Total hysterectomy and anterior vaginal wall suspension for concurrent uterine and bladder prolapses: Long-term anatomical results of additional vault and/or posterior compartment prolapse repair

ObjectiveTo review the long-term results of an intraoperative decision to repair or not repair associated vault and posterior compartment defects after total hysterectomy (TH) and anterior vaginal wall suspension (AVWS) for uterine and bladder prolapses.MethodsAfter gaining Institutional Review Board approval, the operative records of women receiving TH and AVWS concurrently with a minimum follow-up period of 6 months were reviewed. Two groups were identified: Group 1 (G1) underwent TH + AVWS and intraoperative apical and/or posterior repairs, and Group 2 (G2) had TH + AVWS alone. The definition of prolapse recurrence was Pelvic Organ Prolapse—Quantification ≥ Stage 2 and/or any reoperation for prolapse.ResultsFrom 1998 to 2009, a total of 94 women were evaluated. At the mean 3 years follow-up, the rates of overall prolapse recurrence following initial surgeries between G1 and G2 were 30% and 24%, respectively. Additional operative repair for G1 and G2 was 18.5% and 16%, respectively. The progression rate for both groups was < 8%. The overall success for G1 and G2 was 70% and 76%, respectively.ConclusionAt long-term follow-up, nearly one in five apical recurrences in these two surgical groups was observed with stable results in the anterior compartment. The posterior compartment required the least surgical intervention.     

Bilateral extraperitoneal uterosacral suspension: a new approach to correct posthysterectomy vaginal vault prolapse

Restoration of apical vaginal support remains a challenging problem for the pelvic reconstructive surgeon. The transvaginal use of the uterosacral-cardinal ligament complex is gaining increasing popularity in the surgical treatment of uterovaginal and posthysterectomy vault prolapse. We describe an extraperitoneal surgical approach using this ligamentous complex to reattach the vaginal apex in women with posthysterectomy vault prolapse and report our surgical experience with this procedure in 123 women over 5 years. The relevant anatomy related to the procedure and risk of ureteric injury with uterosacral suspension is also reviewed. Extraperitoneal vault suspension can be combined with the use of polypropylene mesh if required. The extraperitoneal approach is an alternative procedure in women with vault prolapse with or without concomitant enterocele or where access to the Pouch of Douglas is difficult particularly after previous pelvic surgery. We believe this procedure to have less risk of ureteral injury than the intraperitoneal approach.     

Efficacy of Laparoscopic Sacrocervicopexy for Apical Support of Pelvic Organ Prolapse

Background and Objectives:

To evaluate the efficacy of laparoscopic sacrocervicopexy for apical support in sexually active patients with pelvic organ prolapse.

Methods:

One-hundred thirty-five women with symptomatic prolapse of the central compartment (Pelvic Organ Prolapse Quantitative [POP-Q] stage 2) underwent laparoscopic sacrocervicopexy. The operating physicians used synthetic mesh to attach the anterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory with subtotal hysterectomy. Anterior and posterior colporrhaphy was performed when necessary. The patients returned for follow-up examinations 1 month after surgery and then over subsequent years. On follow-up a physician evaluated each patient for the recurrence of genital prolapse and for recurrent or de novo development of urinary or bowel symptoms. We define “surgical failure” as any grade of recurrent prolapse of stage II or more of the POP-Q test. Patients also gave feedback about their satisfaction with the procedure.

Results:

The mean follow-up period was 33 months. The success rate was 98.4% for the central compartment, 94.2% for the anterior compartment, and 99.2% for the posterior compartment. Postoperatively, the percentage of asymptomatic patients (51.6%) increased significantly (P < .01), and we observed a statistically significant reduction (P < .05) of urinary urge incontinence, recurrent cystitis, pelvic pain, dyspareunia, and discomfort. The present study showed 70.5% of patients stated they were very satisfied with the operation and 18.8% stated high satisfaction.

Conclusion:

Laparoscopic sacrocervicopexy is an effective option for sexually active women with pelvic organ prolapse.     

