Pectineal ligament suspension of prolapsed vaginal vault

Objective

To report on a collective pectineal ligament suspension experience acquired over 12 years in India with 119 women who presented with prolapsed vaginal vault. The feasibility and effectiveness of the procedure was assessed for the open and laparoscopic routes.

Methods

The prolapsed vaginal vault was suspended unilaterally to the pectineal ligament using polyester tape at 3 urban and 3 rural hospitals. The procedure was done through a Cherney incision in 104 women. In the remaining 15 women, it was done laparoscopically at a single urban center.

Results

There were no intraoperative complications. The mean follow-up was 5.5 years (range, 0.5–12 years). Only 2 women had vaginal prolapse recurrence, at 3 and 5 years. Two had asymptomatic tape erosion, at 2 and 5 years, and a mild cystocele appeared in 5 women and a low rectocele in 4. However, none of these women required further vaginal surgery during their follow-up period.

Conclusion

The present study demonstrates the long-term safety and effectiveness of pectineal ligament suspension for vaginal vault prolapse by the open and the laparoscopic routes. As it was done by surgeons of varying experience at centers with varying resources, the procedure can be readily mastered by any gynecologic surgeon.     

Lesiones vaginales por pesario. Estudio de casos y revisión de la literatura

Objective

We studied the adverse events occurring with the use of vaginal ring pessaries.

Material

We report a series of nine cases of adverse events involving vaginal pessaries occurring within a 4-year period with over 23719 consultations and representing an incidence of 0.03%.

Results

The mean age of the patients was 83 years (range: 70-96), and the mean parity was 3.77 (range: 2-6 children). The mean age of onset of the use of a pessary was 80 years. The mean number of years of use was 3 (range 1-5 years).The indications for pessary use were contraindication of surgery due to heart disease and, in women with prior surgery, the recurrence of prolapse or vaginal vault prolapse, and waiting for surgery.The adverse events found consisted of vaginal erosion and bleeding in 4/9 (44.44%) and vaginal discharge with vaginal infection in 5/9 (55.55%).

Conclusion

The use of a pessary warrants special care and hygiene measures to ensure long-term successful use.     

The Effect of Vertical Versus Horizontal Vaginal Cuff Closure on Vaginal Length After Laparoscopic Hysterectomy

Study Objective

To determine whether vertical versus horizontal closure of the vaginal cuff during laparoscopic hysterectomy has an effect on postoperative vaginal length and pelvic organ prolapse.

Prolapso de la cúpula vaginal tratado mediante operación de Richter-Amreich asociada a colporrafia anterior

Objective

To study prospectively the succes rate of the sacrospinous vault suspension, using the vaginal approach associating an anterior colporrhaphy, in the cases of posthisterectomy vaginal vault prolapse.

Material and methods

Between January 1999-July 2005, 41 patients without urinary incontinence and vaginal vault prolapse were treated with the Richter-Amreich’s procedure associated with anterior colporrhaphy by the same surgeon. We have used the the Miya hook in all interventions and 2 sutures of Polyglactin 00. Every patient was 393 followed up a month after the operation and anually till now. We considered success as the lack of prolapse a month after the intervention, and relapse when another prolapse happened in a year or more after surgery. Patients were include in a database and Epi-info 3.3^TM was used to perform the statistical analysis.

Results

There were vaginal vault prolapse at 1- month follow-up in 4 of the 41 (success rate of 91.2%). Another 3 patients presented minor cystocele (grade 1), and one had a grade 2 cystocele without descent of vaginal apex (9.8%). There is no worsening of these cases till now in the annual follow-ups. The most common postoperatory complication was anemia, that was present in 13 patients (31,7%). The length of complete surgery was 102 ± 35 minutes. There is a clear correlation between operating time and surgeon experience.

Conclusions

This technique is an effective method, economic and safe to treat posthysterectomy prolapse of the apical vaginal compartment.     

Hysterectomy in Denmark 1977–2011: changes in rate,indications, and hospitalization

Objective

To describe conditions regarding hysterectomy for benign indications during the past 35 years in Denmark.

Study design

Population-based register study of 167,802 women who underwent hysterectomy for benign conditions in the period 1977–2011. Patient data regarding operative techniques, hospitalization, indications, patient age, and geography were extracted from the Danish National Patient Register.

