Robotic-assisted pelvic organ prolapse surgery

Background This study describes technical aspect and short-term results of pelvic organ prolapse surgery using the da Vinci robotic system. Methods During a 1-year period, 18 consecutive patients with pelvic organ prolapse were operated on using the da-Vinci system. Clinical data were prospectively collected and analyzed. Results All but one procedure was successfully completed robotically (95%). Performed procedures were colpohysteropexy (n = 12), mesh rectopexy (n = 2), or sutured rectopexy combined with sigmoid resection (n = 4). Average setup time was 21 min and significantly decreased with experience. Mean operative time was 172 min (range, 45–280). There were no mortality and no specific morbidity due to the robotic approach. Mean hospital stay was 7 days. At 6 months, all patients were free of pelvic organ prolapse and stated that they were satisfied with anatomical and functional results. Conclusion Our experience indicates that using the da-Vinci robotic system is feasible, safe, and effective for the treatment of pelvic organ prolapse.     

Economics of pelvic organ prolapse surgery

Introduction and hypothesis

The aim was to review the economic costs associated with pelvic organ prolapse surgery.

Methods

Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation usually depends on level 4 studies or “majority evidence” from level 2/3 studies or Delphi processed expert opinion. Grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.

Results

The annual economic costs of pelvic organ prolapse surgeries are significant and over the next decades will grow at twice the rate of population growth because of our aging population. In a single institution study vaginal reconstructive surgery and pessary use were more cost-effective than expectant management, traditional abdominal sacral colpopexy (ASC) or robot-assisted sacral colpopexy (RSC; grade C). Two studies have demonstrated that ASC incurs lower inpatient costs than LSC or RSC (grade C). Data from a single RCT demonstrated the LSC to incur lower inpatient costs than RSC specifically relating to shorter operating times in the LSC group (grade B). Data from a single RCT demonstrated LSC to be a more effective cost-minimising surgery than total vaginal mesh for vaginal vault prolapse (grade B). Data from a meta-analysis of anterior vaginal compartment prolapse operations demonstrated that commercial mesh kits for anterior repair are less cost-effective than non-kit mesh and anterior colporrhaphy (grade B).

Conclusions

There is a paucity of good economic data relating to pelvic organ prolapse surgery. Transvaginal mesh surgeries have not been proven to be cost-effective. It is recommended that all randomised controlled trials relating to prolapse surgery include a formal cost analysis.     

Concomitant pelvic organ prolapse surgery with TVT procedure

The aim of this study is to evaluate the efficacy and feasibility of concomitant pelvic reconstructive surgery with tension-free vaginal tape (TVT) procedure to treat pelvic organ prolapse women with urodynamic stress incontinence (USI) or occult USI. Seventy-five women with pelvic organ prolapse and diagnosed as USI or occult USI were enrolled in this study. All patients with USI or occult USI underwent TVT treatment under general anesthesia, combined with transvaginal total hysterectomy (VTH), anterior–posterior colporrhaphy (APC), and/or right sacrospinous ligament suspension (SSS) reconstructive surgeries. The subjective assessment was evaluated by using a visual analog scale (VAS) score and a urinary symptomatic questionnaire. The objective assessment was carried out with a 1-h pad test, cough stress test, and urodynamic examination. Of the 75 patients, 35 patients with grade III uterine prolapse underwent VTH and APC, 30 patients with grade IV uterine prolapse underwent VTH, SSS, and APC, and the other 10 patients who had previous hysterectomy with total vaginal vault prolapse underwent SSS and APC. The mean follow-up interval was 25 months (12–42 months). The mean hospitalization was 5.9 days and the mean catheterization time was 3.8 days. The subjective success rate for the treatment of urine incontinence was 88%, and the objective complete cure rate was 84%. The rate of postoperative complications with persistent urinary urgency, de novo detrusor overactivity, dysfunctional voiding, and tape erosion were 50, 8, 12, and 1.3%, respectively. There were no bladder perforations during the TVT procedure and no perioperative complications requiring conversion to laparotomy. Pelvic organ prolapse women with USI or occult USI can be treated by reconstructive surgeries combined with a TVT procedure to treat and prevent postoperative USI.     

