Risk factors for surgical failure after posterior intravaginal slingplasty: a case series

Objective

The goal of this study was to analyze the potential risk factors of surgical failure after posterior intravaginal slingplasty for uterine or vaginal vault prolapse.

Study design

Women with symptomatic uterine or vaginal vault prolapse that extended to or beyond the introitus were eligible for inclusion. Each woman underwent a detailed history taking and a vaginal examination for staging of pelvic organ prolapse before treatment. Follow-up evaluations were at 3, 6, 9, 12, 18, 24, and 30 months after the operation. Surgical failure is defined as the presence of symptomatic uterine or vaginal vault prolapse ≧stage 2 (higher than 0, at the hymen) after posterior intravaginal slingplasty.

Results

The surgical failure rate (8/61) following posterior intravaginal slingplasty was 13.1%. Using univariable logistic regression, C or D point stage IV before surgery was significantly associated with surgical failure of posterior intravaginal slingplasty for uterine or vaginal vault prolapse. Complications (11/61 = 18%) included vaginal erosion (9.8%), blood loss over 500 ml (4.9%), and perineal pain (3.3%).

Conclusion

Procidentia is a significant risk factor for surgical failure of posterior intravaginal slingplasty, and therefore this procedure should never be used alone in patients with complete uterine or vaginal vault prolapse.     

Vaginal mesh colpopexy for the treatment of concomitant full thickness rectal and pelvic organ prolapse: a case series

Objective

To present our case series of concomitant rectal and pelvic organ prolapse (POP) treated with vaginal colpopexy with synthetic mesh.

Study design

Charts of patients with full thickness rectal prolapse and POP were reviewed for presenting symptoms, physical examination with POP-Q including rectal prolapse evaluation, and perioperative complications and outcomes.

Results

Four patients aged 63-78 were identified with full thickness rectal prolapse and POP. All of them had symptoms related to both conditions. Rectal prolapse protrusion ranged from 2 cm to 3 cm outside the anus. All patients had vaginal mesh colpopexy; two of them with anterior and posterior vaginal mesh and 2 with posterior mesh only. At a follow-up of 6-44 months, all patients had resolution of both POP and rectal prolapse signs and symptoms.

Conclusion

Vaginal colpopexy with mesh may be a unique treatment to address both POP and full thickness rectal prolapse in selected patients. Further research is needed to determine the safety and efficacy of this method.     

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.     

Morbidity associated with posterior intravaginal slingplasty for uterovaginal and vault prolapse

Objective This study was carried out to evaluate the safety and efficacy of posterior intravaginal slingplasty (IVS) for upper genital prolapse. Setting Gynaecology Department, Benenden Hospital, Kent, UK. Materials and methods An observational study was conducted on 127 women, who underwent posterior IVS using the IVS Tunneller (Tyco HealthCare, USS, Norwalk, CT, USA). The indications for surgery were uterovaginal prolapse in 65% and vault prolapse in 35%. Patient follow-up was at 6 weeks, 6 months, 1 year and annually thereafter. Results In addition to posterior IVS, hysterectomy was performed in 22 patients, anterior colporrhaphy in 63 patients and transobturator mid-urethral tape insertion in eight patients. The mean operating time was 46 ± 18.5 min and for posterior IVS alone was 27.4 ± 10 min, and the mean peri-operative drop in haemoglobin level was 1.4 ± 0.75 gm/dL. There were no rectal, vesical or ureteric injuries. After a mean follow-up of 14 months (range 2–26 months), upper genital support was maintained in 88%, cystocele formation occurred in 8% and recurrent rectocele was seen in 11%. There was a 17% risk of tape erosion (21/127) and a re-operation rate of 24% (30/127). The risk of tape erosion was related to patient age above 60 years (RR = 1.6, 95% CI 1.02–2.5) and current treatment for diabetes (RR = 4, 95% CI 1.7–9.2). Parity, body mass index, menopausal status, HRT use, hysterectomy and surgeon’s experience were not found to influence tape erosion rate. Conclusion Posterior intravaginal slingplasty is a minimally invasive procedure for upper genital prolapse with an acceptable success rate. However, the operation is associated with high vaginal erosion and re-operation rates. No financial support was granted to this study.     

