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.

     

Sacrocolpopexy: is there a consistent surgical technique?

Introduction

Sacrocolpopexy is the gold standard treatment for vault prolapse. Current reported standards regarding surgical approach and technique vary. Our aim was to evaluate the surgical techniques used and identify any consistency.

Methods

Electronic surveys were sent to 148 candidates enrolled in a sacrocolpopexy workshop at the 2012 American Urogynecologic Society (AUGS) annual meeting and as a link in the International Urogynecology Association (IUGA) e-magazine. The survey assessed demographics, specific surgical steps including dissection techniques, number and type of sutures, graft materials, and the approach to intraoperative complications.

Results

Within the AUGS group, 61 candidates responded (41 %). From the IUGA membership, 128 responded for a total of 189. Overall, 59 % identified their primary practice as urogynaecology, 43 % having completed a fellowship. Only 33 % reported performing sacrocolpopexy as the primary surgery for vault prolapse. Technical aspects: 99.4 % used polypropylene mesh, with 57 % attaching it to the vagina using non-absorbable monofilament sutures. An average of 3–4 sutures were used on the anterior and posterior walls respectively. Suture location: 22.5 % reported not placing apical sutures and 55.7 % place their anterior wall sutures midway down the vagina. Posteriorly, 47 (30 %) placed sutures through the uterosacral ligaments, 19 (12.4 %) through the levator ani and 15 % extend the mesh to the perineal body. The mesh was attached to the sacrum using permanent sutures by 75 %. Dissection of the sacrum was deemed the most technically difficult aspect.

Conclusion

Surgical technique varies widely despite the level of expertise and training. This study highlights the need for an evaluation of the effect of surgical technique on outcomes.

     

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.

     

Risk factors for recurrent obstetric anal sphincter injury (rOASI): a systematic review and meta-analysis

Objectives

The objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their previous pregnancy and analyse risk factors for recurrence through a systematic review and meta-analysis.

Data sources

A review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were made in Ovid MEDLINE (1996 to May 2015), PubMed, EMBASE and Google Scholar, including bibliographies and conference proceedings.

Methods of study selection

Observational studies (cohort/case–control) evaluating rOASI and risk factors were selected by two reviewers who also analysed methodological quality of those studies. Pooled odds ratios (OR) for rOASI and individual risk factors were calculated using RevMan 5.3.

Tabulation, integration and results

From the eight studies assessed, overall risk of rOASI was 6.3 % compared with a 5.7 % risk of OASI in the first pregnancy. The risk in parous women with no previous OASI was 1.5 %. Factors that increased the risk in a future pregnancy were instrumental delivery with forceps [OR 3.12, 95 % confidence interval (CI) 2.42–4.01) or ventouse (OR 2.44, 95 % CI 1.83–3.25), previous fourth-degree tear (OR 1.7, 95 % CI 1.24–2.36) and birth weight ≥4 kg (OR 2.29, 95 % CI 2.06–2.54). Maternal age ≥35 years marginally increased the risk (OR 1.16, 95 % CI 1–1.35).

Conclusion

The overall rate of rOASI and associated risk factors for recurrence are similar to the rate and risk factors of primary OASI. Antenatal decisions could be based on assessment of foetal weight and intrapartum decisions based upon the requirement for an instrumental delivery.

     

Elastin density: Link between histological and biomechanical properties of vaginal tissue in women with pelvic organ prolapse?

Introduction and hypothesis

The aim of the study was to correlate histological and biomechanical characteristics of the vaginal wall in women with pelvic organ prolapse (POP).

Methods

Tissue samples were collected from the anterior [point Ba; POP Questionnaire (POP-Q)] and/or posterior (point Bp; POP-Q) vaginal wall of 15 women who underwent vaginal surgery for POP. Both histological and biomechanical assessments were performed from the same tissue samples in 14 of 15 patients. For histological assessment, the density of collagen and elastin fibers was determined by combining high-resolution virtual imaging and computer-assisted digital image analysis. For biomechanical testing, uniaxial tension tests were performed to evaluate vaginal tissue stiffness at low (C₀) and high (C₁) deformation rates.