Transvaginal repair of genital prolapse: preliminary results of a new tension-free vaginal mesh (Prolift™ technique)—a case series multicentric study

Our goal was to report the preliminary results of a transvaginal mesh repair of genital prolapse using the Prolift™ system. This retrospective multicentric study includes 110 patients. All patients had a stage 3 (at the hymen) or stage 4 (beyond the hymen) prolapse. Total mesh was used in 59 patients (53.6%), an isolated anterior mesh in 22 patients (20%) and an isolated posterior mesh in 29 patients (26.4%). We report one bladder injury sutured at surgery and two haematomas requiring secondary surgical management. At 3 months, 106 patients were available for follow-up. Mesh exposure occurred in five patients (4.7%), two of them requiring a surgical management. Granuloma without exposure occurred in three patients (2.8%). Failure rate (recurrent prolapse even asymptomatic or low grade symptomatic prolapse) was 4.7%. According to the perioperative and immediate post-operative results, Prolift™ repair seems to be a safe technique to correct pelvic organ prolapse. Anatomical and functional results must be assessed with a long-term follow-up to confirm the effectiveness and safety of the procedure.     

Longterm followup of posthysterectomy vaginal vault prolapse abdominal repair: a report of 85 cases

BACKGROUND: There are many surgical procedures to treat posthysterectomy vaginal vault prolapse. Abdominal sacral colpopexy is one of these procedures. The aim of this study was to review the cases of 85 consecutive patients treated by this technique since 1978 by the same surgical team using the same procedure. Our surgical procedure will be explained. STUDY DESIGN: Eighty-five patients were treated in our department between 1978 and 1998 for posthysterectomy vaginal vault prolapse. The mean age was 55.42 years. The mean weight was 63.37 kg. Their parity ranged from 0 to 5 (mean, 2.54). The interval of time between hysterectomy and vaginal vault prolapse repair ranged from 1 to 37 years (mean, 17.92 years). The main indication for hysterectomy was uterine leiomyomas. Of these patients, 67.05% had stress urinary incontinence, and mean urethral closure pressure was 48.7 cm H2O. All patients had abdominal sacral colpopexy associated with a Burch procedure and a posterior perineal repair. RESULTS: Seventeen patients had postoperative fever. Twenty-two had urinary tract infections. Two patients had to undergo blood transfusion. Three patients had postoperative urinary retention. The median longterm followup was 10.5 years; 27.05% of patients had relapsing stress urinary incontinence. Two patients had a relapse of the vaginal vault prolapse. CONCLUSIONS: The abdominal sacral colpopexy is a safe operation with low morbidity and long-standing good results. It can be recommended for sexually active women. Nevertheless, the Burch procedure performed with this operation failed to prevent recurrence of urinary incontinence.     

The UK National Prolapse Survey: 10 years on

Introduction and hypothesis

To assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners and changes in practice since a previous similar survey.

Methods

An online questionnaire survey (Typeform Pro) was emailed to British Society of Urogynaecology (BSUG) members. They included urogynaecologists working in tertiary centres, gynaecologists with a designated special interest in urogynaecology and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP and was a revised version of the questionnaire used in the previous surveys. The revised questionnaire included additional questions relating to the use of vaginal mesh and laparoscopic urogynaecology procedures.

Results

Of 516 BSUG members emailed, 212 provided completed responses.. For anterior vaginal wall prolapse the procedure of choice was anterior colporrhaphy (92% of respondents). For uterovaginal prolapse the procedure of choice was still vaginal hysterectomy and repair (75%). For posterior vaginal wall prolapse the procedure of choice was posterior colporrhaphy with midline fascial plication (97%). For vault prolapse the procedure of choice was sacrocolpopexy (54%) followed by vaginal wall repair and sacrospinous fixation (41%). The laparoscopic route was preferred for sacrocolpopexy (62% versus 38% for the open procedure). For primary prolapse, vaginal mesh was used by only 1% of respondents in the anterior compartment and by 3% in the posterior compartment.

Conclusion

Basic trends in the use of native tissue prolapse surgery remain unchanged. There has been a significant decrease in the use of vaginal mesh for both primary and recurrent prolapse, with increasing use of laparoscopic procedures for prolapse.