Results

The overall rate of hysterectomy was around 180/100,000 woman years during the period. A rise in laparoscopic and vaginal hysterectomy was seen at the expense of abdominal hysterectomy. The indication of pelvic organ prolapse and abnormal uterine bleeding increased while the indication of fibroids decreased. The average age of women at time of hysterectomy increased from 46 years in 1977–1981 to 50 years in 2006–2011. The mean number of hospitalization days was reduced by 75%. Regional differences were detected regarding route of hysterectomy and hospitalization.

Conclusions

This study demonstrates a change in the pattern of indications for hysterectomy, increased age of the affected women, reduced length of stay in the hospital, and a rise in the percentage of minimal invasive surgical procedures.     

Laparoscopic sacrocolpopexy in the treatment of vaginal vault prolapse: 8 years experience

Objective

The aim of this study was to evaluate the long-term results of a laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse.

Study design

Between January 1999 and January 2007, 165 laparoscopic sacrocolpopexy procedures, using a polypropylene mesh, were performed on women affected by vaginal vault prolapse.Intraoperative complications included: 5 bladder injuries and 3 sigmoid perforations. Postoperative complications included: 10 cases of fever, 5 cases of lumbosciatica, 15 cases of detrusor overactivity, 2 cases of vaginal haematoma, and 5 cases of minimal dispareunia.At 1, 6 and 12 months after surgery, a clinical evaluation was carried out for all patients. After this period, we contacted the women annually.

Results

We treated 165 women, with an average age of 67 (range 58–76 years; S.D. 19.22), average parity of 3 (range 2–5), and average body mass index of 28 (range 24–30). In many of them, more than one additional procedure was performed.At a median follow-up of 43 months (range 6–96 months), out of a total of 138 patients (27 were lost at follow-up), we obtained successful treatment in 131 women (success rate of 94.9%), with a high rate of satisfaction from the procedure. Recurrent vaginal vault prolapse was registered in seven women (5.07%): in 3, the vaginal vault collapsed after a period ranging from 7 to 20 days, caused by the use of a Vyprol mesh (hence use of same was suspended), and in a further three women the mesh detached after less than 1 month. Finally, in one case, we reported an erosion between the first and the second follow-up and the mesh was visualized in the vagina.

Conclusions

Our study shows that laparoscopic sacrocolpopexy, in the hands of an expert surgeon, can be considered a safe, effective procedure for the treatment of vaginal vault prolapse, allowing long-term anatomical restoration (94.9% success rate).     

De novo stress urinary incontinence after vaginal repair for pelvic organ prolapse: one-year follow-up

Objective

A few studies have reported a wide range (2–43%) in incidence of de novo stress urinary incontinence (SUI) following surgical repair of pelvic organ prolapse (POP) in previously continent women. The aim of this study was to re-examine this incidence up to one year following vaginal repair of prolapse.

Study design

Retrospective review of a cohort of women who underwent reconstructive vaginal repair of POP without a concomitant anti-incontinence procedure between 2003 and 2007 at two tertiary referral centers. Women were considered eligible if they were stress continent by symptoms and objective assessment (including urodynamics testing) prior to surgical repair. All women who had had any anti-incontinence procedure previously were excluded. The endpoint was subjective SUI that prompted the patient to undergo any treatment within one year from their prolapse surgery.

Results

64 women, with a mean age of 61 (±11) years, were eligible for the study: 26 (41%) had preoperative symptoms of overactive bladder. Fifty-four patients were available for analysis at the one-year visit. Seven women (13.5%) had symptoms of SUI but only one (2%) was found to have SUI objectively. Another patient underwent anti-incontinence surgery following her prolapse surgery.

Conclusion

The incidence of de novo SUI requiring treatment in previously continent women who underwent vaginal repairs for POP without concomitant anti-incontinence surgery is low (4%). A large-scale prospective study is necessary to further evaluate this finding.     

Mild hydronephrosis after uncomplicated hysterectomy

Objective

To explore differences in the incidence of hydronephrosis following different hysterectomy methods for benign gynecological disease.

Study design

Retrospective chart review of ultrasound findings on all patients undergoing simple hysterectomy for benign gynecological pathology between July 2004 and September 2008. Elective renal ultrasonography was performed pre-operatively and within 3 days after hysterectomy as part of the routine follow-up in our hospital.

