Evidence to justify retention of transvaginal mesh: comparison between laparoscopic sacral colpopexy and transvaginal Elevate™ mesh

Introduction and hypothesis

To determine if laparoscopic sacral colpopexy (LSC) offers better apical support with a lower exposure rate than transvaginal mesh surgery with Elevate?.

Methods

This was a retrospective cohort study comparing patients with apical prolapse (POP-Q point C ≥ ?1) who underwent Elevate? mesh repair (n = 146) with patients who underwent laparoscopic sacral colpopexy (n = 267).

Results

The sacral colpopexy group had a mean age of 59 years and a BMI of 25.7. Patients in the Elevate? group were older, with a mean age of 63 and a BMI of 26.3. Most of the patients of both groups presented with pelvic organ prolapse stage III (LSC 73.8% and Elevate? 87.0%) and their mean POP-Q point C were not significantly different (LSC 1.4 vs Elevate? 1.2 cm). Operative time was longer in the LSC group (113 vs 91 min, p < 0.001), but estimated blood loss was lower (75 cm³ vs 137 cm³, p < 0.001). No difference in mesh exposure rate could be found between the two groups at one year (Elevate? 0.7% vs LSC 2.6%, OR 0.26, 95% CI 0.03 to 2.10, p = 0.21). One-year objective cure rate, defined as no descent beyond the hymen, was 97.0% in the LSC group and 96.6% in the Elevate? group (p = .81). The overall recurrence (objective, subjective recurrence or reoperation) was also not different between the groups (LSC 4.5% vs Elevate 4.8%, p = 0.89).

Conclusion

Transvaginal Elevate? mesh delivers comparable apical support with a low exposure rate similar to that of laparoscopic sacral colpopexy.

     

A prospective comparison of two commercial mesh kits in the management of anterior vaginal prolapse

Introduction and hypothesis

Vaginal mesh kits are increasingly used in the management of pelvic organ prolapse. This study aimed to determine similarity of outcomes of the Anterior Prolift® with Perigee® systems for anterior compartment prolapse.

Methods

Consecutive women undergoing Perigee® or Anterior Prolift® for symptomatic stage 2 or greater anterior vaginal prolapse were prospectively evaluated. Main outcome measures included objective and subjective success rates, perioperative outcomes, patient satisfaction, and complications.

Results

One hundred and six women (Prolift, 52; Perigee, 54) completed questionnaires, and 91 (Prolift, 46; Perigee, 45) were examined postoperatively. At follow-up (Prolift: median, 11.0; range, 5–23 months; Perigee: median, 11.5; range, 6–23 months), objective success rates (Prolift, 89%; Perigee, 80%; p?=?0.23), subjective success rates (Prolift, 94%; Perigee, 96%; p?=?0.62), mean ± SD patient satisfaction (Prolift, 8.2?±?2.0; Perigee, 8.2?±?1.8; p?=?0.91), and complication rates did not differ significantly between the two groups.

Conclusions

The Anterior Prolift® was found to not differ significantly from Perigee® at 11 months.

     

Anatomical and functional changes to the pelvic floor after robotic versus laparoscopic ventral rectopexy: a randomised study

Introduction and hypothesis

To compare the effect of laparoscopic and robot-assisted ventral rectopexy for posterior compartment procidentia on the pelvic floor anatomy and function.

Methods

A prospective randomised single-centre study was carried out of 29 female patients, who underwent robot-assisted or laparoscopic ventral mesh rectopexy for external or internal rectal prolapse with symptoms of obstructive defecation and/or faecal incontinence. Anatomical changes were measured by Pelvic Organ Prolapse Quantification (POP-Q) and magnetic resonance defecography. Functional changes were evaluated using symptom questionnaires before and 3 months after surgery.

