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.

     

Prevalence of levator ani muscle avulsion and effect on quality of life in women with pelvic organ prolapse

Introduction and hypothesis

Levator ani muscle (LAM) avulsion is associated with pelvic organ prolapse (POP). There is limited information on the prevalence of LAM avulsion in Chinese women with POP. This study evaluated the prevalence of LAM avulsion in women presenting with POP and the effects on their quality of life (QoL).

Methods

This prospective study was conducted in a tertiary urogynecology center. Chinese women presenting with POP were recruited and completed standardized questionnaires exploring their symptoms and QoL and underwent gynecological examination to assess the stage of POP and involved compartments. Four-dimensional translabial ultrasound (US) was performed on all women, and evaluation of LAM avulsion was done offline.

Results

Three hundred and ninety-eight women completed the study. The prevalence of LAM avulsion was 38.9% [95% confidence interval (CI) 34.1–43.7%]; 31 (7.8%), 26 (6.5%), and 98 (24.6%) had left, right, and bilateral LAM avulsion, respectively. LAM avulsion was associated with a more advanced stage of prolapse (P < 0.005) and prolapse of stage ≥II of all three compartments. Bilateral LAM avulsion was associated with a more severe stage of prolapse. More women with LAM avulsion reported bothersome symptoms of prolapse and had higher Pelvic Organ Prolapse Distress Inventory (POPDI) and Urinary Incontinence Questionnaire (UIQ) scores, implying more impairment in QoL. However, after multivariate linear regression analysis, POP stage remained a significant predictor of POPDI and UDI scores (P ≤ 0.006); LAM avulsion was not a predictor (P = 0.2 and 0.27, respectively).

Conclusions

LAM avulsion was detected in 39% of Chinese women with POP. It was associated with a more advanced POP stage, and these women had more impairment of QoL. However, LAM avulsion was not an independent factor influencing the QoL of these women.

     

Advanced uterovaginal prolapse: is vaginal hysterectomy with McCall culdoplasty as effective as in lesser degrees of prolapse?

Introduction and hypothesis

There is a paucity of data on the success of vaginal surgery for severe prolapse. The authors hypothesized that the success rates of total vaginal hysterectomy (TVH) with McCall culdoplasty in women with advanced pelvic organ prolapse (POP) and in women with less severe POP are similar.

Methods

This was a retrospective review of women undergoing TVH with McCall culdoplasty from 2005 to 2014. Advanced POP was defined as exteriorized uterovaginal prolapse with Pelvic Organ Prolapse Quantification (POP-Q) point C, Ba or Bp ≥50% of the total vaginal length. The primary aim was to compare surgical success of TVH with McCall culdoplasty for the repair of advanced POP and less severe POP at ≥1 year.

Results

A total of 311 women were included, 38 with advanced POP and 273 with less severe POP. Women with advanced POP were older (71.6 vs. 61.8 years, respectively; p < 0.0001), but there were no significant differences in the length of follow-up (102.5 vs. 117 weeks, p = 0.2378), success rates (76.3% vs. 68.5%, p = 0.3553) or reoperation rates (2.6% vs. 4%, p > 0.9999) between women with advanced POP and less severe POP, respectively. There was a higher failure rate in the anterior compartment in those with advanced POP (18.4% vs. 6.2%, p = 0.0168), but not in the apical or posterior compartment.

Conclusions

TVH with McCall culdoplasty is equally effective for the treatment of advanced uterovaginal prolapse as for the treatment of less severe POP. Surgeons should consider this traditional surgery for their patients even if they have high-stage uterovaginal prolapse.

     

Interethnic variation in pelvic floor morphology in women with symptomatic pelvic organ prolapse

Introduction and hypothesis

There is a lack of epidemiological studies evaluating female pelvic organ prolapse in developing countries. Current studies have largely focused on women of white ethnicity. This study was designed to determine interethnic variation in pelvic floor functional anatomy, namely, levator hiatal distensibility and pelvic organ descent, in women with symptomatic pelvic organ prolapse in a multi-ethnic South African population.