Risk factors of surgical failure following sacrospinous colpopexy for the treatment of uterovaginal prolapse

Purpose

Trans-vaginal sacrospinous colpopexy is one of the surgical procedures used to repair varying degrees of vaginal vault and uterovaginal prolapse. The purpose of this study is to analyse the potential risk factors of surgical failure following sacrospinous colpopexy.

Methods

A retrospective study of 114 women who underwent unilateral sacrospinous colpopexy at Jordan University Hospital from January 2005 to January 2008 were included. Patient demographics, clinical characteristics and concomitant pelvic organ prolapse surgery were assessed. The patients were evaluated at 6 weeks, and every 6 months thereafter. Twelve (11 %) had recurrent apical (vaginal cuff) prolapse, 26 (23 %) had recurrent prolapse at any compartment were compared with those who had successful surgery. Univariate and logistic regression analyses were used to assess the independent prognostic values of the variables associated with surgical failure.

Results

After a mean follow-up of 40 months, the statistically significant predictors of surgical failure included the presence of advanced pre-operative stages of prolapse (stages III and IV), the more distally located points Ba, Bp and C and a lack of mesh augmentation of the anterior vaginal wall during surgery (P = 0.01, 0.027, 0.024, 0.034 and 0.006, respectively). However, a history of prior vaginal repair, the more distally located point Ba and a lack of anterior vaginal wall mesh augmentation were defined as independent predictive variables based on logistic regression analyses (P = 0.04, 0.005 and 0.046, respectively).

Conclusions

The presence of advanced anterior vaginal wall prolapse, prior vaginal repair and a lack of mesh augmentation of the anterior compartment are significant risk factors for the surgical failure of sacrospinous suspension surgery.     

Perioperative course and medium-term outcome of the transobturator and infracoccygeal hammock for posthysterectomy vaginal vault prolapse

Objective

To describe the perioperative course and medium-term anatomic and functional outcomes of the transobturator-infracoccygeal hammock for posthysterectomy vaginal vault prolapse repair.

Methods

A prospective consecutive series of 52 women with a stage 2 vaginal vault prolapse or higher that occurred after total hysterectomy who underwent surgery between 2003 and 2007. Principal outcome measures were anatomic cure (stage 1 or lower) and impact on quality of life measured using the pelvic floor distress inventory (PFDI) and pelvic floor impact self-reported questionnaire (PFIQ). Anatomical results were analyzed using χ² and Fisher exact tests, and PFDI and PFIQ scores were analyzed using the Wilcoxon test.

Results

With a median follow-up of 36 months, the anatomic cure rate was 96%. Significant improvements were noted in POPQ-S scores after surgery (P < 0.05). Stress urinary incontinence was cured in 73% of patients and improved in 15% of patients. The PFDI and PFIQ scores were improved (P < 0.05). One mesh extrusion was observed. The rates of mesh contraction and new cases of dyspareunia were 31% and 13%, respectively.

Conclusion

The transvaginal mesh hammock represents a useful treatment for recurrent and major vaginal vault prolapse, and has few complications.     

Severe mesh complications following intravaginal slingplasty

OBJECTIVE: Synthetic meshes are increasingly used in the management of stress urinary incontinence and pelvic organ prolapse. This report describes severe complications following anterior and/or posterior intravaginal slingplasties employing a multifilament polypropylene mesh. METHODS: We describe the symptoms, findings, subsequent management, and outcome of 19 consecutive women who have been referred with complications following anterior (n = 11) and/or posterior intravaginal slingplasty (n = 13) employing the multifilament polypropylene tape. RESULTS: The main indications for removal of the 11 anterior intravaginal slings were intractable mesh infection in 6 women, retropubic abscess with cutaneous sinus in one, and vesico-vaginal fistula in one, intravesical mesh and pain syndrome in one, and voiding difficulties and pain syndrome in two. The main indications for removal of the 13 posterior intravaginal slings were intractable mesh infection in three and pain syndrome and dyspareunia in 10 women. Removal of the slings was performed after a median time of 24 months post-slingplasty. At follow-up between 6 weeks and 6 months, in all women genital pain, chronic vaginal discharge and bleeding, voiding, and defecation difficulties had been markedly alleviated (5) or they had ceased (14). Twelve of 17 sexually active women (71%) resumed sexual intercourse without difficulties. Ten women required subsequent surgery for stress incontinence and pelvic organ prolapse. CONCLUSION: Surgeons should be aware of the potential complications of synthetic meshes. Until data on the safety and efficacy of the intravaginal slingplasties are available, these procedures cannot be recommended.     