Results

After rectopexy, changes in POP-Q measurements were statistically significant for points Ap, Bp, C, D and Ba. The descent of the anorectum and cervix/vaginal cuff during straining were significantly reduced with regard to the reference line (mean, ?10.4?±?14.9 mm, p?=?0.001) and (?13.3?±?18.1 mm, p?<?0.001) respectively. Pelvic organ mobility (POM) was reduced statistically significantly for the posterior (mean, ?16.6?±?20.8 mm, p?<?0.001) and apical compartments (mean, ?13.1?±?14.8, p?<?0.001). The PFDI-20, PFIQ-7 and PISQ-12 questionnaires showed statistically significant improvement of symptoms and sexual function. No significant differences were observed between the robot-assisted and laparoscopic techniques in terms of anatomical or functional parameters.

Conclusion

Ventral mesh recto-colpo-sacropexy effectively corrects the anatomy of the posterior compartment, elevates the vaginal apex and reduces pelvic organ mobility of the posterior and middle compartments. The robot-assisted and laparoscopic techniques had similar anatomical and functional outcomes.

     

RCT of vaginal extraperitoneal uterosacral ligament suspension (VEULS) with anterior mesh versus sacrocolpopexy: 4-year outcome

Introduction and hypothesis

This study assessed the safety and efficacy of vaginal extraperitoneal uterosacral ligament suspension (VEULS) with anterior overlay mesh versus sacrocolpopexy (SCP) for posthysterectomy vault prolapse.

Methods

This was a multicenter randomized trial of women with posthysterectomy vault prolapse stage >2 according to the Pelvic Organ Prolapse Quantification (POP-Q) system. Primary outcome was a composite of no vaginal bulge symptoms, no anatomical recurrence in the anterior or apical compartment at or beyond the hymenal ring, and no surgical retreatment for prolapse 12 months postsurgery. Secondary outcomes were peri- and postoperative complications, changes in prolapse, and urogenital and sexual symptoms at 12, 24, and 48 months based on the Pelvic Floor Distress Inventory (PFDI)-20.

Results

Between 2006 and 2011, 82 eligible women were randomized: 39 received VEULS and 43 received SCP. Primary composite outcome at 12 months for success was 41% for VEULS and 65% for SCP [odds ratio (OR 2.68, p?=?0.03)]. Perioperative complications were more common in the SCP group. C-point was higher for SCP (?6.0 VEULS vs ?8.0 SCP, p?=?0.005) and total vaginal length (TVL) was longer for SCP (8.0 VEULS vs 9.0 SCP, p?=?0.05). Cumulative mesh exposure rate at 4 years was similar between the uterosacral [4/39 (10.3%)] and sacrocolpopexy [4/43 (9.3%)] groups, bearing in mind that not all patients were examined at 4 years. Subjective outcomes derived from three domains of the PFDI-20 were similar at 12, 24, 48 months. Postoperative Pelvic Organ Prolapse Distress Inventory (POPDI) score improved similarly for both groups at all timepoints, with the minimally important difference of at least 21 reached for both groups.

Conclusions

Composite outcome of success was better for SCP at 12 months, but subjective outcomes for prolapse at all timepoints over 4 years for VEULS and SCP were not significantly different.

     

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.     

Laparoscopic sacral hysteropexy versus laparoscopic sacrocolpopexy with hysterectomy for pelvic organ prolapse

Introduction and hypothesis

Treating pelvic organ prolapse (POP) with uterine conservation and sacral hysteropexy has uncertain subjective and objective outcomes. We sought to compare laparoscopic sacral hysteropexy with laparoscopic sacrocolpopexy/total laparoscopic hysterectomy (TLH with LSC).

Methods

Clinical data of 34 patients who underwent TLH with LSC and 65 patients who underwent laparoscopic sacral hysteropexy performed by the same group of surgeons between January 2008 and December 2013 were reviewed retrospectively. The primary outcome was subjective satisfaction rate based upon validated questionnaire (Patient Global Impression of Change [PGI-C]). Secondary outcomes were: anatomical cure, impact on quality of life based upon validated questionnaires (pelvic floor distress inventory-short form 20 [PFDI-20], Pelvic Floor Impact Questionnaire 7 [PFIQ-7], and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 [PISQ-12]), surgical complications, and cost.