     

Posterior intravaginal slingplasty for vaginal prolapse

Objective To evaluate the results of the posterior intravaginal slingplasty (IVS).Patients and methods From a urogynecology database, 42 patients who had undergone posterior IVS procedures were analyzed. All the selected patients had also had a posterior colporrhaphy (88% with mesh inserted into the rectovaginal space).Results Intraoperatively, there was one complication, a rectum perforation. All patients were followed-up, with a median of 13 months. Recurrent prolapse, grade 3 or 4, developed in 12 patients (29%) which included ten cystoenteroceles (24%), four rectoenteroceles (10%), and three cases of utero/vault prolapse (7%). Repeat surgery was performed in six patients (14%). For utero/vault prolapse, eight patients presented preoperatively with grades 3 and 4 prolapse. On follow-up, three patients had utero/vault prolapse, one of whom did not have utero/vault prolapse on presentation. Therefore, of the eight patients presenting with utero/vault prolapse, only two had repeat prolapse on follow-up, which reflected an improvement of 75%.Conclusion The posterior IVS delivered satisfactory results for vault and posterior compartment prolapse, with a 75% improvement in vault prolapse. It was not possible, however, to separate the effect of posterior IVS and posterior colporrhaphy on the prevention of recurrent prolapse nor on the improvement of difficulty in defecation. Due to the utilization of the now-abandoned vaginal anterior colposuspension procedure for the treatment of anterior compartment prolapse, no conclusions regarding the impact of the posterior IVS on the anterior compartment can be made.This study was approved by the Ethics Review Board of the University of the Free State (no. 124/04).     

Anterior vaginal compartment surgery

Aim

To review the safety and efficacy of anterior vaginal compartment 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 the 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. A grade A recommendation usually depends on consistent level 1 evidence. A grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. A grade C recommendation usually depends on level studies or “majority evidence” from level 2/3 studies or Delphi processed expert opinion. A 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

Absorbable mesh augmentation of anterior compartment native tissue repair improves the anatomical outcome compared with native tissue repair alone with no increased complication rate in meta-analysis of 2 RCTS (grade B). Biological grafts in meta-analysis have improved anatomical outcomes with no change in subjective outcomes compared with native tissue repairs (grade B). There is conflicting level 1 evidence to support porcine dermis and a single RCT to support small intestine submucosa as graft agents in anterior compartment prolapse surgery (grade B). Consistent level 1 data support a superior anatomical outcome for polypropylene mesh compared with a biological graft in the anterior compartment. Mesh exposure rate was significantly higher in the polypropylene mesh group (grade A). Consistent level 1 evidence demonstrates superior subjective and objective outcomes following anterior transvaginal polypropylene mesh as compared to anterior colporrhaphy (grade A). These outcomes did not translate into improved functional results using validated questionnaires or a lower reoperation rate for prolapse. The mesh group was also associated with longer operating time, greater blood loss and apical or posterior compartment prolapse as compared with anterior repair. Anterior polypropylene mesh had a mesh extrusion rate of 10.4 % with 6.3 % requiring a surgical correction (grade B). Single level 3 evidence does not support the use of transvaginal polypropylene mesh for recurrent anterior vaginal wall prolapse (grade C).

Conclusion

Polypropylene anterior compartment mesh offers improved objective and subjective outcomes compared with native tissue repair; however, these benefits must be considered in the context of increased morbidity associated with anterior polypropylene transvaginal mesh.     

Anterior vaginal wall hammock with fascia lata for the correction of stage 2 or greater anterior vaginal compartment relaxation