Methods

This prospective observational study included 258 consecutive women referred for pelvic organ prolapse assessment and management at a tertiary urogynaecological clinic. After a detailed history and clinical examination, including POPQ assessment, patients underwent a 4D transperineal ultrasound. Offline analysis was performed using 4D View software. Main outcome measures included levator muscle distensibility, pelvic organ descent, and levator ani defects (avulsion).

Results

Mean age was 60.6 (range, 25–91) years, mean BMI 29.83 (range, 18–53). Points Ba and C were lower and the genital hiatus more distensible in black women (all p < 0.05). They were found to have greater hiatal area (p = 0.017 at rest, p = 0.006 on Valsalva) compared with South Asians and whites and showed greater pelvic organ mobility (all p < 0.05) than Caucasians on ultrasound. Levator defects were found in 32.2% (n = 83) of patients and most were bilateral (48.2%, n = 40), with significant interethnic differences (p = 0.014).

Conclusion

There was significant variation in clinical prolapse stage, levator distensibility, and pelvic organ descent in this racially diverse population presenting with pelvic organ prolapse, with South Asians having a lower avulsion rate than the other two ethnic groups (p = 0.014).

     

Ranula: Current Concept of Pathophysiologic Basis and Surgical Management Options

Background

There is no consensus opinion on a definitive surgical management option for ranulas to curtail recurrence, largely from the existing gap in knowledge on the pathophysiologic basis.

Aim

To highlight the current scientific basis of ranula development that informed the preferred surgical approach.

Design

Retrospective cohort study.

Setting

Public Tertiary Academic Health Institution.

Method

A 7-year 7-month study of ranulas surgically managed at our tertiary health institution was undertaken—June 1, 2008–December 31, 2015—from case files retrieved utilising the ICD-10 version 10 standard codes.

Results

Twelve cases, representing 0.4 and 1.2% of all institutional and ENT operations, respectively, were managed for ranulas with a M:F = 1:1. The ages ranged from 5/12 to 39 years, mean = 18.5 years, and the disease was prevalent in the third decade of life. Main presentation in the under-fives was related to airway and feeding compromise, while in adults, cosmetic facial appearance. Ranulas in adults were plunging (n = 8, 58.3%), left-sided save one with M:F = 2:1. All were unilateral with R:L = 1:2. Treatment included aspiration (n = 2, 16.7%) with 100% recurrence, intra-/extraoral excision of ranula only (n = 4, 33.3%) with recurrence rate of 50% (n = 2, 16.7%), while marsupialisation in children (n = 1, 8.3%) had no recurrence. Similarly, transcervical approach (n = 5, 41.7%) with excision of both the ranula/sublingual salivary gland recorded zero recurrence. Recurrence was the main complication (n = 4, 33.3%).

Conclusion

With the current knowledge on the pathophysiologic basis, extirpation of both the sublingual salivary gland and the ranula by a specialist surgeon is key for a successful outcome.

     

Radiological Changes After Resection Rectopexy in Patients with Rectal Prolapse—Influence on Clinical Symptoms and Quality of Life

Background

Resection rectopexy is performed to correct the anatomic defect associated with rectal prolapse. The aim of the study was to determine whether the change in the radiological prolapse grade has an influence on patients’ symptoms and quality of life.

Methods

The study investigated 40 patients who underwent resection rectopexy for rectal prolapse. The following were determined before and after surgery: radiological prolapse grade, anorectal angle and pelvic floor position in defecography, clinical symptoms (Cleveland Clinic Incontinence and Constipation Scores, Kelly-Hohlschneider Score), quality of life.

Results

Defecography revealed postoperative improvement in the prolapse grade and pelvic floor position (p < 0.05). The clinical symptoms and quality of life improved in both, the total population (n = 40) and in patients with improved radiological prolapse grade (n = 30): all clinical scores (p < 0.05), SF-36 (vitality, social role, mental health p < 0.05), and Fecal Incontinence Quality of Life Scale (lifestyle, coping, embarrassment p < 0.05). Patients without improved radiological findings showed no change in their symptoms or quality of life.

Conclusion

Our study demonstrates that the radiological prolapse grade is improved by resection rectopexy. Correction of the anatomic defect was associated with improvement in symptoms and quality of life. Defecography may therefore be useful in the postoperative assessment of persistent symptoms or reduced quality of life.