Repair of recurrent vaginal vault prolapse using sacrospinous ligament fixation with mesh interposition and reinforcement

OBJECTIVE: Our goal was to study the efficacy of performing the repeated sacrospinous ligament fixation with mesh interposition and reinforcement in women with recurrent vaginal vault prolapse. MATERIALS AND METHODS: Fifteen consecutive patients with symptomatic severe vaginal vault or uterus prolapse after previous sacrospinous ligament fixation were enrolled. The sacrospinous ligament fixation was performed with a mesh interposition between sacrospinous ligament complex and vaginal apex. The mesh was extended to anterior and posterior vaginal wall for the repair of concurrent cystocele and rectocele, if indicated. The surgical results and complications were evaluated. The prolapse evaluation was performed according to International Continence Society (ICS) ordinal stages of pelvic organ prolapse. RESULTS: The mean age was 55 years. The mean follow-up was 2.9 years (range 1.0-5.5 years). Repeated sacrospinous ligament fixation was performed for all patients. Eleven were performed unilaterally to the right and four to the left. The average time for sacrospinous fixation was 20 min. The average blood loss for sacrospinous fixation was 75 ml. No major complication except one accidental rectotomy was observed. It was repaired intraoperatively without sequel. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies, and tension-free vaginal tape procedures. No recurrence of apical prolapse was observed. However, two patients developed stage I prolapse on anterior vaginal wall (cystocele) and required no further repair. Minor postoperative complications were observed. CONCLUSION: Repeated sacrospinous ligament fixation with mesh interposition and reinforcement is a safe and effective procedure for the correction of recurrent vault prolapse. The extended implanted mesh can be used for the repair of concurrent cystorectocele effectively. A long-term follow-up is necessary to detect any late complication.     

Clinical outcome of transvaginal sacrospinous fixation with the Veronikis ligature carrier in genital prolapse

Objective

To evaluate the clinical outcome of sacrospinous fixation (SSF) using the Veronikis ligature carrier (VLC) for genital prolapse.

Study design

A retrospective longitudinal study was performed. From December 2003 through June 2008, SSF was performed in 76 patients using the VLC as part of their site-specific reconstructive pelvic surgery. All patients were followed up postoperatively at 6 weeks, 3 months, 6 months, 12 months, and annually thereafter.

Results

The median operative time of SSF was 34 min. It took less than 5 min to introduce two sutures through the ligament using the VLC. Four patients (5.3%) had recurrent vaginal vault descent at 3-8 months, and received SSF again. Three patients had recurrent stage 1 cystocele at 6-12 months, but did not require further surgery.

Conclusion

The VLC allowed effective introduction of the suspending suture through the sacrospinous ligament and might be considered an important surgical component in the treatment of severe genital prolapse.     

Transvaginal repair of genital prolapse with polypropylene mesh using a tension-free technique

Objectives

To assess the perioperative complications and short-term outcomes of prolapse repair using transvaginal polypropylene mesh.

Study design

Retrospective study. In the period from April 2007 to September 2009, 67 women underwent vaginal repair with implantation of a soft mesh manufactured by Gynecare.

Results

All the patients had a stage 3 or stage 4 prolapse. Total mesh was used in eight patients (11.9%), isolated anterior mesh in 36 patients (53.7%) and isolated posterior mesh in 23 patients (34.4%). We reported one intraoperative bladder injury and no other serious complications. At 3 months, all the 67 patients were available for follow-up. Vaginal erosion occurred in eight patients (11.9%), shrinkage of mesh in six patients (8.7%), granuloma without exposure in four patients (5.9%), de novo urinary incontinence in three patients (4.5%) and flatus incontinence in one patient (1.5%). Failure rate was 7.5% (recurrent prolapse stage 3 or 4, even asymptomatic).

Conclusion

Our study suggests that transvaginal polypropylene mesh applied with a tension-free technique is a safe and effective method with low intraoperative complications but with considerable potential postoperative morbidity.     