Results

After a mean follow-up of 33 months, the subjective satisfaction rate was significantly higher in the TLH with LSC cohort (92.3 % vs 100 %; p?<?0.001). The POP-Q scores in both groups were significantly improved postoperatively. However, the anatomical cure in the two groups (72.3 % vs 88.2 %; p?=?0.07) did not differ significantly The postoperative PFIQ-7 and PFDI-20 scores were significantly better in the TLH with LSC cohort than in the laparoscopic sacral hysteropexy cohort (p?=?0.043 and p?=?0.035 respectively).

Conclusions

Relative to laparoscopic sacral hysteropexy, the TLH with LSC approach provides similar anatomical results, excellent patient satisfaction, and improved quality of life scores.

     

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.     

Magnetic resonance imaging of abdominal versus vaginal prolapse surgery with mesh

Introduction and hypothesis

We compared two surgical approaches in patients with symptomatic prolapse of the vaginal apex with normal controls by analyzing pelvic landmark relationships measured using magnetic resonance imaging (MRI) before and after surgery.

Methods

In this prospective multicenter pilot study involving 16 participants, nulliparous controls (n?=?6) were compared with ten parous (3.0?±?1.0) women with uterine apical prolapse equal to or greater than?stage 2. Group A (n?=?5) underwent abdominal sacral colpopexy with monofilament polypropylene mesh and group B (n?=?5) with vaginal mesh kit repair (Total ProLift). Subtotal hysterectomy was performed in all group A and no group B women. All patients underwent preoperative and 3-month postoperative Pelvic Organ Prolapse Quantification (POP-Q) and dynamic MRI. Comparison of MRI pelvic angles and distances was performed and analyzed by Mann–Whitney rank sum test and chi-square test.

Results

Vaginal apical support is similar at 3 months for abdominal sacral colpopexy (ASCP) and ProLift by POP-Q examination and MRI analysis. In both treatment groups, the postoperative POP-Q point C and MRI parameters were similar to nulliparous controls at 3?months.

Conclusions

Anatomic outcomes for ASCP compared with ProLift were similar at 3 months in terms of vaginal apical support by POP-Q and MRI analysis. Continued comparative analysis of postoperative support with objective imaging seems warranted.     

Comparison of complications and prolapse recurrence between laparoscopic and vaginal uterosacral ligament suspension for the treatment of vaginal prolapse

Introduction and hypothesis

Our objective was to compare complications and prolapse recurrence between laparoscopic (L-USLS) and vaginal (V-USLS) uterosacral ligament suspensions.

Methods

This is a retrospective study of USLS procedures performed at a large academic center from 2011 to 2014. Patient demographics, surgical data, complications, and prolapse recurrence of L-USLS and V-USLS were compared. Logistic regression identified predictors of operative time, complications, and prolapse recurrence.

Results

There were 54 L-USLS and 119 V-USLS procedures with median follow-up of 21.5 weeks (IQR 9.3–50.8). Women undergoing L-USLS were less likely to have medical comorbidities and had less severe prolapse, but were more likely to report prior hysterectomy. L-USLS had longer operative times (190.1?±?46.8 vs 172.7?±?47.3 min, p?=?0.03), but after correcting for concomitant procedures, the operative times of the two approaches were not significantly different (adjusted OR 1.00, 95%CI 0.99–1.00). There was no significant difference in complications between groups (24.1 % vs 21.8 %, p?=?0.75). However, there were nonsignificant trends toward more ureteral injuries and suture removals following V-USLS.Postoperative POP-Q points of the groups did not differ, except for total vaginal length (TVL), which was longer after L-USLS (8.3?±?1.1 cm vs 7.4?±?1.2 cm, p?<?0.001). 19 patients met the composite definition of prolapse recurrence, with no significant difference between groups (16.2 % vs 16 %, p?=?0.98). After adjusting for preoperative prolapse stage, route was not a significant predictor of prolapse recurrence (adjusted OR 0.39, 95 % CI 0.12–1.30).