Complications of transvaginal monofilament polypropylene mesh in pelvic organ prolapse repair

Introduction and hypothesis  This study aimed to document intraoperative and postoperative complications associated with the use of transvaginal polypropylene mesh in the repair of pelvic organ prolapse (POP). Methods  This is a retrospective review of 127 cases of transvaginal repair of POP using synthetic mesh. Results  Mean postoperative value (±SD) for pelvic organ prolapse quantification (POPQ) measurements Aa, Ap, and C were: −2.4 ± 1.1 (cm), −2.4 ± 0.9 (cm), and −7.7 ± 1.2 (cm), respectively. The difference between preoperative and postoperative values of these points was significant (p < 0.0001). Mesh erosion rate was 13/127 (10.2%) with significant correlation between mesh erosion and concurrent vaginal hysterectomy (p = 0.008). Combined anterior and posterior vaginal mesh surgery increased the risk of intraoperative bleeding and blood transfusion (p < 0.05). Conclusions  Concurrent vaginal hysterectomy is associated with increased risk of vaginal mesh erosion. Combined anterior and posterior vaginal mesh repair is an increased risk factor for intraoperative bleeding and blood transfusion.     

Primary treatment of pelvic organ prolapse: pessary use versus prolapse surgery

Introduction and hypothesis

The objective of this study was to compare the functional outcomes after pessary treatment and after prolapse surgery as primary treatments for pelvic organ prolapse (POP).

Methods

This was a prospective cohort study performed in a Dutch teaching hospital in women with symptomatic POP of stage II or higher requiring treatment. Patients were treated according to their preference with a pessary or prolapse surgery. The primary endpoint was disease-specific quality of life at 12 months follow-up according to the prolapse domain of the Urogenital Distress Inventory (UDI) questionnaire. Secondary outcomes included adverse events and additional interventions. To show a difference of ten points in the primary outcome, we needed to randomize 80 women (power 80%, α 0.05, taking 10% attrition into account).

Results

We included 113 women (74 in the pessary group, 39 in the surgery group). After 12 months, the median prolapse domain score was 0 (10th to 90th percentile 0–33) in the pessary group and 0 (10th to 90th percentile 0–0) in the surgery group (p < 0.01). Differences in other domain scores were not statistically significant. In the pessary group, 28% (21/74) of the women had a surgical intervention versus 3% (1/39) reoperations in the surgery group (p = 0.01).

Conclusions

In women with POP of stage II or higher undergoing surgery, prolapse symptoms were less severe than in those who were treated with a pessary, but 72% of women who were treated with a pessary did not opt for surgery. Trial registration number: Dutch trial register NTR2856.

     

A comparison of preoperative and intraoperative evaluation of patients undergoing pelvic reconstructive surgery for pelvic organ prolapse using the pelvic organ prolapse quantification system

OBJECTIVE: To compare the pre- and intraoperative situation using the POP-Q system during optimally standardized conditions of both examinations. STUDY DESIGN: In a prospective observational study, 108 women were compared. The POP-Q in the outpatient department (preoperative) was compared with the situation just prior to surgery after full anesthesia was reached (intraoperative). During the intraoperative measurement, traction with 0.5 kg force was applied on all relevant places. RESULTS: The pre- and intraoperative measurements were all significant correlated with the R-values between 0.43 and 0.85. All six points, which are measured during the POP-Q, were more prolapsed in the intra- as compared with the preoperative situation. The points Bp, C, and D were significantly more prolapsed, but for the points Aa, Ba, and Ap this was not significant. Fifteen patients were upstaged by the intraoperative measurements and five patients were downstaged in the overall POP-Q grading system. CONCLUSIONS: Intraoperative evaluation of the prolapse can reveal significant changes as compared with the preoperative situation. In general, the prolapse is more pronounced especially in the middle and posterior compartment.     