PURPOSE: We determined the efficacy of the anterior vaginal wall hammock (AVWH) using fascia lata for the correction of anterior vaginal compartment relaxation. MATERIALS AND METHODS: A total of 58 patients with stage 2 or greater anterior vaginal compartment relaxation underwent an AVWH procedure with autologous or allograft fascia lata from June 1998 to March 2001. Patients were evaluated preoperatively with a history and pelvic organ prolapse quantitative examination. Postoperatively patients were evaluated at 6 weeks, 6 months and yearly thereafter with pelvic organ prolapse quantitative staging of the anterior, middle and posterior compartments. Objective cure was defined as stage 0 or 1 relaxation. Subjective cure was defined as no symptoms of pelvic pressure or a vaginal bulge. RESULTS: Of the 69 (89%) patients who underwent surgery 58 were available for followup. Median age of the population was 61.9 years and median followup was 24.7 months (range 12 to 57). There were 11 objective failures (19%) in the anterior compartment, of which 1 (2%) was symptomatic. Two patients (4%) had enteroceles that required surgical correction. Of the patients 16 (28%) had new onset or worsening stage 2 posterior relaxation at a median of 15.2 months postoperatively, including 7 (12%) who were symptomatic and underwent subsequent repair. CONCLUSION: The AVWH procedure with fascia lata is safe and effective for correcting stage 2 or greater anterior compartment relaxation. The whole pelvic floor must be evaluated and repaired to minimize the progression of prolapse of the middle and posterior compartments.     

Perineal hernia extruding into the labium majus after multiple surgeries for pelvic organ prolapse

A 78-year-old woman presented with a large bulge in the right labium majus. She had a previous history of two anterior and posterior vaginal wall prolapse repairs, a vaginal hysterectomy for uterovaginal prolapse, a sacrospinous ligament fixation for vaginal vault prolapse, and a LeFort partial colpocleisis for recurrent vault prolapse. Magnetic resonance imaging (MRI) revealed an anterior perineal hernia containing small bowel. Surgery was performed to close the pelvic floor defect through a perineal approach, and polypropylene mesh was used as a bolster. The hernial sac contained small bowel with very thin adhesions. Over 6 months of follow-up, there was no recurrence of the hernia or mesh complications. Perineal hernias after gynecological surgeries for benign diseases are rare. The indications for repair and the optimal surgical approach are not well described.     

Anterior vaginal mesh sacrospinous hysteropexy and posterior fascial plication for anterior compartment dominated uterovaginal prolapse

Introduction and hypothesis  

The surgical management of multi-compartment prolapse is challenging and often requires a combination of techniques. This study evaluates anterior vaginal mesh repair, sacrospinous hysteropexy and posterior fascial plication in women with anterior compartment dominated uterovaginal prolapse.     

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.     

Leaflet resection for the degenerative mitral valve regurgitation; early/long-term assessment

Leaflet resection for posterior leaflet prolapse has been a standard repair procedure with good longterm durability. The aim of this study was to review our experience of mitral valve repair, in which resection of the anterior and/or posterior leaflets was performed. Between October 1991 and December 2010, 172 patients with degenerative mitral valve regurgitation underwent mitral valve reconstruction,including 98 patients with the posterior leaflet prolapse, 47 patients with the anterior leaflet prolapse, 17 patients with both leaflets and 10 patients with the commissure prolapse. Most patients in this study were supposed to be caused by fibroelastic deficiency and we have not experienced systolic anterior motion after repair. The mean follow-up period was 8.7 ± 5.5 years. The freedom from reoperation rates at 15 years in 88.7 ± 5.3% of the anterior leaflet procedure, 96.6 ± 2.5% of the posterior leaflet, and 100% of both leaflets. The results of resection of a diseased prolapsed mitral leaflet have been promising so far. However, reoperation was required in 7 patients (4.1%) and reoperation rate was higher in patients with anterior prolapse and longer follow-up will evaluate precisely be benefit.     

Combining colposacropexy and Ripstein procedure for combined vaginal vault and rectal prolapse: With and without retropubic colpourethropexy for stress urinary incontinence

The literature concerning the concurrent surgical correction for coexisting posthysterectomy vault and intussuscepting rectal prolapse is reviewed. Only two such papers have been published in the past, reporting a total of three cases. Five such cases and their surgical correction using Marlex mesh for both modified Ripstein procedure and colposacropexy are presented. The need for thorough preoperative urodynamic evaluation and defecography is discussed. All patients had good anatomic correction of their genital and rectal prolapse in follow-up. One patient, who had a prior retropubic urethropexy only, was treated by a combined Ripstein and colposacropexy and postoperatively developed recurrent stress urinary incontinence as a consequence of overcorrection by the colposacropexy. This was subsequently corrected by a combined abdominovaginal Marlex mesh sling procedure. There were no operative or postoperative complications, and it is concluded that, in the hands of experienced surgeons, colposacropexy and Ripstein procedure for combined vaginal vault and rectal prolapse can be a safe and effective treatment.     

Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results,quality of life and perioperative outcome—a prospective study with 101 cases

Our prospective study evaluates laparoscopic sacrocolpopexy for vaginal vault prolapse focusing on perioperative data, objective anatomical results using the pelvic organ prolapse quantification (POP-Q) system and postoperative quality of life using the Kings Health questionnaire. One hundred one patients completed the study. Fifty five had laparoscopic supracervical hysterectomy and sacrocolpopexy for uterine prolapse and 46 had laparoscopic sacrocolpopexy for post-hysterectomy prolapse. Median follow-up was 12 months. The subjective cure rate was 93% the objective cure rate (no prolapse in any compartment) according to the International Continence Society classification of prolapse was 98%. The main site of objective recurrence (6%) was the anterior compartment. No apical recurrences and no vaginal mesh erosion occurred. Postoperatively overall quality of life and sexual quality showed significant improvement with less than 1% de-novo dyspareunia. The procedure is recommended for experienced laparoscopic surgeons because of severe intraoperative complications like bladder or rectal injuries.     

Evaluation of Current Biologic Meshes in Pelvic Organ Prolapse Repair

Pelvic organ prolapse (POP) is a common disorder estimated to affect 15%-30% of women over the age of 50 years. About 11% of women will require surgery by the age of 80 years and there is an estimated 30% rate of prolapse recurrence. In an attempt to improve surgical outcomes, biologic grafts and synthetic meshes have been implemented in the repair of POP. Biologic grafts have been used with the hope of avoiding complications associated with synthetic mesh. This presents the existing data surrounding the use of biologic grafts in the surgical repair of anterior compartment, vaginal vault, and posterior compartment prolapse.     

Gluteo-vaginal fistula after posterior intravaginal slingplasty: a case report

In patients with posthysterectomy prolapse of the vaginal vault, the posterior intravaginal slingplasty (posterior IVS, Tyco Healthcare, USA) has been suggested as an alternative to traditional vaginal vault suspensions. The goal of this technique is to recreate the uterosacral ligaments and to reinforce the rectovaginal fascia with the use of prosthetic material. We report the case of a 53-year-old woman with a history of 27 months of perineal suppurative discharge after she underwent a vaginal vault prolapse and rectocele repair using a posterior IVS (Tyco Healthcare®, USA). The IVS tape was reinforced by interposing a rectovaginal monofilament polypropylene mesh (Parietex®, Sofradim®, France). Imaging studies and surgical exploration confirmed infection of the IVS mesh with the formation of a gluteo-vaginal fistula while the rectovaginal mesh was intact.     

Laparoscopic promontory sacral colpopexy: is the posterior, recto-vaginal, mesh mandatory?

OBJECTIVE(S): The aim of our retrospective study was to determine if systematic placement of a posterior mesh, in addition to an anterior vesico-vaginal mesh, is necessary for laparoscopic treatment of pelvic organ prolapse. METHODS: A laparoscopic promontory sacral colpopexy was performed in 108 patients, including 55 patients with a concurrent laparoscopic Burch procedure (50.9%). We compared 33 patients treated with a single anterior mesh (SAM) and 71 treated with a double, anterior and posterior, mesh (DM). RESULTS: The difference between the SAM and DM groups was statistically significant in terms of posterior compartment failure (rectocele and/or enterocele): 31.3% and 5.9%, respectively (p=0.0006). This significant difference persisted in the Burch (B) group (p=0.001), but not in the non-Burch (NB) group (p=0.98). Among the SAM group, this difference between the B and NB groups, was significant (57.1% versus 0%; p=0.0015) and above all not a single posterior failure was observed in the NB group. CONCLUSION(S): The placement of a posterior mesh, if highly effective, appeared unnecessary in the absence of an associated Burch procedure or a patent posterior prolapse. The posterior mesh also increased risk of postoperative complications and side effects.