Conclusions

L-USLS has comparable clinical outcomes, with similar rates of complications and prolapse recurrence to the traditional vaginal approach.

     

Clinical predictors and risk factors for vaginal mesh extrusion

Purposes

Our study aims to enhance the accuracy of the clinical diagnosis in patients with vaginal mesh extrusion following transvaginal mesh placement for pelvic organ prolapse using significant clinical parameters and risk factors.

Methods

All patients who underwent vaginal mesh removal were retrospectively reviewed from January 2000 to May 2014. Eligible patients were divided into two groups according to the presence of vaginal mesh extrusion.

Results

A total of 862 patients, 798 were included. 357 (44.7%) had evidence of vaginal mesh extrusion, and 441 (55.3%) had no evidence of vaginal mesh extrusion. The mean age of the vaginal mesh extrusion group was slightly higher than in the group without vaginal mesh extrusion (58.7 ± 11.2 vs. 56.4 ± 11.5, respectively; p = 0.002). From multivariate analysis, the significant clinical correlations for vaginal mesh extrusion were vaginal bleeding [60 (16.9) vs. 14 (3.2%), p < 0.001], hispareunia [48 (13.5) vs. 15 (3.4%), OR = 4.163, p < 0.001], and vaginal discharge [45 (12.6) vs. 18 (4.1%), p = 0.001]. The risk factors were multiple mesh implantations [218 (67.06) vs. 175 (39.68%), p < 0.001] and menopause [314 (88) vs. 364 (82.7%), p = 0.145]. Demographic data, including BMI, sexual activity, vaginal atrophy, both local and systemic hormonal use, smoking status, and hysterectomy status, were not significantly different, as well as the clinical symptoms including dyspareunia, vaginal infection, and symptomatic vaginal bulge.

Conclusions

Vaginal bleeding, hispareunia, and vaginal discharge were the most significant clinical predictors for raising suspicion of vaginal mesh extrusion. Multiple mesh implantations were a significant risk factor for extrusion.

     

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.     

Laparoscopic Sleeve Gastrectomy and Gastric Bypass for The Aging Population

Background

Laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most common bariatric surgeries for treating morbid obesity. The purpose of this study is to determine differences in outcomes from RYGB or SG between patients ages?≥?60 years and?<?60 years.

Methods

A retrospective review of patients who underwent RYGB and SG at our institution from 01/2008 to 05/2012 was conducted. Forty patients from each group (≥60 years and?<?60 years) were matched based on gender, body mass index (BMI), co-morbidities, and type of bariatric surgery performed, and their charts were reviewed up to 1 year post-operatively. Primary end points measured were mean length of stay, operative time, incidence of complications, and readmissions in the first post-operative year. A secondary end point measured was percent total weight loss (%TWL) and excess weight loss (%EWL).

Results

There were no significant differences between group?<?60 and group?≥?60 in operative time (210 vs. 229 min; p?=?0.177), in-hospital post-operative complication rates (2.5 vs. 5 %; p?=?1.0), long-term complication rates (2.5 vs. 10 %; p?=?0.359), and 30-day readmission rates (2.5 vs. 12.5 %; p?=?0.2). Patients in group?<?60 had shorter lengths of stay (2.2 vs. 2.7 days; p?=?0.031), but this difference is not clinically significant. Both groups achieved similar %TWL (21.4 vs. 20.5 %; p?=?0.711) and %EWL (50.6 vs. 50.7 %; p?=?0.986).

Conclusions

Advanced age (≥60 years) is not a significant predictor of a worse outcome for SG and RYGB.

     

Self-retaining support implant: an anchorless system for the treatment of pelvic organ prolapse—2-year follow-up

Introduction and hypothesis

The search for an improved vaginal mesh prompted the development of a new anchorless implant. The objective was to report on outcome after 2 years of a technique using a self-retaining support (SRS) implant.

