Tension-free vaginal mesh repair for recurrence of pelvic organ prolapse after vaginal mesh procedures: a case report

A 61-year-old woman presented with the chief complaint of a vaginal bulge for 2 years. She had undergone two operations for pelvic organ prolapse. The initial procedure was the Manchester procedure and posterior colporrhaphy, and the second was a vaginal repair with mesh for recurrent rectocele 3 years after the initial surgery. She noticed the vaginal bulge shortly after the second surgery. A gynecological examination revealed a stage III rectocele associated with a 2 cm, firm mass at the posterior vaginal wall. T2-weighted magnetic resonance imaging showed a 2 × 3 cm high-intensity mass located between the vaginal wall and rectum. The recurrent rectocele might have been caused by incomplete support from the mesh, which was not fixed in the vaginal wall, resulting in formation of a mass. The patient underwent complete mesh removal and tension-free vaginal mesh-posterior surgery for the rectocele. The excised mesh had shrunk from a 7 × 5 cm rectangle mesh preoperatively into a firm 2 × 2 × 3 cm mass. No recurrence has been seen for 18 months postoperatively.     

Delayed onset advanced pelvic organ prolapse after pelvic trauma in a nulliparous young female: case report

Reports have shown that high-energy pelvic trauma might be associated with advanced pelvic organ prolapse in conjunction with other causes. We report the case of a 21-year-old nulliparous, premenopausal, non-overweight woman with no predisposing factors for prolapse who developed stage IV massive pelvic organ prolapse and stress urinary incontinence 4 years after a severe pelvic traumatic accident. Most likely, the pelvic trauma, as a single factor, was the causative factor for the massive procidentia. The onset on the prolapse was delayed until 4 years after the pelvic accident. The patient was managed with sacrospinous ligament hysteropexy along with anterior and posterior vaginal wall repair and perineorrhaphy. Despite satisfactory surgical management, long-term regular follow-up is still required.     

Pessary use in advanced pelvic organ prolapse

The objective of this study was to review our experience with pessary use for advanced pelvic organ prolapse. Charts of patients treated for Stage III and IV prolapse were reviewed. Comparisons were made between patients who tried or refused pessary use. A successful trial of pessary was defined by continued use; a failed trial was defined by a patients discontinued use. Thirty-two patients tried a pessary; 45 refused. Patients who refused a pessary were younger, had lesser degree of prolapse, and more often had urinary incontinence. Most patients (62.5%) continued pessary use and avoided surgery. Unsuccessful trial of pessary resorting to surgery included four patients (33%) with unwillingness to maintain, three patients (25%) with inability to retain and two patients (17%) with vaginal erosion and/or discharge. Our findings suggest that pessary use is an acceptable first-line option for treatment of advanced pelvic organ prolapse.     

Effectiveness of a continuous-use ring-shaped vaginal pessary without support for advanced pelvic organ prolapse in postmenopausal women

Introduction and hypothesis

There is considerable variation in the clinical management of pessaries. This study was aimed at exploring the efficacy of the continuous use of ring pessaries without support for the treatment of advanced pelvic organ prolapse (POP) in nonhysterectomized postmenopausal women.

Methods

We conducted this prospective study of fitted pessaries between January 2013 and June 2015 in the Department of Obstetrics and Gynecology at Macarena Hospital, Seville University, Spain. A total of 171 nonhysterectomized postmenopausal patients with symptomatic POP (stages III and IV) were counseled for two treatment options: either surgery or vaginal pessary. A total of 94 patients who agreed to use the vaginal ring pessary were included. A successful fitting was defined as the continued use of the device until the end of the study (a median 27-month follow-up). The data were analyzed with continuity correction tests, Mann–Whitney U tests, and Fisher’s exact test.

Results

Pessary use was continued by 80.8% of the patients. Most discontinuations (50.0%) occurred within the first week after device insertion. The adverse events rate was 31.6%, and all adverse events were Clavien–Dindo grade I. The complications were extrusion of the pessary (18.4%), bleeding or excoriation (10.5%), and pain or vaginal discharge (2.6%). No major complications occurred.

Conclusions

The ring pessary without support was successfully fitted in patients with advanced POP, resulting in a high success rate. There were few side effects and complications associated with continuous use of this pessary without periodic removal or replacement.

     

Case of longitudinal vaginal septum with pelvic organ prolapse

Longitudinal vaginal septum is a rare mullerian anomaly and its association with pelvic organ prolapse (POP) is unusual. A case of longitudinal vaginal septum with stage IV POP in a 35-year-old multiparous woman is being reported. Examination revealed an incomplete longitudinal vaginal septum (9 × 6 × 2 cm) with stage IV POP. Vaginal hysterectomy with repair and reconstruction was done along with excision of the longitudinal vaginal septum which was technically challenging due to proximity to rectum. This is the only case report of stage IV pelvic organ prolapse associated with a thick longitudinal vaginal septum in a multiparous woman without any obstetric complications. Surgery required increased caution per operatively while dissecting the septum from the vaginal wall and the adjacent organs.     