     

Robotic or laparoscopic sacrohysteropexy versus open sacrohysteropexy for uterus preservation in pelvic organ prolapse

Introduction and hypothesis

The aim of this study was to compare robotic or laparoscopic sacrohysteropexy (RLSH) and open sacrohysteropexy (OSH) as a surgical treatment for pelvic organ prolapse (POP).

Methods

Among 111 consecutive patients who had undergone sacrohysteropexy for POP, surgical outcomes and postoperative symptoms were compared between the RLSH (n?=?54; robotic 14 cases and laparoscopic 40 cases) and OSH (n?=?57). groups The medical records of enrolled patients were reviewed retrospectively.

Results

Compared with the OSH group, the RLSH group had shorter operating time (120.2 vs 187.5 min, p?<?0.0001), less operative bleeding (median estimated blood loss 50 vs 150 ml; p?<?0.0001; mean hemoglobin drop 1.4 vs 2.0 g/dl; p?<?0.0001), and fewer postoperative symptoms (13 vs 45.6 %; p?<?0.0001). Patients’ overall satisfaction (94.4 vs 91.2 %; p?=?0.717) and required reoperation due to postoperative complications (3.7 vs 1.8 %; p?=?0.611) did not differ between groups.

Conclusions

RLSH could be a feasible and safe procedure in patients with POP and should be considered as a surgical option that allows preservation of the uterus. Prospective randomized trials will permit the evaluation of potential benefits of RLSH as a minimally invasive surgical approach.

     

Prolapse symptoms are associated with abnormal functional anatomy of the pelvic floor

Introduction and hypothesis

The etiology of pelvic organ prolapse (POP) likely includes over-distension or tears (avulsion) of the levator ani muscle. However, there is a lack of studies evaluating the association between symptoms of POP and these factors. This study was designed to determine the association between POP symptoms and clinical prolapse stage on the one hand, and pelvic floor functional anatomy on the other hand.

Methods

This prospective observational study included 258 patients seen at a tertiary urogynecological unit with symptoms of POP as defined by pertinent ICIQ questions. After informed consent and a detailed history including ICIQ responses, 3D transperineal ultrasonography was performed using a GE Voluson i ultrasound system. Offline analysis was performed on de-identified datasets.

Results

The mean age of the patients was 60.6 years (25–91 years) and their mean BMI was 29.8 kg/m² (18–53 kg/m²). Levator defects were found in 78 (32.4%) of the patients and the defect was bilateral in almost half of these patients (n?=?36). There were significant associations between awareness and visualization of a vaginal lump on the one hand and hiatal area measurements as well as diagnosis of avulsion on the other. Interference with everyday life was significantly associated with hiatal area and prolapse stage, but not with avulsion.

Conclusions

There is a significant association between awareness, visualization and/or feeling of a vaginal lump and abnormal pelvic floor functional anatomy, that is, hiatal ballooning and levator avulsion.

     

Patient-reported outcomes after sacrospinous fixation of vault prolapse with a suturing device: a retrospective national cohort study

Introduction and hypothesis

Innovations in suturing devices have facilitated sacrospinous ligament fixation (SSF) for the correction of vaginal vault prolapse. It is uncertain if outcomes using suturing devices differ from those using a traditional suturing technique. We hypothesize that no difference exists in the efficacy and safety 1 year after SSF for vault prolapse performed with suturing devices or using a traditional technique. The objective was to compare SSF using a suturing device with traditional SSF for the treatment of vault prolapse, regarding symptoms of prolapse recurrence, patient satisfaction, incidence of re-operation, and complications 1 year postoperatively.

Methods

We carried out a retrospective cohort study using register-based national data from 2006 to 2013. The Swedish Quality Register of Gynecological Surgery includes assessments pre-operatively, at hospital admittance, surgery, discharge, and questionnaires at 8 weeks and 1 year after surgery.Demographic variables and surgical methods were included in multivariate logistic regression analyses.