Results

Of 385 eligible patients, six were excluded because of pre-existing hydronephrosis or suspected intra-operative ureteral injury. In the resulting group of 379 patients, abdominal (33.3%), vaginal (11.8%) or laparoscopic hysterectomy (54.9%) was performed. The last group included total laparoscopic hysterectomy (TLH, 20.3%), laparoscopic supracervical hysterectomy (LASH, 19.3%), and laparoscopically assisted vaginal hysterectomy (LAVH, 15.3%). Overall, 56.7% of patients showed mild hydronephrosis (5–15 mm pelvicalyceal dilatation) after surgery. Mostly, it occurred unilaterally. The incidence varied according to the type of procedure, the highest being documented following vaginal hysterectomy (64.4%) and the lowest after LASH (46.6%), but this did not reach statistical significance.

Conclusion

Mild hydronephrosis is a frequent finding after uncomplicated hysterectomy for benign pathology in otherwise asymptomatic patients. Although not statistically significant, there may be variability of mild hydronephrosis depending on the hysterectomy method.     

Vaginal cuff dehiscence after hysterectomy

Objective

To determine the incidence of vaginal cuff dehiscence (VCD) among women undergoing hysterectomy according to clinico-surgical factors including surgical route, and to describe patient characteristics associated with VCD.

Methods

In a retrospective study, the medical records of all women who underwent hysterectomy between January 2005 and March 2011 at a university teaching hospital in Seoul, Republic of Korea, were reviewed. The incidence of VCD was determined in relation to the following factors: patient age, hysterectomy route, indication for hysterectomy, and extent of resection (either simple or radical hysterectomy).

Results

Among 9973 hysterectomies, 37 (0.37%) cases of VCD were identified. The incidence of VCD was significantly higher after abdominal hysterectomy (0.6%) than after laparoscopic (0.2%) or vaginal (0.4%) hysterectomy (P = 0.016). Compared with laparoscopic approaches, abdominal hysterectomy was associated with a higher risk of VCD (odds ratio, 2.735; 95% confidence interval, 1.380–5.420). However, there was no significant difference in the incidence of VCD according to surgical indication or extent of resection.

Conclusion

Laparoscopic hysterectomy was found to be associated with a lower risk of VCD compared with abdominal hysterectomy. The lower risk is probably related to the different techniques used for colpotomy and cuff closure.     

La histerectomía laparoscópica: un abordaje posible. Estudio retrospectivo de las histerectomías laparoscópicas realizadas en un hospital público

Objective

To assess the outcomes of laparoscopic hysterectomy in a public hospital.

Material and methods

We performed a retrospective study of laparoscopic hysterectomies carried out between January 2005 and December 2007. The parameters evaluated were indication, type of hysterectomy, uterine weight, length of hospital stay, and complications.

Results

In the period analyzed, we performed 284 hysterectomies, of which 103 (36.36%) were laparoscopic. The morbidity rate was 9.7% and complications were related to the learning curve. The mean length of hospital stay was 2.56 days.

Conclusions

Laparoscopic hysterectomy is a safe procedure that requires a learning curve of 30-40 procedures. Due to its advantages, this option should be offered in all gynecology services.     

Hysterectomy trends over a 9-year period in an endoscopic teaching center

Objective

To investigate trends in the performance of hysterectomy at a single certified endoscopic teaching center.

Methods

Data were collected retrospectively from 953 patients who underwent hysterectomy between 2002 and 2010 for benign indications at UKSH, Germany. Preoperative risk scores were assigned to patients.

Results

The most frequent indications for hysterectomy were uterine myoma, adenomyosis, prolapse, endometrial hyperplasia, menstrual disorders, and endometriosis. The shortest operating time was recorded for vaginal hysterectomy (VH) and the longest for laparoscopically assisted VH (LAVH). The average uterine weight was highest for abdominal hysterectomy (AH) and lowest for VH. The major postoperative complication rate was 11.8% for laparoscopic supracervical hysterectomy (LSH) and 23.5% for AH. The highest intraoperative complication rate occurred with AH (46.4%) and the lowest with total laparoscopic hysterectomy (TLH; 3.6%). The minor postoperative complication rate was 5.9%. The mean preoperative score was 1.09 ± 1.51 for AH, 0.75 ± 0.96 for VH, 1.04 ± 1.30 for LSH, 1.0 ± 1.40 for LAVH, and 1.38 ± 1.52 for TLH.

Conclusion

Laparoscopic hysterectomies have become more common and were associated with decreased complication rates, despite the higher preoperative risk score of these patients.     

Vaginal cuff closure with absorbable bidirectional barbed suture during total laparoscopic hysterectomy

Objective

Hysterectomy represents one of the most performed procedures in gynecological surgery. The minimally invasive approach increases patients’ benefits and reduces hospitalization costs. The aim of this study was to demonstrate the efficacy and safety of double barbed suture in vaginal cuff closure during total laparoscopic hysterectomy.