Results

Biomechanical testing highlights the hyperelastic behavior of the vaginal wall. At low strains (C₀), vaginal tissue appeared stiffer when elastin density was low. We found a statistically significant inverse relationship between C₀ and the elastin/collagen ratio (p?=?0.048) in the lamina propria. However, at large strain levels (C₁), no clear relationship was observed between elastin density or elastin/collagen ratio and stiffness, likely reflecting the large dispersion of the mechanical behavior of the tissue samples.

Conclusion

Histological and biomechanical properties of the vaginal wall vary from patient to patient. This study suggests that elastin density deserves consideration as a relevant factor of vaginal stiffness in women with POP.

     

Is the levator–urethra gap helpful for diagnosing avulsion?

Introduction and hypothesis

Levator avulsion is a risk factor for female pelvic organ prolapse (POP) and recurrence after POP surgery. Imaging diagnosis requires the observation of an abnormal muscle insertion on tomographic ultrasound imaging (TUI). This study was designed to compare the diagnostic performance of the qualitative diagnosis (visual qualitative assessment) to measurement of the distance between muscle insertion and urethra [levator–urethra gap; (LUG)].

Methods

This was a retrospective analysis of data obtained in a tertiary urogynecological unit. All patients presented with symptoms of pelvic floor dysfunction and underwent 4D translabial pelvic floor ultrasound (US), supine, and after voiding. Avulsion was defined qualitatively as abnormal muscle insertion and quantitatively as LUG ≥25 mm on at least three consecutive central axial plane slices, with one examiner using both methods. We examined the correlation between both methods and validated them against clinical prolapse, significant organ descent on US, and hiatal ballooning.

Results

Between January and July 2013, 233 patients were seen, of whom 202 had complete volume data sets. The qualitative method diagnosed avulsion in 22 % and the quantitative method in 24.3 %. Agreement was good, with a kappa of 0.79 (0.70–0.87). Avulsion diagnosed by either method was associated with clinical and sonographic prolapse and hiatal ballooning, with odds ratios nonsignificantly higher for the quantitative method.

Conclusion

Qualitative analysis of slices on TUI and a method using LUG measurement show good agreement for the diagnosis of avulsion. The LUG method is at least equally as valid in its capacity to predict significant prolapse on clinical examination and US, as well as ballooning of the levator hiatus.

     

Surgery for stress urinary incontinence in Finland 1987–2009

Introduction and hypothesis

To estimate the incidence rates of stress urinary incontinence (SUI) surgery among Finnish women from 1987 to 2009 by age, and to evaluate the trends in SUI surgery.

Methods

We conducted a retrospective register-based study. All SUI procedures on adult women over age 18 years in Finland were identified from the nationwide Care Register for Health Care. Age-specific incidence rates per 1,000 women were calculated for each year. The cumulative incidence of SUI surgery was calculated.

Results

There were 38,340 procedures for SUI in 1987–2009. The overall age-adjusted incidence rate increased 2.6-fold from 0.5/1,000 women in 1987 to 1.3/1,000 in 2002, but declined thereafter by 2009 to 0.8/1,000. There was a six-fold increase in the incidence rate in the age group 60–69 years and a ten-fold increase in the age group 70–79 years from 1987 to 2002. These marked increases in operation rates coincided with the increased use of tension-free vaginal tape (TVT). In 2002, TVT accounted for 96 % of all SUI procedures. Mid-urethral slings with transobturator techniques surpassed TVT in popularity in 2007. The life-long cumulative incidence of SUI surgery was 9.9 % in 2002 and 6.3 % in 2009.

Conclusions

The incidence rates of SUI surgery increased significantly in Finland, especially among women aged 60 to 79 years. Mid-urethral slings have become the dominant procedure.

     

Oestrogen-soaked vaginal packing for decubitus ulcer in advanced pelvic organ prolapse: a case series

Introduction

Cervicovaginal decubitus ulceration is a well-known complication of advanced pelvic organ prolapse (POP). There is no consensus for its management. This case series describes the outcome of using repeated vaginal packs soaked with oestrogen cream to reduce POP and promote decubitus ulcer healing. We aimed to investigate the speed of ulcer healing and endometrial safety with this regimen.