Results

In the suturing device group (SDG, n = 353), 71.5% were asymptomatic of recurrence after 1 year compared with 78.7% in the traditional SSF group (TSG, n = 195); risk difference ? 7.3% (95%CI ?15.2%; 0.7%). Adjusted odds ratio (aOR) for being asymptomatic 1 year postoperatively was 0.56 (95%CI 0.31; 1.02, p = 0.057). Patient satisfaction was similar in SDG and TSG (78.1% vs 78.4%). Reoperation occurred in 7.4% in the SDG compared with 3.6% in the TSG, risk difference 3.8% (95%CI 0.0%; 7.5%), aOR 3.55 (95%CI 1.10; 11.44, p = 0.03).

Conclusions

Patient satisfaction was similar 1 year after SSF, despite symptoms of recurrence being more likely and reoperation more common after using a suturing device compared with a traditional technique. The methods did not differ with regard to surgical complications.

     

Risk factors for recurrence in female urethral diverticulectomy: a retrospective study of 66 patients

Purpose

We aimed to report surgical outcomes in female urethral diverticula and to investigate the risk factors for diverticula recurrence.

Methods

A total of 66 patients underwent urethral diverticulectomies from January 2009 to October 2015 at out institution. Patient and diverticula characteristics were collected. Mean follow-up was 28.8 months (range 4–85 months). Recurrence was defined as requiring a repeat diverticulectomy.

Results

Mean age was 44.9 years. Mean duration of symptoms was 28.1 months. Seven cases had previous urethral surgeries. Mean diverticula size was 2.8 cm. Main clinical symptoms included dribbling (n = 41), vaginal mass (n = 41), dysuria (n = 33), frequency/urgency (n = 29), infection (n = 24), stress urinary incontinence (SUI) (n = 20) and dyspareunia (n = 8). 10 cases had proximal diverticula, 10 cases had multiple diverticula, and 35 cases had horseshoe/circumferential diverticula. Postoperatively, the recurrence rate was 19.7 %. Preoperative SUI disappeared in 14 cases, and de novo SUI was developed in six cases. One case developed urethral stricture, and no cases reported urinary fistula. Among 60 cases with pathological results, neoplastic change was seen in one case (1.7 %). Besides, atypical hyperplasia (n = 2) and metaplasia (n = 3) were observed. Univariate analysis suggested that age, duration, follow-up, diverticula size and diverticula shape were not associated with surgical outcomes. Patients with multiple diverticula (p = 0.032), proximal diverticula (p = 0.042) and those with previous urethral procedures (p = 0.004) were at risk of recurrent diverticula confirmed by multivariate logistic regression analysis.

Conclusions

The surgical outcomes of urethral diverticulectomies were acceptable. Multiple diverticula, proximal diverticula and previous urethral surgery were three independent risk factors for recurrent diverticula.

     

Pre-treatment double- or triple-positive tumor markers are predictive of a poor outcome for patients undergoing radiofrequency ablation for hepatocellular carcinoma

Purposes

We evaluated the therapeutic effect of radiofrequency ablation (RFA) on hepatocellular carcinoma (HCC) according to the number of positive tumor markers.

Methods

The subjects of this study were 160 patients who underwent percutaneous and surgical RFA for HCC. Patients were divided into negative (n = 51), single- (n = 69), double- (n = 31), and triple-positive (n = 9) tumor marker groups according to the pre-treatment expression of these markers. We looked for any relationships among clinical parameters, outcomes, and tumor markers.

Results

The 3-year recurrence-free and overall survival rates of the negative, single-, double-, and triple-positive groups were 30, 19, 16, and 11 % (P = 0.02), and 94, 88, 67, and 37 % (P < 0.001), respectively. The 2-year local recurrence rates were 6.5, 0, 41.2, and 61.9 %, respectively (P < 0.001). Multivariate analysis revealed that a double- or triple-positive pre-treatment tumor marker profile was independently associated with local recurrence [hazard ratio (HR) 5.48, 95 % confidence interval (CI) 2.44–12.33, P < 0.001] and overall survival (HR 4.21, 95 % CI 1.89–9.37, P < 0.001).

Conclusion

RFA may not be suitable for patients with HCC who have pre-treatment expression of ≥two of these tumor markers.

     

Oncologic outcomes of patients with positive surgical margin after partial nephrectomy: a 25-year single institution experience

Purpose

To evaluate oncologic outcomes and management of patients with microscopic positive surgical margin (PSM) after partial nephrectomy (PN) for renal cell carcinoma (RCC).