Study design

A retrospective cohort study of 88 consecutive patients treated with total laparoscopic hysterectomy for benign or precancerous conditions was undertaken from January 2010 to December 2011. Vaginal cuff suture was performed with traditional interrupted suture with polycolic acid (Vicryl™) in 40 patients and with bidirectional barbed device, Quill SRS™, in 48 patients.

Results

No difference in vaginal cuff dehiscence, major vaginal bleeding or spotting, and infection was evident between the two groups, with significant reduction in operative times for the bidirectional barbed suture group.

Conclusion

Vaginal cuff suture performed with bidirectional barbed QUILL SRS™ is a safe and well-tolerated procedure that reduces operative times.     

A prospective randomized comparison of vaginal hysterectomy,laparoscopically assisted vaginal hysterectomy,and total laparoscopic hysterectomy in women with benign uterine disease

Objectives

To compare the clinical results of three minimally invasive hysterectomy techniques: vaginal hysterectomy (VH), laparoscopically assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH).

Study design

A prospective, randomized study was performed at a tertiary care center between March 2004 and October 2005. A total of 125 women indicated to undergo hysterectomy for benign uterine disease were randomly assigned to three different groups (40 VH, 44 LAVH, and 41 TLH). Outcome measures, including operating time, blood loss, rate of complications, inflammatory response, febrile morbidity, consumption of analgesics, and length of hospital stay, were assessed and compared between groups.

Results

Vaginal hysterectomy had the shortest operating time (66 min) and smallest drop in hemoglobin. However, there were technical problems with salpingo-oophorectomy from the vaginal approach (3/20 cases) and this group had a significantly higher rate of febrile complications (20%) compared to LAVH (2.3%) and TLH (7.3%). The increase in inflammatory markers was higher in vaginal hysterectomy patients. Laparoscopically assisted vaginal hysterectomy had an acceptable operating time (85 min), a low complication rate, lack of severe post-operative complications, and the lowest consumption of analgesics. However, it had the highest blood loss. Total laparoscopic hysterectomy had the longest operating time (111 min) and severe complications occurred only in this group. Conversions to another hysterectomy method occurred in all three groups, most of these conversions were to LAVH.

Conclusions

Based on our results, in women with non-malignant disease of the uterus, LAVH and VH seem to be the preferred hysterectomy techniques for general gynecological surgeons. Vaginal hysterectomy had the shortest operating time and least drop in hemoglobin, making it a suitable method for women for whom the shortest duration of surgery and anesthesia is optimal. LAVH is a versatile procedure, combining the advantages of both the vaginal and laparoscopic approach, and is preferable in cases when oophorectomy is required. Total laparoscopic hysterectomy did not appear to offer any significant benefits over the other two methods and should be strictly indicated in women where neither VH nor LAVH are feasible and should only be performed by very experienced laparoscopists.     

Mesh-Free Laparoscopic High Uterosacral Ligament Suspension during Total Laparoscopic Hysterectomy for Uterine Prolapse

Study Objective

To demonstrate a mesh-free approach for uterine prolapse during a hysterectomy.

Comparison study of single-port (Octoport™) and four-port total laparoscopic hysterectomy

Objective

To compare the perioperative surgical outcomes and complication rates between single-port total laparoscopic hysterectomy and conventional four-port total laparoscopic hysterectomy.

Study design

Between June 2009 and April 2011, 56 patients underwent total laparoscopic hysterectomy. Of these 56 patients, 28 underwent single-port (Octoport™) total laparoscopic hysterectomy and 28 underwent conventional four-port total laparoscopic hysterectomy. We analyzed the following parameters for all the patients: age, body mass index, operative time, blood loss, change in hemoglobin level, vaginal stump suture time and length of hospital stay.

Results

The general characteristics of the patients were similar in both groups. There were no statistically significant differences in blood loss, hemoglobin change, length of postoperative hospital stay and complication rate. However, the mean operative time of the single-port group was significantly longer than that of the four-port group (93.5 ± 24.0 min vs. 78.7 ± 17.4 min; P = 0.011). The operative time for vaginal stump suture was profoundly decreased with experience in the single-port group.

Conclusion

With the exception of operative time, the surgical outcomes and incidence of complications of the single-port group were comparable to those of the four-port group. However, the operative time decreased in the single-port group with increasing experience.     

Risk factors for vaginal prolapse after hysterectomy

Objective

To identify risk factors for pelvic organ prolapse (POP) and their influence on the occurrence of vaginal prolapse after hysterectomy.