Perioperative outcomes after robotic versus vaginal surgery for pelvic organ prolapse

Journal of Robotic Surgery - The objectives of the study were to compare post-anesthesia care unit opioid use and pain scores, surgical and hospitalization times, and perioperative adverse events...     

The effect of pelvic organ prolapse repair on vaginal sensation

Introduction and hypothesis

The objective was to evaluate vaginal and clitoral sensation before and after robotic sacrocolpopexy for the repair of pelvic organ prolapse.

Methods

Twenty-two women, mean age 63 years (range 41–77), were admitted for robotic sacrocolpopexy repair of pelvic organ prolapse; 4 were lost to follow-up. Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina (anterior and posterior areas) and clitoris 1 day before and a mean of 12?±?4 months following surgery. Student’s paired t test was used to compare sensory thresholds before and after surgery.

Results

For the 18 women who completed follow-up, sensitivity was significantly higher after surgery (sensory threshold decreased) at the clitoral and vaginal regions, to cold and warm stimuli. In contrast, the vaginal and clitoral vibratory sensory thresholds did not change significantly following surgery.

Conclusion

The repair of pelvic organ prolapse by robotic sacrocolpopexy could potentially play a role in restoring clitoral and vaginal wall sensation. The effects of these sensory changes on sexual function and the quality of sexual life need further investigation.

     

Histology of the vaginal wall in women with pelvic organ prolapse: a literature review

Introduction and hypothesis

The pathophysiology of pelvic organ prolapse (POP) is incompletely understood. The purpose of this study is to describe the current knowledge about histology of the vaginal wall and its possible involvement in the pathogenesis of pelvic organ prolapse.

Methods

Eligible studies were selected through a MEDLINE search covering January 1986 to December 2012. The research was limited to English-language publications.

Results

Investigations of changes in the vaginal tissue that occur in women with genital prolapse are currently still limited and produced contrary results. The heterogeneity of the patients and the control groups in terms of age, parity and hormonal status, of the localization of biopsies and the histological methods as well as the lack of validation of the quantification procedures do not allow clear and definitive conclusions to be drawn.

Conclusions

This review shows that current knowledge of the histological changes observed in women with POP are inconclusive and relatively limited. More studies are needed in this specific field to better understand the mechanisms that lead to POP.     

A new vaginal speculum for pelvic organ prolapse quantification (POPQ)

The purposes of this study were to introduce a new vaginal speculum, describe the technique of using the new speculum in identifying and measuring the severity of pelvic organ prolapse (POP), and present results of a pilot study comparing the new speculum to the conventional instruments used in performing POP quantification (POPQ). The new speculum has retractable upper and lower blades marked in centimeters. POPQ was performed with one instrument using the new speculum and multiple instruments performing the conventional technique. Twenty-two patients underwent POPQ—11 using the new speculum and 11 using conventional instruments. The duration of the procedure and the level of discomfort were assessed. The POPQ method using the new speculum is described. Preliminary experience with the new speculum showed that the length of examination is significantly shorter (p<0.001) and the comfort level is better than with the conventional technique (p=0.088). A new vaginal speculum with adjustable blades simplifies POPQ. Preliminary testing suggests potential savings in procedure time and reduction in patient discomfort.     

Informed surgical consent for a mesh/graft-augmented vaginal repair of pelvic organ prolapse

Introduction and hypothesis

Complex issues surround informed surgical consent for pelvic reconstructive surgery.

Methods

Vaginally placed mesh/grafts are used with the intent to increase durability of the repair but potentially introduce unique complications, offering new challenges in informed surgical consent counseling.

Results

Informed consent is a process that takes place throughout the entire consultation with the patient. A written document often accompanies that process. This paper outlines necessary components of informed surgical consent and the theory behind each component.

Conclusions

We explore elements that should be included in the consent process with regard to expected benefits, alternatives, and material risks that are specific to the use of a mesh/graft-augmented vaginal repair of prolapse. Included is an appendix that may serve as a template for the creation of a surgeon’s own written informed consent document.

     

Management of ureteral injuries associated with vaginal surgery for pelvic organ prolapse

Due to the anatomic proximity of the urinary and genital tracts, iatrogenic ureteral injury during pelvic organ prolapse repairs is a serious complication that we have managed in increasing number at our institution. However, few centers have reported on their experience with ureteric injuries associated with gynecologic reconstructive surgery. These ureteral injuries may lead to much morbidity, in particular the formation of ureterovaginal fistula, and the potential loss of renal function especially when diagnosed postoperatively. It is necessary, therefore, for surgeons to have a thorough knowledge of ureteral anatomy and to take precautions to prevent such injuries. The purpose of this article is to review this pertinent anatomy and the key principles of management of ureteric complications of transvaginal surgery for pelvic organ prolapse. The present study illustrates the application of our treatment algorithm based on the time of presentation and the patient condition.     

Role of concurrent vaginal hysterectomy in the outcomes of mesh-based vaginal pelvic organ prolapse surgery

Introduction and hypothesis

Hysterectomy is often performed at the time of pelvic organ prolapse (POP) surgery; yet, there is insufficient evidence regarding the specific effect of hysterectomy on outcomes. We sought to determine the outcomes and associated short-term complications of mesh-based POP surgery with and without concurrent hysterectomy.