Combined surgery in pelvic organ prolapse is safe and effective

Objective In women, rectal prolapse is often accompanied by other signs of generalized pelvic floor weakness including uterine and bladder prolapse. The purpose of this study was to compare whether there are differences in outcomes of rectal prolapse surgery between women having combined pelvic organ prolapse (POP) surgery with a urologist or urogynecologist (CS) vs those having abdominal rectal prolapse surgery alone (RP). Method Charts were reviewed to collect perioperative data on those having surgery from 1995 to 2001. Phone surveys were conducted to obtain Cleveland Clinic Foundation (CCF) Incontinence score, Knowles‐Eccersley‐Scott‐Symptom (KESS) Constipation Score, Short Form 36 (SF‐36) quality of life score and recurrence rate. Appropriate statistical analysis was performed. Results Ninety‐four operations were performed (23 CS and 71 RP). Forty‐six (49%) could be contacted by phone. Mean follow‐up was similar in both groups (CS 4.1 vs RP 3.6 years; P = 0.796). There were no significant differences between both groups regarding age, American Society of Anesthesiology classification Score, complications, length of hospital stay, CCF Incontinence score, KESS Constipation Score, SF‐36 Score and recurrence rate of rectal prolapse. The operative time (CS 226 vs RP 122 min; P < 0.001) and blood loss (CS 377 vs RP 183 ml; P < 0.001) were significantly increased in the CS group. Conclusion Combined surgery for POP is safe and effective when considering outcomes of rectal prolapse surgery. Therefore surgeons should not hesitate to address all pelvic floor issues during the same operation by working in partnership with the anterior pelvic floor colleagues.     

Reoperation for pelvic organ prolapse within 10 years of primary surgery for prolapse

Introduction and hypothesis

A presumed high failure rate of conventional procedures for prolapse has been part of the rationale for new surgical approaches. The aim of the present retrospective cohort study was to estimate the reoperation rate for prolapse within 10?years of primary surgery for prolapse.

Methods

We identified all patients who underwent primary surgery for prolapse at four large regional centers in Austria in 1997 and 1998. Hospital databases were searched to determine whether patients had been reoperated for prolapse through 2008.

Results

A total of 456 patients underwent a primary operation for prolapse in 1997 and 1998. The most common primary operation was vaginal hysterectomy with colporrhaphy (89?%). We identified 13 reoperations for prolapse, for a 10-year reoperation rate of (at least) 2.9?%. The median interval between primary and secondary surgery was 5.5?years (range 1.5–10 years).

Conclusion

The reoperation rate for prolapse after primary vaginal hysterectomy and colporrhaphy appears to be modest in this series of patients.     

Factors influencing the outcome of surgery for pelvic organ prolapse

Introduction and hypothesis

Pelvic organ prolapse (POP) surgery is a common gynecological procedure. Our aim was to assess the influence of obesity and other risk factors on the outcome of anterior and posterior colporrhaphy with and without mesh.

Methods

Data were retrieved from the Swedish National Register for Gynecological Surgery on 18,554 women undergoing primary and repeat POP surgery without concomitant urinary incontinence (UI) surgery between 2006 and 2015. Multivariate logistic regression analyses were used to identify independent risk factors for a sensation of a vaginal bulge, de novo UI, and residual UI 1 year after surgery.

Results

The overall subjective cure rate 1 year after surgery was 80% (with mesh 86.4% vs 77.3% without mesh, p < 0.001). The complication rate was low, but was more frequent in repeat surgery that were mainly mesh related. The use of mesh was also associated with more frequent de novo UI, but patient satisfaction and cure rates were higher compared with surgery without mesh. Preoperative sensation of a vaginal bulge, severe postoperative complications, anterior colporrhaphy, prior hysterectomy, postoperative infections, local anesthesia, and body mass index (BMI) ≥30 were risk factors for sensation of a vaginal bulge 1 year postsurgery. Obesity had no effect on complication rates but was associated increased urinary incontinence (UI) after primary surgery. Obesity had no influence on cure or voiding status in women undergoing repeat surgery.