Methods

This was a retrospective study of patients with stage 3 or 4 POP and intact uterus with decubitus ulcer who were planned for surgery that included hysterectomy after ulcer healing. Vaginal packs are replaced at least biweekly—or more frequently if extruded—until ulcer resolution.

Results

Thirteen patients were studied. Mean age was 69?±?6 years and mean duration of menopause was 19?±?6 years. Nine patients had a single ulcer and four had multiple ulcers. Mean ulcer diameter was 2.8?±?1.5 cm and mean duration for ulcer healing was 26?±?14 days. Hysterectomy and pelvic floor reconstruction was performed a median of 5 (range 0–153) days after ulcer healing was first noted. Histopathological examination of the endometrium following hysterectomy showed three specimens with endocervical hyperplasia; one had concurrent proliferative endometrium, two had simple endometrial hyperplasia and another two had proliferative endometrium.

Conclusion

Oestrogen-soaked vaginal packing is a viable option for managing a decubitus ulcer in advanced POP. We document a measurable impact on the endometrium with this short-term preoperative regimen. Further research is needed to evaluate its efficacy in promoting ulcer healing and endometrial safety.

     

Obstetric anal sphincter injuries after episiotomy: systematic review and meta-analysis

Introduction

There is conflicting evidence on whether mediolateral episiotomy (MLE) reduces the risk of obstetric anal sphincter injuries (OASI) in spontaneous vaginal deliveries (SVD).

Objectives

A systematic review was undertaken to compare rates of OASI amongst women who had undergone mediolateral episiotomy versus those who did not.

Methods

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Search strategy

Electronic searches were performed in literature databases: CINAHL, Cochrane, EMBASE, Medline and MIDIRS from database inception to July 2015. Studies were eligible if MLE was compared to spontaneous tears and if OASI was the outcome of interest.Two reviewers independently selected and extracted data on study characteristics, quality and results. We computed events of OASI in those who did and did not have an episiotomy from individual studies and pooled these results in a meta-analysis where possible.

Main results

Of the 2090 citations, 16 were included in the review. All were non-randomised, population based or retrospective cohort studies. There was great variation in quality amongst these studies. Data from 7 studies was used for meta-analysis. On collating data from these studies where the majority of women (636755/651114) were nulliparous, MLE reduced the risk of OASI (RR 0.67 95 % CI 0.49-0.92) in vaginal delivery.

Conclusion

The pooled analysis of a large number of women undergoing vaginal birth, most of who were nulliparous, indicates that MLE has a beneficial effect in prevention of OASI. An accurately given MLE might have a role in reducing OASI and should not be withheld, especially in nulliparous women. Caution is advised as the data is from non-randomised studies.

     

Safety and efficacy of single-incision sling for female stress urinary incontinence: 3 years’ results

Introduction and hypothesis

The purpose of this study was to investigate the success and complication rates of single-incision sling for treating stress urinary incontinence (SUI), with a 3-year follow-up.

Methods

This study comprised 173 female patients with SUI or mixed urinary incontinence (MUI) with dominant SUI who underwent minisling procedure. All patients had positive cough stress test preoperatively; they were followed up for 3 years after surgery (1, 3, 6, 12 months, and yearly).

Results

Total follow-up was 36 months, and mean age 51 years (44–77); 128 (74 %) patients presented SUI and 45 (26 %) MUI. Objective and subjective cure and failure rates were 83.8 % (145 cases), 6.4 % (11 cases), and 9.8 % (17 cases), respectively. There were no differences in cure rates between 1 and 3 years. Mean body mass index was 28.7 (26.1–35.2), and mean operating time 7.9 min. (6.5–11.9). There were no major intraoperative complications. Eleven patients (6.4 %) had de novo urge incontinence that resolved using anticholinergic drugs; no patient had urinary retention. Vaginal mesh extrusion was reported in nine (5.2 %) patients.

Conclusions

The minisling system attained high success rates at 3 years’ follow-up. The procedure was easy to learn and has lower complication rate.