Methods

Patients with anterior vaginal wall prolapse, with/without apical prolapse, were recruited. Participants underwent surgical repair using the SRS device. Demographic data, pre-surgical Pelvic Organ Prolapse Quantification (POP-Q) scoring, quality of life (QoL) questionnaires (Pelvic Floor Distress Inventory Short Form 20 [PFDI-20], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire 12 [PISQ-12]), and surgical data were collected. Patients were followed at 2 weeks, 2, 6, 12, and 24 months after surgery. Objective anatomical success was defined using the NIH criteria.

Results

Twenty women were recruited for the study with an average age of 62.1 years and an average parity of 4.0 deliveries. Average BMI was 28. Pre-operative mean POP-Q measurements were Aa =1.40 (?1 to 3) cm, Ba = 2.3 (?1 to 6) cm and C = 0.4 (?7 to 6) cm. Surgical time averaged 31.2 min. Estimated blood loss averaged 165 ml. No intra-operative complications were observed. One case (5%) of frame erosion was documented 8 months after surgery. At 2 years’ follow-up, mean POP-Q measurements were: Aa = ?2.95 (?3 to ?2) cm, Ba = ?2.85 (?3 to ?2) cm, and C point ?6.90 (?10 to ?3) cm. Seventeen (85%) patients had stage 0 and 3 patients (15%) had stage 1. No mesh erosions or chronic pelvic pain were documented at follow-up. The total PFDI score at follow-up was decreased by 92.8 points (p < 0.0001).

Conclusions

At 2 years’ follow-up, the SRS implant was found to be safe, showing no intra-operative or immediate post-operative complications. All women presented with POP-Q measurements of the anterior and apical compartment at normal value (Ba ≤ ?2 cm) and statistically significant subjective improvement.

     

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.

     

Mesh complications and failure rates after transvaginal mesh repair compared with abdominal or laparoscopic sacrocolpopexy and to native tissue repair in treating apical prolapse

Objective

Our objective was to quantitate the extent of complications and failure rate for apical prolapse repair with transvaginal mesh (TVM) use versus sacrocolpopexy over a minimum of 2 years of follow-up.

Methods

Truven CCAE and Medicare Supplemental databases 2008–2013 were used for analysis. Patients with apical prolapse repair via transvaginal mesh (TVMR), abdominal sacrocolpopexy (ASCP), laparoscopic sacrocolpopexy (LSCP), or native tissue repair (NTR) and continuously enrolled for years were in the study cohort. Surgical failures were identified by reoperation for any prolapse or subsequent use of pessary. SAS® 9.3 was used for analysis.

Results

Mesh removal/revision was reported highest in TVMR (5.1 %), followed by LSCP (1.7 %) and ASCP (1.2 %). In those with concomitant sling, combined rates for mesh/sling revision were high, at 9.0 % in TVMR?+?sling, 5.6 % in ASCP?+?sling, and 4.5 % LSCP?+?sling. Sling-alone cases reported a 3.5 % revision rate. Pelvic pain (16.4–22.7 %) and dyspareunia (5.6–7.5 %) were high in all three approaches for apical prolapse repairs. Reoperation for apical prolapse was more common for TVMR (2.9 %) compared with NTR (2.3 %) [odds ratio (OR) 1.27; confidence interval (CI) 1.1–1.47; p 0.002]. Both ASCP and LSCP were superior to NTR (ASCP 1.5 %, OR 0.63, CI 0.46–0.86; p 0.003) and LSCP 1.8 % (OR 0.79, CI 0.62-1.01; p 0.07). Overall prolapse recurrence, as indicated by any compartment surgery for prolapse and/or pessary use, was also noted highest in TVMR (5.9 % OR 1.23, CI 1.11–1.36; p <0.0001). Laparoscopic sacrocolpopexies were slightly superior at 4.0 % overall recurrence (OR 0.83, CI 0.7–0.98); p 0.03). Failure of incontinence surgery was higher when the initial procedure combined prolapse and sling surgery (1.97 %) versus sling alone (1.6 %).

Conclusions

Reoperation for apical prolapse is more common with TVMR than with sacrocolpopexies and NTR. Incontinence procedures are more likely to fail when performed along with prolapse repair than when performed alone. When mesh is used for repair, mesh revision is highest with TVMR and lowest with ASCP.