Methods

We reviewed our database to identify patients who underwent PN between 1990 and 2015 for RCC and had PSM on final pathology. A 1:3 matching was performed to a negative surgical margin (NSM) cohort. Kaplan–Meier method and log-rank test were used to estimate survival and differences in outcomes, respectively. Cox proportional hazards models were conducted to estimate the Hazards ratio.

Results

A total of 2297 patients underwent PN at our institution, of which 1863 (81%) had RCC. Microscopic PSM was found in 34 (1.8%) RCC patients who were matched to 100 patients with NSM. Of these 34 patients, local recurrence (n = 4), distant kidney recurrences (n = 4), and metastases (n = 5) developed during a median follow-up of 62 months. Bilateral tumors/tumors in a solitary kidney (n = 12/13, 92%), and multifocal tumors (n = 7/13, 54%) were found in patients who developed recurrence/metastasis. PSM patients were at a higher risk of shorter overall survival (p = 0.001), local recurrence-free survival (p = 0.003), distant recurrence-free survival (p = 0.032) and metastasis-free survival (p = 0.018). There was statistically significant association between PSM and bilateral tumors, prior treated RCC at presentation and higher nephrometry score in multivariable model.

Conclusions

There was a low rate of microscopic PSM in our large cohort of patients undergoing PN despite tumor complexity. Higher nephrometry score, bilateral tumors, and prior treated RCC independently predicted PSM which showed worse survival, recurrence and metastasis compared to patients with NSM.

     

Vaginal wall weakness in parous ewes: a potential preclinical model of pelvic organ prolapse

Introduction and hypothesis

Ewes develop pelvic organ prolapse (POP) and may be a suitable model for preclinical studies evaluating cell-based therapies for POP. The aim of this study was to establish a clinical score of vaginal weakness and to compare POP Quantification System (POP-Q) values in conscious nulliparous and parous ewes and determine whether ewes are a suitable POP model.

Methods

Ewes (n?=?114) were examined while conscious, without sedation, and standing in a V conveyer by adapting the human POP-Q measurement. Ovine POP was defined as descent to the introitus from POP-Q points Aa 3 cm above the introitus on the anterior wall, Ap 3 cm above the introitus on the posterior wall, or increased Ba anterior wall descent above the urethra (≥0). A test–retest showed good inter- and intrarater reliability.

Results

There was no evidence of tissue mobility at Aa, Ap, Ba (all ?3 cm) in nulliparous ewes (n?=?14). In contrast, multiparous ewes had a median of ?1 and interquartile range (IQR) (?2 to 0) for Aa, [0 (?1 to 0)] for Ap and [0 (?2.75 to 0)] for Ba (n?=?33; P?<?0.0001 in comparison with nulliparous) ewes. Ovine vaginal displacement was seen in 50.9 % of parous ewes and was strongly associated with parity (P?=?0.003).

Conclusions

A modified POP-Q in conscious ewes was established showing that the vaginal wall of parous animals has similar regions of weakness as do women and may be similarly related to parity. Ewes appear to be a representative preclinical model of human vaginal prolapse.

     

Characteristics associated with pelvic organ prolapse in women with significant levator ani muscle deficiency

Introduction and hypothesis

Age is a factor associated with symptomatic pelvic organ prolapse (POP) among women with significant levator ani deficiency.

Methods

This cross-sectional study included patients who were referred for varied pelvic floor disorders, had 3D endovaginal ultrasound as part of their evaluation, and were diagnosed with significant levator ani muscle deficiency defined as a score of 12 or more on 3D endovaginal ultrasound. Patients were categorized as having no pelvic organ prolapse (stages 0 and 1), or symptomatic prolapse (stages 2–4).

Results

Seventy-six women were available for analysis and found to have significant levator ani muscle deficiency, including 51 with symptomatic POP and 25 without POP. Patients with symptomatic POP were older, (mean age 66 (SD?±?11.8) vs 48 (SD?±?17.3) years; p <0.0001), had greater mean minimal levator hiatus (MLH) area (19.7 cm² (SD?±?4.6) vs 17.5 cm² (SD?±?3.5); p?=?0.048), and were more likely to be menopausal (91.3 % vs 54.5 %; p <0.001) compared with those with no POP. In a modified Poisson regression analysis excluding nulliparous women, increasing age (RR?=?2.39, 95 % CI 1.03–5.55) and smoking (RR?=?1.34, 95 % CI 1.08–1.67) remained associated with symptomatic POP after controlling for one another and the MLH area.

