven women underwent 1,385 prolapse procedures. Mean age was 64?±?12, and 70 % had stage III prolapse. Vaginal mesh procedures declined over time (p?=?0.001), comprising 27 % of repairs in early 2008, 15 % at the first FDA notification, 5 % by the second FDA notification, and 2 % at the end of 2011. The percentage of native tissue anterior/posterior repairs (p?<?0.001) and apical suspensions (p?=?0.007) increased, whereas colpocleisis remained constant (p?=?0.475). Despite an overall decrease in open sacral colpopexies (p?<?0.001), an initial increase was seen around the first FDA notification. We adopted laparoscopic/robotic techniques around this time, and the percentage of minimally invasive sacral colpopexies steadily increased thereafter (p?<?0.001). All sacral colpopexies combined as a group declined over time (p?=?0.011).

Conclusions

Surgical treatment of prolapse continues to evolve. Over a 4-year period encompassing two FDA notifications regarding vaginal mesh and the introduction of laparoscopic/robotic techniques, we performed fewer vaginal mesh procedures and more native tissue repairs and minimally invasive sacral colpopexies.     

Pelvic organ prolapse repair using the Uphold™ Vaginal Support System: a 1-year multicenter study

Introduction and hypothesis

The objective was to assess safety and clinical outcomes in women operated on using the Uphold? Lite Vaginal Support System.

Methods

We carried out a 1-year, multicenter, prospective, single cohort study of 207 women with symptomatic Pelvic Organ Prolapse Quantification (POP-Q) stage ≥2 apical pelvic organ prolapse, with or without concomitant anterior vaginal wall prolapse. Safety data were collected using a standardized questionnaire. Anatomical outcome was assessed by the POP-Q and subjective outcomes by the Pelvic Floor Distress Inventory after 2 months and 1 year using a one-way repeated measures analysis of variance. Pain was evaluated using a visual analog scale.

Results

The overall rate of serious complications was 4.3 % (9 out of 207 patients), including 3 patients with bladder perforations, 1 with bleeding >1,000 ml, 2 who had undergone re-operations with complete mesh removal because of pain, and 3 surgical interventions during follow-up because of mesh exposure. POP-Q stage ≤1 after 1 year was 94 % and subjective symptom relief was reported by 91 % of patients (p?<?0.001). Pain after 2 months and 1 year was 60 % lower compared with the preoperative mean (p?<?0.001). Minor complications occurred in 20 women (9.7 %) and were dominated by lower urinary tract dysfunction. No predisposing risk factors for complications were found.

Conclusions

The Uphold? Lite procedure in women with apical pelvic organ prolapse provided satisfactory restoration of vaginal topography and symptom relief. However, serious complication rates were largely comparable with those of other transvaginal mesh kits.

     

Transischioanal trans-sacrospinous ligament rectocele repair with polypropylene mesh: a prospective study with assessment of rectoanal function

Introduction and hypothesis

Despite good anatomical outcomes of pelvic organ prolapse (POP) repair by the vaginal route using synthetic mesh, complications limit their use. Clinical data are needed to generalize prolapse mesh repair by the vaginal route. The current study aims to evaluate midterm rectoanal function and clinical outcomes after transischioanal rectocele repair using a medium weight polypropylene mesh.

Methods

Between March 2003 and June 2004, 230 patients with stage II–IV anterior and/or posterior POP were included in a prospective multicenter study. The current study is based on the analysis of the 116 patients who underwent a rectocele repair via the infracoccygeal route through the sacrospinous ligament. Anatomical cure was defined when rectocele was at stage <II in the Pelvic Organ Prolapse Quantification (POP-Q) system. Postoperative functional results were evaluated using the self-administered Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ).