     

Long-term outcomes and predictors of failure after surgery for stage IV apical pelvic organ prolapse

Introduction and hypothesis

The aim of this study was to compare outcomes after uterosacral ligament suspension (USLS) or sacrocolpopexy for symptomatic stage IV apical pelvic organ prolapse (POP) and evaluate predictors of prolapse recurrence.

Methods

The medical records of patients managed surgically for stage IV apical POP from January 2002 to June 2012 were reviewed. A follow-up survey was sent to these patients. The primary outcome, prolapse recurrence, was defined as recurrence of prolapse symptoms measured by validated questionnaire or surgical retreatment. Survival time free of prolapse recurrence was estimated using the Kaplan–Meier method, and Cox proportional hazards models evaluated factors for an association with recurrence.

Results

Of 2633 women treated for POP, 399 (15.2%) had stage IV apical prolapse and were managed with either USLS (n = 355) or sacrocolpopexy (n = 44). Those managed with USLS were significantly older (p < 0.001) and less likely to have a prior hysterectomy (39.7 vs 86.4%; p < 0.001) or prior apical prolapse repair (8.2 38.6%; p < 0.001). Median follow-up was 4.3 years [interquartile range (IQR) 1.1–7.7]. Survival free of recurrence was similar between USLS and sacrocolpopexy (p = 0.43), with 5-year rates of 88.7 and 97.6%, respectively. Younger age [adjusted hazard ratio (aHR) 1.55, 95% confidence interval (CI) 1.12–2.13; p = 0.008] and prior hysterectomy (aHR 2.8, 95% CI 1.39–5.64; p = 0.004) were associated with the risk of prolapse recurrence, whereas type of surgery approached statistical significance (aHR 2.76, 95% CI 0.80–9.60; p = 0.11).

Conclusions

Younger age and history of prior hysterectomy were associated with an increased risk of recurrent prolapse symptoms. Notably, excellent survival free of prolapse recurrence were obtained with both surgical techniques.

     

The impact of serum uric acid reduction on renal function and blood pressure in chronic kidney disease patients with hyperuricemia

Background

Febuxostat is tolerable in chronic kidney disease (CKD) patients with hyperuricemia. However, the long-term effect of lowering uric acid with febuxostat on renal function and blood pressure has not been elucidated.

Methods

This was a 2 years retrospective observational study. 86 CKD patients with hyperuricemia who continued with allopurinol (allopurinol group, n?=?30), switched from allopurinol to febuxostat (switched group, n?=?25), or were newly prescribed febuxostat (febuxostat group, n?=?31) were included in this study. Serum uric acid, estimated glomerular filtration rate (eGFR), blood pressure, and urinary protein were analyzed. Moreover, the impact of serum uric acid reduction on renal function and blood pressure was assessed.

Results

Serum uric acid in the switched and febuxostat groups was significantly reduced at 6 months (switched group; 8.49?±?1.32–7.19?±?1.14 mg/dL, p?<?0.0001, febuxostat group; 9.43?±?1.63–6.31?±?0.90 mg/dL, p?<?0.0001). In the allopurinol group, serum uric acid was increased (6.86?±?0.87–7.10?±?0.85 mg/dL, p?=?0.0213). eGFR was significantly increased (35.2?±?12.8–37.3?±?13.9 mL/min/1.73 m², p?=?0.0232), while mean arterial pressure (93.1?±?10.8–88.2?±?9.5 mmHg, p?=?0.0039) was significantly decreased at 6 months in the febuxostat group, resulting in the retention of eGFR for 2 years.

Conclusions

The impact of serum uric acid reduction might have beneficial effects on CKD progression and blood pressure. However, a large prospective study is needed to determine the long-term efficacy of febuxostat therapy in CKD patients with hyperuricemia.

     

Comparison of functional outcomes of robotic and open partial nephrectomy in patients with pre-existing chronic kidney disease: a multicenter study

Background

We compared renal functional outcomes of robotic (RPN) and open partial nephrectomy (OPN) in patients with chronic kidney disease (CKD), a definite indication for nephron-sparing surgery.