Methods

We utilized the New York Statewide Planning and Research Cooperation System (SPARCS) database to identify patients under 55 years of age undergoing surgeries for POP with mesh between 2009 and 2014. Patients who had a hysterectomy at the time of mesh-based POP surgery were compared with those who underwent mesh-based POP surgery without hysterectomy. Outcome measures of the patient groups before and after propensity score matching were compared. We assessed the difference Chi-squared tests and log-rank tests in the entire cohort and Mantel–Haenszel stratified Chi-squared tests and Prentice-Wilcoxon tests in the matched cohort.

Results

A total of 1,601 women underwent mesh-based POP surgery. 921 patients underwent concurrent hysterectomy, whereas 680 had mesh-based uterine-preserving POP surgery. After propensity score matching, there was no difference in reintervention rates between groups for up to 3 years. Concurrent hysterectomy with mesh-based POP repair was consistently associated with longer hospitalization (20.0% vs 12.8% stayed longer than 2 days) and higher charges (median charges were $22,689 vs $19,273).

Conclusions

Concurrent hysterectomy during mesh-based POP surgery in patients under 55 years led to more expensive charges and a longer stay compared with uterine-preserving mesh surgery. There was no difference in reintervention rates between groups for up to 3 years.

     

Basic procedures in tension‐free vaginal mesh operation for pelvic organ prolapse

A variety of tension‐free vaginal mesh (TVM) systems are available for surgical treatment of pelvic organ prolapse (POP). These include Prolift, Apogee/Perigee and Avaulta, all of which vary in terms of mesh size, shape and surgical technique to such an extent that they cannot truly be considered the same operation for the purpose of evaluating results. I began carrying out self‐made mesh cut out from Gynemesh PS in 2005. This system has four main characteristics: (i) the mesh is intended as a replacement for defective visceral pelvic fascia; (ii) it bridges between the left and right arcus tendineus fascia pelvis (white line, or ATFP); (iii) large‐size mesh is held in place by passing cannulas through the obturator fascia (anterior wall) or the sacrospinous ligament (SSL) to attach the arms of the mesh graft; and (iv) the bladder neck is preserved. The mesh that I have used since then has been essentially similar to the Prolift System, developed by a French TVM group, in terms of size and shape of its central portion. Mesh grafts used for the anterior wall are quite large, so skillful execution will provide sufficient room between the left and right ATFP in almost all cases. This video discusses the fundamental techniques necessary for skillful execution of the tension‐free vaginal mesh (TVM) procedure using the Prolift System, focusing on the following points: (i) surgical separation of the correct layers of the vaginal wall, and the area separated, and effective hemostasis; (ii) precise puncture technique, especially the second puncture for the anterior TVM (TVM‐A) procedure and the sacrospinous ligament (SSL) puncture in the posterior TVM (TVM‐P) procedure; (iii) firmly securing the mesh to the vaginal wall or cervical canal; and (iv) careful mesh placement and formation of a bridge between the left and right arcus tendineus fascia pelvis (ATFP). Proper separation of the vaginal wall layers, in particular, is crucial for preventing unnecessary blood loss and mesh erosion. The second puncture in the TVM‐A is the most important of the puncture maneuvers for the procedure. Penetrating the tough tissue near the ischial spine represents a significant challenge, and the SSL penetration in the TVM‐P procedure is unexpectedly difficult for those without sufficient experience. In order to become proficient, the surgeon must have hands‐on experience under the supervision of experts. Finally, TVM is a relatively new procedure, so one must master the fundamentals before gaining true proficiency. The technique does not call for virtuosity on the part of the surgeon, but key points must be mastered to reduce the risk of complications and recurrences. With repeated hands‐on training, surgical skills will gradually improve to the requisite level. This is a translated section of a video article originally published in Japanese as a DVD in the Audio‐Visual Journal Vol.15 No.15. 2009 by The Japanese Urological Association.     

A 5-year prospective follow-up study of vaginal surgery for pelvic organ prolapse

The objective of this study was to evaluate anatomic, functional, short- and long-term outcome of vaginal surgery for pelvic organ prolapse. This was a prospective observational study of 185 consecutive women planned for vaginal prolapse reconstructive surgery. Stage of prolapse, urinary incontinence (UI), bowel and mechanical symptoms were assessed preoperatively and at 1, 3 and 5 years postoperatively. The mean follow-up time was 53 months. The anatomic recurrence rate was 41.1% but less than half of them were symptomatic. Anterior compartment was most prone for recurrence and the majority of the recurrences took place within the first year. UI remained at the same level at 1-year follow-up. De novo urge occurred in 22.6% and de novo stress incontinence in 6.0%. An improvement was seen in difficulty in emptying bowel 1 year after surgery (54%). Patients were primarily cured from mechanical symptoms. Re-operation rate was 9.7%; if additional operation for incontinence was included, it was13.5%.