Results

Of the 116 patients who received a posterior mesh with two arms via the infracoccygeal route through the sacrospinous ligament, midterm anatomical results were available for 78 women representing 67 % (78/116) of the operated patients. The mean follow-up was 36 (± 8.1) months. No rectal injury occurred during surgery. The objective success rate was 94.8 % and subjective (by patient satisfaction) was 93.23 %. Colorectal-Anal Impact (CRAI) and Colorectal-Anal Distress Inventory (CRADI) scores were both significantly decreased at midterm follow-up in comparison with baseline (42.7 at baseline vs 11.4 at 24- or 36-month follow-up, p?=?0.001 for CRAI, and 81.1 vs 34.4, p?<?0.001 for CRADI) highlighting the benefits of rectocele repair on colorectal-anal function.

Conclusions

Polypropylene mesh with two arms via the infracoccygeal route through the sacrospinous ligament has good anatomical results at midterm follow-up with significant improvement in symptoms and quality of life and is associated with few complications. Obstructive symptoms reported in cases of rectocele can be improved by transvaginal mesh repair.     

Iliococcygeus fixation or abdominal sacral colpopexy for the treatment of vaginal vault prolapse: a retrospective cohort study

Introduction and hypothesis

To compare the efficacy and safety of iliococcygeus fixation (ICG) and abdominal sacral colpopexy (SCP) in the treatment of vaginal vault prolapse.

Methods

Patients with symptomatic vaginal vault prolapse after hysterectomy were considered in this analysis. Surgical outcomes, i.e., the capacity to restore the anatomy of the vaginal cuff and improvement in the prolapse-related symptoms were compared. Continuous variables were compared using the Student’s t test, while non-continuous variables using a Chi-squared test or Fisher’s exact test.

Results

Sacrocolpopexy was performed in 41 patients, while ICG fixation was carried out in 36 patients. Operative time was significantly shorter (78 vs 140 min, p?<?0.001) and median blood loss higher in the ICG group (150 ml vs 100 ml, p=0.01). The rates of postoperative complications of the two groups were not statistically different. Relapse rate was similar in the two groups (15 % in the SCP and 22 % in the ICG group respectively, p=0.36). Considering the POP-Q score, both SCP and ICG achieved a significant and comparable correction of vaginal prolapse. The evaluation of postoperative subjective symptoms revealed a significant improvement in voiding and vaginal bulging related to pelvic organ prolapse in both groups.

Conclusions

Both ICG fixation and SCP are effective in restoring normal anatomy in patients with vaginal vault prolapse and in relieving associated symptoms. Owing to its lower morbidity and to the advantage of not using a synthetic device, ICG might be an excellent option for the treatment of recurrent vaginal vault prolapse following hysterectomy.     

Surgical outcomes of anterior trans-obturator mesh and vaginal sacrospinous ligament fixation for severe pelvic organ prolapse in overweight and obese Asian women

Introduction and hypothesis

The aim of this study is to compare the outcomes of patients who underwent surgical repair of advanced pelvic organ prolapse amongst with normal-weight, overweight and obese Asian women.

Methods

Vaginal sacrospinous ligament fixation with anterior mesh repair as primary surgery was performed on 200 patients with advanced pelvic organ prolapse (POP-Q ≥ stage III). POP-Q < stage II was objective cure and subjective cure was based on POPDI-6 (questions 2 and 3). Patients completed the UDI-6, IIQ-7, POPDI-6, and PISQ-12 pre- and post-surgery. Outcome measures were observed in three categories of Asian BMI (normal weight 18.5 to 23.0 kg/m², overweight >23.0 to 27.5 kg/m², and obese ≥27.5 kg/m²).

Results

Postoperative data were available for 195 patients. Objective cure for the normal-weight, overweight, and obese were 93.0%, 92.5% and 90.6% respectively with an overall mean follow-up of 35.69?±?18.97 months. The subjective cure was no different. All categories improved significantly with regard to anatomical outcome, UDI-6, IIQ-7, POPDI-6, PISQ-12 after primary surgery (p?<?0.05) and none had recurrence requiring further surgery. However, obese patients have significantly less improvement in POPDI-6 (p <0.037) and PISQ-12 (p <0.005) compared with normal weight. There were no differences with regard to perioperative complications and the vaginal mesh exposure rate was 4.1%.