Conclusions

Among women with significant levator ani deficiency, older women and smokers had an increased prevalence of symptomatic POP. On average, women without POP, but with significant levator ani deficiency were 18 years younger than women with POP and significant muscle deficiency.

     

Prolapse or incontinence: what affects sexual function the most?

Introduction and hypothesis

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) adversely affect sexual function in women. Comparative studies of the two subgroups are few and results are conflicting. The aim of this study was to compare the effect of POP and SUI on the sexual function of women undergoing surgery for these conditions.

Methods

The study population comprised women with POP or SUI in a tertiary referral hospital in the UK. Women who underwent SUI surgery had no symptoms of POP and had urodynamically proven stress incontinence. Patients with POP had ≥ stage 2 prolapse, without bothersome urinary symptoms. Pre-operative data on sexual function were collected and compared using an electronic pelvic floor assessment questionnaire (ePAQ). The incidence of sexual dysfunction and comparison of symptoms in both groups were calculated using the Mann–Whitney U test.

Results

Three hundred and forty-three women undergoing surgery for either SUI or POP were included. Patients were age-matched, with 184 undergoing SUI surgery (age range 33–77 years) and 159 POP surgery (age range 27–78 years; p?=?0.869). The overall impact of POP and SUI was not significantly different in the two subgroups (p?=?0.703). However, both patients (73 % vs 36 %; p?=?0.00) and partners (50 % vs 24 %; p?=?0.00) avoid intercourse significantly more frequently in cases with POP compared with SUI. This did not have a significant impact on quality of life.

Conclusions

The impact of bothersome SUI or POP on sexual function was found to be similar, but patient and partner avoidance in women with POP was greater than those with SUI.

     

Partial nephrectomy versus ablative therapy for the treatment of renal tumors in an imperative setting

Purpose

To compare partial nephrectomy (PN) and percutaneous ablative therapy (AT) for renal tumor in imperative indication of nephron-sparing technique (NST).

Materials and methods

Between 2000 and 2015, 284 consecutive patients with a kidney tumor in an imperative indication of NST were retrospectively included in a multicenter study. PN [open (n = 146), laparoscopic (n = 9), or robotic approach (n = 17)] and AT [radiofrequency ablation (n = 104) or cryoablation (n = 8)] were performed for solitary kidney (n = 146), bilateral tumor (n = 78), or chronic kidney disease (CKD) (n = 60).

Results

Patients in the PN group had larger tumors and a higher RENAL score. There were no differences between the two groups with respect to age, reasons for imperative indication, and preoperative eGFR. Patients in the AT group had a higher ASA and CCI. PN had worse outcomes than AT in terms of transfusion rate, length of stay, and complication rate. Local radiological recurrence-free survival was better for PN, but metastatic recurrence was similar. Percentage of eGFR decrease was similar in the two groups. Temporary or permanent dialysis was not significantly different. On multivariate analysis, PN and AT had a similar eGFR change when adjusted for tumor complexity, reason of imperative indication and CCI.

Conclusion

In imperative indication of nephron-sparing treatment for a kidney tumor, either PN or AT can be proposed. PN offers the ability to manage larger and more complex tumors while providing a better local control and a similar renal function loss.

     

Patient characteristics associated with treatment choice for pelvic organ prolapse and urinary incontinence

Introduction and hypothesis

Women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI) frequently undergo more than one treatment prior to settling on their final strategy. We hypothesize that women who are younger, with worse POP and SUI symptoms will desire and choose surgical treatment.

Methods

A retrospective cohort study was performed over 1 year identifying new patients presenting with POP and/or SUI at a university hospital. Our aim was to determine patient desire for either surgical or conservative treatment, as well as the actual treatment chosen and received after the first visit and 1 year later. To identify predictors of choice, baseline demographic characteristics were obtained.