Methods

Medical records from 2 groups of women who had undergone hysterectomy were reviewed retrospectively. The study group was 82 women who had undergone surgery for vaginal prolapse after hysterectomy; the control group was 124 women who had undergone hysterectomy with no diagnosis of vaginal prolapse by the time of the study. All hysterectomy procedures had been performed for benign gynecological disease, including POP. Both groups of women completed a self-administered questionnaire to obtain additional information on the occurrence of POP.

Results

The incidence of vaginal prolapse after hysterectomy was significantly higher in women with a higher number of vaginal deliveries, more difficult deliveries, fewer cesareans, complications after hysterectomy, heavy physical work, neurological disease, hysterectomy for pelvic organ prolapse, and/or a family history of pelvic organ prolapse. Premenopausal women had vaginal prolapse corrected an average of 16 years after hysterectomy, and postmenopausal women 7 years post hysterectomy.

Conclusion

Before deciding on hysterectomy as the approach to treat a woman with pelvic floor dysfunction, the surgeon should evaluate these risk factors and discuss them with the patient.     

Vaginal sacrocolporectopexy for the surgical treatment of uterine and vaginal vault prolapses: confirmation of the surgical method and perioperative results of 101 cases

Purpose

In this study, we sought to confirm the surgical method of vaginal sacrocolporectopexy and previously reported positive perioperative results of this procedure in a large patient group. We describe the approach which offers a vaginal, safe alternative to sacrospinous repair, laparoscopic or open vaginosacropexy and the use of synthetic meshes to treat pelvic organ prolapse.

Methods

We conducted a monocentric, prospective, nonrandomized study for treatment of patients with uterine and vaginal vault relapse (grade 2–4). All patients underwent a preoperative urogynecological urodynamic examination. We focus on method, operative time, complications, blood transfusions, hospital stay and clinical data.

Results

Between March 2006 and March 2011, 101 consecutive patients of mean age 64 (40–89) years, with sub or total uterine prolapse (n?=?69, grade 2–4) and vaginal vault prolapse (n?=?32, grade 2–4) were treated with vaginal sacrocolporectopexy. Cystocele (grade 2–4) was found in 88 (87.1?%) and rectocele (grade 2–4) in 43 (42.5?%) patients. Mean duration of surgery with sacrocolporectopexy was 70?min (28–165) without hysterectomy, and 76?min (40–219) with hysterectomy. Regression analysis of all patients (n?=?101) showed a significant decrease of operative time in the group without hysterectomy after 40 cases. Three bladder lesions, two in patients with a history of hysterectomy, occurred during surgery and were corrected intraoperatively without further complications. No patient required a blood transfusion. Hemoglobin levels decreased slightly from a preoperative mean of 13.6?mg/dl (10.3–15.7) to a postoperative mean of 11.7?mg/dl (8.6–14.7).

Conclusion

Vaginal sacrocolporectopexy is a safe vaginal method for the treatment of sub-/total uterine/vaginal vault prolapse.     

Comparison of prevalence of hypoactive sexual desire disorder (HSDD) in women after five different hysterectomy procedures

Objective

The advantages of the various methods used for hysterectomy are currently a topic of debate, and there is particular controversy over whether the cervix should be left in situ or not. The aim of this study was to compare the prevalence of hypoactive sexual desire disorder (HSDD) after five different hysterectomy procedures.

Study design

The Brief Profile of Female Sexual Function (B-PFSF) score was measured to compare postoperative prevalence of HSDD after the different surgical procedures. The questionnaire was sent to 590 women who had undergone hysterectomy between 2002 and 2007 for benign conditions. The following procedures were performed: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopy-assisted vaginal hysterectomy (LAVH), laparoscopic supracervical hysterectomy (LASH), and total laparoscopic hysterectomy (TLH).

Results

A total of 304 questionnaires returned and 258 were found to be eligible for analysis. The mean follow-up intervals were 2 years for women after LASH and TLH and 3 years for women after AH, VH, and LAVH. The women in the AH group were significantly older than those in the LASH group, and the women in the VH group were significantly older than those in the LASH or TLH groups. The median B-PFSF score was highest at 26 in women after LASH, 25 in women after TLH, 23 in women after LAVH, 23.5 in women after VH, and 21 in women after AH. There were no statistically significant differences between the groups.

Conclusions

No differences were observed using the B-PFSF score with regard to the prevalence of HSDD after hysterectomy, irrespective of the surgical technique used.