Conclusions

There was no difference in the objective outcome of sacrospinous ligament fixation with anterior mesh repair surgery among the three Asian BMI categories; however, obese patients showed less improvement in POP symptoms and sexual function.     

Prospective study of an ultra-lightweight polypropylene Y mesh for robotic sacrocolpopexy

Introduction and hypothesis

To prospectively evaluate the use of a particular polypropylene Y mesh for robotic sacrocolpopexy.

Methods

This was a prospective study of 120 patients who underwent robotic sacrocolpopexy. We compared preoperative and 12-month postoperative objective and subjective assessments via the Pelvic Organ Prolapse Quantification (POP-Q), the Pelvic Floor Distress Inventory, Short Form 20 (PFDI-20); the Pelvic Floor Impact Questionnaire, Short Form 7 (PFIQ-7); and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire 12 (PISQ-12). Objective “anatomical success” was defined as POP-Q stage 0 or 1 at all postoperative intervals. We further defined “clinical cure” by simultaneously considering POP-Q points and subjective measures. To be considered a “clinical cure,” a given patient had to have all POP-Q points ≤0, apical POP-Q point C ≤5, no reported pelvic organ prolapse symptoms on the PFDI-20, and no reoperation for prolapse at all postoperative intervals.

Results

Of the 120 patients, 118 patients completed the 1-year follow-up. The objective “anatomical success” rate was 89 % and the “clinical cure” rate was 94 %. The PFDI-20 mean score improved from 100.4 at baseline to 21.0 at 12 months (p?<?0.0001); PFIQ-7 scores improved from 61.6 to 8.0 (p?<?0.0001); and PISQ-12 scores improved from 35.7 to 38.6 (p?<?0.0009). No mesh erosions or mesh-related complications occurred.

Conclusion

The use of this ultra-lightweight Y mesh for sacrocolpopexy, eliminated the mesh-related complications in the first postoperative year, and provided significant improvement in subjective and objective outcomes.     

Native tissue repair or transvaginal mesh for recurrent vaginal prolapse: what are the long-term outcomes?

Introduction and hypothesis

The objective of this study was to assess outcomes in native tissue (NT) and transvaginal mesh (TVM) repair in women with recurrent prolapse.

Methods

A retrospective two-group observational study of 237 women who underwent prolapse repair after failed NT repair in two tertiary hospitals. A primary outcome of “success” was defined using a composite outcome of no vaginal bulge symptoms, no anatomical recurrence in the same compartment beyond the hymen (0 cm on POPQ) and no surgical re-treatment for prolapse in the same compartment. Secondary outcomes assessed included re-operation for prolapse in the same compartment, dyspareunia and mesh-related complications.

Results

Of a total of 336 repairs, 196 were performed in the anterior compartment and 140 in the posterior compartment. Compared with the TVM groups, women undergoing repeat NT repair were more likely to experience anatomical recurrence (anterior 40.9 % vs 25 %, p?=?0.02, posterior 25.3 % vs 7.5 %, p?=?0.01), report vaginal bulge (anterior 34.1 % vs 12 %, p?<?0.01, posterior 24.1 % vs 7.5 %, p 0.02) and had a higher prolapse re-operation rate (anterior 23.9 % vs 7.4 %, p?<?0.01, posterior 19.5 % vs 7.5 %, p?=?0.08). Using composite outcomes, the success rate was higher with TVM repair in both compartments (anterior 34.2 % vs 13.6 %, p <0.01, posterior 56.6 % vs 23.0 %, p <0.01). Re-operations for mesh exposure were 9.3 % anteriorly and 15.1 % posteriorly. Although the number of women requiring a prolapse re-operation is lower in the TVM group, the overall re-operation rate was not significantly different when procedures to correct mesh complications were included.

Conclusions

Although the success rate is better with the use of TVM for recurrent prolapse, the total re-operation rates are similar when mesh complication-related surgeries are included.