A 5-year prospective study of vaginal pessary use for pelvic organ prolapse

Objective

To evaluate prospectively the use of vaginal pessaries for pelvic organ prolapse (POP) and to identify complications and reasons for discontinuing pessary use over a 5-year period.

Methods

A prospective observational study was conducted among all women with POP referred to the urogynecology clinic of a UK hospital between June 2002 and June 2005 who opted to use a vaginal pessary. Patients were followed-up for 5 years.

Results

Of the 246 women who chose to use a vaginal pessary, 187 successfully retained the pessary 4 weeks after insertion. Over a 5-year period, 36 (19.3%) of the 187 women were lost to follow-up. Of the 151 women included in the analysis, 21 (13.9%) discontinued use at some point after 4 weeks, whereas 130 (86.1%) used the pessary successfully over 5 years. Overall, 12.1% of the women experienced minor complications (6.9% pain or discomfort, 3.2% excoriation or bleeding, and 2.0% disimpaction or constipation). Most failures (73.8%) occurred within 4 weeks of pessary insertion. After cessation of pessary use, 70 (28.5%) of the 246 women chose surgery and 10 (4.1%) chose no further treatment.

Conclusion

If treatment of POP with a vaginal pessary is successful at 4 weeks, most women will continue to use the pessary over 5 years without a concomitant increase in complications.     

Wide genital hiatus is a risk factor for recurrence following anterior vaginal repair

Objective

To determine if a wide genital hiatus is a risk factor for recurrence of anterior vaginal wall prolapse following anterior vaginal repair.

Methods

A retrospective cohort study was performed on patients who had undergone an anterior vaginal wall repair. Patients were placed into 1 of 2 groups: wide genital hiatus (≥ 5 cm) or normal genital hiatus (< 5 cm). The wide genital hiatus group (n = 35) was compared with the normal genital hiatus group (n = 30) for surgical failure.

Results

There were no significant differences between the 2 groups in demographic data, additional operative procedures, or apical suspensions. The rate of postoperative anterior vaginal wall prolapse was greater in patients with a wide genital hiatus compared with those with a normal genital hiatus (34.3% vs 10% respectively; odds ratio 4.7 [95% confidence interval, 1.0-24.1]; P = 0.02).

Conclusion

The rate of recurrent anterior vaginal wall prolapse is higher in patients with a wide genital hiatus.     

The use of synthetic mesh in vaginal prolapse surgery: a survey of Dutch urogynaecologists

Objective

To evaluate the use of mesh in vaginal prolapse surgery amongst members of the Dutch Urogynaecologic Society.

Study design

A questionnaire evaluating the use of mesh vs. native tissue repair in vaginal prolapse surgery was sent out by email to all members. Some specific questions on standard measures of infection prevention were included.

Results

One hundred and thirty-three completed questionnaires were received. The response rate was 65%. Seventy-one percent of respondents stated that they apply use synthetic meshes in their patients. The mean percentage of mesh use in overall vaginal pelvic organ prolapse surgery was 14%. Most responders use mesh in recurrent surgery only. Prolift^® is the most commonly used brand. All women received prophylactic antibiotics. Although only half of the respondents changed gloves.

Conclusions

Meshes are commonly used in the Netherlands. The major indication is repair of a recurrent prolapse.     

Clinical significance of obstructive defecatory symptoms in women with pelvic organ prolapse

Objective

To determine whether the presence of obstructive defecatory symptoms is associated with the site and severity of pelvic organ prolapse. Methods: A cross-sectional study was performed of women with pelvic organ prolapse of grade 2 or greater who had completed a validated questionnaire that surveyed pelvic floor symptoms. Associations between patient characteristics, site and severity of prolapse, and obstructive bowel symptoms were investigated.

Results

Among 260 women with pelvic organ prolapse, women with posterior vaginal wall prolapse were more likely to report obstructive symptoms, such as incomplete emptying (41% vs 21%, P = 0.003), straining at defecation (39% vs 19%, P = 0.002), and splinting with defecation (36% vs 14%, P < 0.001) compared with women without posterior vaginal wall prolapse. There was no significant association between any bowel symptom and increasing severity of prolapse.

Conclusions

Obstructive bowel symptoms are significantly associated with the presence of posterior vaginal wall prolapse, but not with the severity of prolapse.     