Methods

A multicenter retrospective analysis of OPN and RPN in patients with baseline ≥?CKD Stage III [estimated glomerular filtration rate (eGFR) <?60 mL/min/1.73 m²] was performed. Primary outcome was change in eGFR (ΔeGFR, mL/min/1.73 m²) between preoperative and last follow-up with respect to RENAL nephrometry score group [simple (4–6), intermediate (7–9), complex (10–12)]. Secondary outcomes included eGFR decline >?50%.

Results

728 patients (426 OPN, 302 RPN, mean follow-up 33.3 months) were analyzed. Similar RENAL score distribution (p?=?0.148) was noted between groups. RPN had lower median estimated blood loss (p?<?0.001), and hospital stay (3 vs. 5 days, p?<?0.001). Median ischemia time (OPN 23.7 vs. RPN 21.5 min, p?=?0.089), positive margin (p?=?0.256), transfusion (p?=?0.166), and 30-day complications (p?=?0.208) were similar. For OPN vs. RPN, mean ΔeGFR demonstrated no significant difference for simple (0.5 vs. 0.3, p?=?0.328), intermediate (2.1 vs. 2.1, p?=?0.384), and complex (4.9 vs. 6.1, p?=?0.108). Cox regression analysis demonstrated that decreasing preoperative eGFR (OR 1.10, p?=?0.001) and complex RENAL score (OR 5.61, p?=?0.03) were independent predictors for eGFR decline >?50%. Kaplan–Meier analysis demonstrated 5-year freedom from eGFR decline >?50% of 88.6% for OPN and 88.3% for RPN (p?=?0.724).

Conclusions

RPN and OPN demonstrated similar renal functional outcomes when stratified by tumor complexity group. Increasing tumor age and tumor complexity were primary drivers associated with functional decline. RPN provides similar renal functional outcomes to OPN in appropriately selected patients.

     

Impacts of Supervised Exercise Training in Addition to Interdisciplinary Lifestyle Management in Subjects Awaiting Bariatric Surgery: a Randomized Controlled Study

Background

Experts recommend physical activity (PA) to optimize bariatric surgery (BS) results. However, evidence on the effect of PA before BS is missing. The aim of this study was to assess the impact of adding a Pre-Surgical Exercise Training (PreSET) to an interdisciplinary lifestyle intervention on physical fitness, quality of life, PA barriers, and anthropometric parameters of subjects awaiting BS.

Methods

Thirty candidates for BS (43.2?±?9.2 years, 47.5?±?8.1 kg/m²) have been randomized in two groups: one group following the PreSET (endurance and strength training) and another receiving usual care. Before and after 12 weeks, we assessed physical fitness with a battery of tests (symptom-limited exercise test, 6-min walk test (6MWT), sit-to-stand test, half-squat test, and arm curl test), quality of life with the laval questionnaire, and PA barriers with the physical exercise belief questionnaire.

Results

One control group subject abandoned the study. Subjects in the PreSET group participated in 60.0 % of the supervised exercise sessions proposed. Results showed significant improvements in the 6MWT (17.4?±?27.2 vs. ?16.4?±?42.4 m; p?=?0.03), half-squat test (17.1?±?17.9 vs. ?0.9?±?14.5 s; p?=?0.05), arm curl repetitions (4.8?±?2.3 vs. 1.0?±?4.1; p?=?0.01), social interaction score (10.7?±?12.5 vs. ?2.1?±?11.0 %; p?=?0.02), and embarrassment (?15.6?±?10.2 vs. ?3.1?±?17.8 %; p?=?0.02) in completers (n?=?8) compared to the non-completers (n?=?21). No significant difference between groups in BMI and other outcomes studied was observed after the intervention.

Conclusions

Adding a PreSET to an individual lifestyle counselling intervention improved physical fitness, social interactions, and embarrassment. Post-surgery data would be interesting to confirm these benefits on the long term.