Results

Of the 203 women who met the inclusion criteria, 44.3 % (90/203) desired surgery and 55.7 % (113/203) desired conservative treatment at their first visit. Women who desired surgery were more likely to be younger (p?=?0.003), sexually active (p?=?0.001), have more advanced prolapse (p?=?0.006), and have more bothersome symptoms (p?=?0.05). Of the women who desired surgery at their first visit, 12.2 % (11/90) actually chose conservative treatment. These women were less likely to be insured (p?=?0.01). By 1 year, of the women who initially desired and subsequently chose conservative treatment, 26.5 % (30/113) had undergone surgery. The women who changed from conservative to surgical treatment were more likely to be younger (p?=?0.01), non-White (p?=?0.03), and sexually active (p?=?0.04).

Conclusions

In this study, younger, sexually active women were more likely to either opt for surgery initially or to change their treatment plan from conservative to surgical.

     

A single-centre experience of relaparoscopy in complications of laparoscopic inguinal hernia repair-feasibility and outcomes

Background

Management of complications of laparoscopic inguinal hernia repair remains challenging as well as debatable. Relaparoscopy in management of these complications is relatively newer concept. We tried to analyse the feasibility of relaparoscopy (transabdominal preperitoneal approach) in management of complications of laparoscopic inguinal hernia repair.

Materials and methods

The study group included 61 patients (referral cases) from a prospectively maintained database of previous laparoscopic inguinal hernia surgery with majority of the patients of recurrence (n = 39). Other complications were mesh infections (n = 15), pubic osteitis (n = 3), migration of mesh into adjacent viscera (n = 3) and meralgia paresthetica (n = 1). All patients underwent transabdominal preperitoneal approach (TAPP) between January 2007 and December 2013.

Results and outcome

Most of the patients had previous TEP repair (n = 49) with variable complications detected in the range of 9 days to 38 months. Small-sized mesh (n = 12) and rolled up mesh (n = 10) were the causes of recurrence in 57 % cases. Mycobacterium tuberculosis (40 %) and mixed bacterial infections (33 %) strains were detected in the infected mesh. Pubic osteitis and meralgia paresthetica were tackers induced. All patients dealt with TAPP approach. Recurrent hernia cases underwent mesh placement and infected mesh was removed in mesh infection. Tackers were removed in cases of osteitis pubis and meralgia paraesthesia. Median operative time was 62 min (42–126 min) and hospital stay 3 days (2–13 days). The relaparoscopy was accomplished in 95.1 % of cases with no major intraoperative complications and minimal postoperative morbidity.

Conclusion

Relaparoscopy through TAPP approach remains safe and feasible option to deal with primary laparoscopic hernia repair complications. Surgical techniques during primary laparoscopic repair are important cause for aforementioned complications. Though, surgical expertize remains warranted for relaparoscopy.

     

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.

     

Liver transplantation for advanced hepatocellular carcinoma in patients with Child-Pugh A and B

Purpose

To investigate the outcomes of living donor liver transplantation for advanced hepatocellular carcinoma in Child-Pugh A/B patients and the usefulness of our expanded selection criteria, the Kyoto criteria.

Methods

A total of 82 recipients with a Child-Pugh class A (n = 27) or B (n = 55) status having either multiple hepatic nodules or solitary tumors ≥5 cm in size treated between February 1999 and August 2012 were enrolled in this study.

Results

The overall recurrence rate was significantly less for the Child-Pugh B patients than for the Child-Pugh A patients (P = 0.042), while the survival rates did not differ. In the Child-Pugh A and B patients, the survival rate was significantly greater, while the recurrence rate was lower among the patients meeting the Kyoto criteria than those exceeding these criteria (P = 0.006, P = 0.001, P = 0.032 and P < 0.001, respectively). In the Child-Pugh B patients, the overall survival and recurrence rates did not differ between the patients treated with and without pretreatment for hepatocellular carcinoma. In the Child-Pugh B patients treated with pretreatment, the overall survival rate was significantly greater, while the recurrence rate was lower among the patients meeting the Kyoto criteria than those exceeding these criteria (P < 0.001, P < 0.001, respectively).

Conclusions

Living donor liver transplantation performed within the Kyoto criteria achieves excellent overall survival and recurrence rates, especially for Child-Pugh B patients, even those with advanced hepatocellular carcinoma.