经阴道后路悬吊带术治疗阴道穹窿膨出的中远期随访结局

目的:探讨经阴道后路悬吊带术(PIVS)治疗女性阴道穹隆膨出的中远期结局。方法:采用回顾性研究方法,对20名子宫切除术后阴道穹隆膨出的患者行PIVS治疗。对其术前、术后资料进行评估,并对术后3年以上随访结果进行总结。结果:平均手术时间53.95±16.88min,术中平均出血量57.50±24.682ml,平均住院天数3.82天,未发生直肠损伤、盆腔血肿等术中严重并发症。半年内所有患者均治愈,中远期随访2例(10.5%)患者因阴道穹隆脱垂复发行子宫托治疗;5例(26.3%)出现吊带侵蚀,剪除后加用雌激素局部治疗,4例好转,1例反复修剪侵蚀的吊带3次,仍有肉芽形成。结论:PIVS术是一种安全、有效、微创的治疗阴道穹隆膨出的手术方式,但术后中远期随访发现吊带侵蚀是一个不可忽视的问题,该术式所用多股编织吊带不宜作为重建材料。     

Short-range clinical, dynamic magnetic resonance imaging and P-QOL questionnaire results after mesh repair in female pelvic organ prolapse

Objective

To evaluate clinical, quality-of-life (QoL) and dynamic magnetic resonance imaging (dMRI) results in patients with pelvic organ prolapse (POP) preoperatively, and 4 and 12 weeks after anterior and/or posterior mesh repair.

Study design

Thirty-six patients (mean age 65 years) with symptomatic pelvic floor descent underwent mesh repair. The prolapse was quantified using the POP-Q system. Before surgery as well as 4 and 12 weeks after surgery, the pelvic organ positions were measured on dynamic magnetic resonance imaging during Valsalva manoeuvre in relation to the pubococcygeal and mid-pubic lines to assess surgery outcome. Patients also completed the P-QOL questionnaire to evaluate subjective changes at each visit.

Results

Four and 12 weeks after surgery patients showed improvement of the POP on clinical examination and on dynamic MRI. The latter demonstrated high significance (p < 0.001) especially in bladder and vaginal cuff/cervix positions during maximal straining. All quality-of-life domains and some symptom questions of the P-QOL questionnaire significantly improved (p < 0.05) 12 weeks after surgery.

Conclusion

Significant anatomical and quality-of-life improvement was demonstrated after anterior and/or posterior mesh repair for POP using dynamic MRI and the P-QOL questionnaire.     

Vaginal support as determined by levator ani defect status 6 weeks after primary surgery for pelvic organ prolapse

Objective

To evaluate whether major levator ani muscle defects were associated with differences in postoperative vaginal support after primary surgery for pelvic organ prolapse (POP).

Methods

A retrospective chart review of a subgroup of patients in the Organ Prolapse and Levator (OPAL) study. Of the 247 women recruited into OPAL, 107 underwent surgery for prolapse and were the cohort for the present analysis. Major levator ani defects were diagnosed when more than 50% of the pubovisceral muscle was missing on MRI. Postoperative vaginal support was assessed via POP-quantification system. Postoperative anatomic outcome was analyzed according to levator ani defect status, as determined by MRI.

Results

Support of the anterior vaginal wall 2 cm above the hymen occurred among 62% of women with normal levator ani muscles/minor defects and 35% of those with major defects. Support of the anterior wall 1 cm above the hymen occurred among 32% women with normal muscles /minor defects and 59% of those with major defects. Levator ani defects were not associated with differences in postoperative apical/posterior vaginal support.

Conclusion

Six weeks after primary surgery for prolapse, women with normal levator ani muscles/minor defects had better anterior vaginal support than those with major levator defects.     

Comparing the midterm outcome of single incision vaginal mesh and transobturator vaginal mesh in treating severe pelvic organ prolapse

Objective

The aim of this study is to compare perioperative parameters and midterm clinical outcomes using two different mesh kits: transobturator vaginal mesh (TVM) (both Perigee and Apogee), versus single incision vaginal mesh (SIM) (combined Elevate anterior/apical system and Elevate posterior/apical system) in treating severe pelvic organ prolapse (POP).