Conclusions

Obesity had an impact on the sensation of a vaginal bulge and the presence of UI after primary surgery but not on complications.

     

Sexual function in women after surgery for pelvic organ prolapse

Our objective was to evaluate the effect of surgical repair of pelvic organ prolapse on female sexual function. Sixty seven women with pelvic organ prolapse were recruited in the study. Degree of pelvic organ prolapse was assessed using pelvic organ prolapse quantitation (POPQ) staging system. Female sexual function index (FSFI) questionnaire was used to assess sexual function of the cases preoperatively and 12–16 weeks after the operation. Mean age of the cases was 36.03 ± 5.38 years. The total mean FSFI score increased from 15.9 ± 10.7 to 21.9 ± 11.1 (P < 0.05). Domain scores of desire, arousal, lubrication, orgasm, and satisfaction were increased significantly (P < 0.05). The mean score for the pain-free intercourse decreased significantly. Results demonstrated that sexual function was improved postoperatively. Using various instruments to assess female sexual function and differences in demographic and cultural characteristics of study groups might be the reasons of discrepancy between the reports.     

Depressive symptoms in women seeking surgery for pelvic organ prolapse

Introduction and hypothesis  

To compare depressive symptoms in women with and without prolapse and evaluate impact on quality of life.     

Seizure and mental status change after surgery for pelvic organ prolapse

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a well-documented postoperative complication but infrequently seen after gynecologic procedures. Clinical presentation is often insidious, and neurologic sequelae may be severe, especially in women. We report the first published case of postoperative hyponatremia due to SIADH after vaginal reconstructive surgery. Our patient sustained a tonic–clonic seizure on postoperative day 2 in the setting of profound hyponatremia. Early detection and prompt treatment allowed her to achieve a complete recovery. Familiarity with uncommon complications of vaginal surgery is important. Prompt initiation of treatment can prevent potentially fatal consequences.     

Optimizing pelvic organ prolapse research

For many years, researchers on this field have suffered from the lack of an efficient method for describing pelvic organ prolapse. Struggling to solve this problem, the International Continence Society has proposed a pelvic organ prolapse quantification (POP-Q) system [Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, Shull B, Smith ARB, Am J Obstet Gynecol, 175(1):1956-1962, 1996], which was validated as a precise and reproducible technique for describing pelvic organ position. However, even though very precise at describing pelvic organ position, our critic to this system is its limited ability to quantify the prolapse itself, since it still classifies prolapse into four grades, almost the same way as Baden and Walker did in 1972. As a result, the same grade can include a wide prolapse intensity range. The objective of this paper is to propose a method that makes POP research more efficient by directly measuring prolapse as a continuous variable that requires lesser number of subjects in order to achieve statistical significance.     

Laparoscopic removal of intravesical mesh following pelvic organ prolapse mesh surgery

With the increasing popularity of mesh in prolapse surgery, complications such as intravesical mesh will arise more frequently. In three cases intravesical mesh was identified in the trigone of the bladder following laparoscopic mesh hysteropexy, open sacral colpopexy, and transvaginal mesh repair and presented 9 months to 7 years later with a variety of symptoms including recurrent urinary tract infections, suprapubic pain, and constant urinary leakage. Each underwent uncomplicated laparoscopic transvesical removal of intravesical mesh. Intravesical mesh can present years following index prolapse surgery and can develop despite the bladder integrity being documented as being intact at the initial surgery. The laparoscopic approach to the removal of intravesical mesh is feasible, minimally invasive, and a precise approach to this challenging complication.