Laparoscopic lateral suspension for anterior and apical prolapse: a prospective cohort with standardized technique.

INTRODUCTION AND HYPOTHESIS: Laparoscopic lateral suspension (LLS) for anterior and apical pelvic organ prolapse (POP) repair is a recent approach. Previous studies used various meshes or sutures. The purpose of this study was to evaluate outcomes of a standardized LLS technique. METHODS: From January 2010 until December 2014, we performed POP repair by LLS with mesh on 88 women with anterior and apical POP ≥ stage 2. We used a polypropylene titanized mesh fixed to the vesico-vaginal fascia with absorbable sutures and treated posterior compartment defect by vaginal approach with native tissue repair if required. Between July 2013 and December 2018, all women were assessed by gynecological examination including the pelvic organ prolapse quantification (POP-Q) system. Subjective outcome was evaluated by the patient global impression of improvement (PGI-I) questionnaire. RESULTS: Seventy-nine women (89.8%) were available for follow-up. The mean duration of follow-up was 3.4 years (SD 1.6). Mean age was 59.6 (SD 11.1) years and mean BMI 25.8 (SD 4.0) kg/m2. Ten patients (12.7%) had previous POP surgery. Fifty-two women (65.8%) required posterior colporraphy for associated posterior defect and 21 (26.6%) had associated urinary incontinence (UI) surgery. There were no perioperative complications. The objective cure rate (no prolapse beyond the hymen and no reoperation for POP recurrence) was 87.3%. The reoperation rate for recurrence was 5.1%. The subjective success rate (PGI ≤ 2) was 96.2%. There were no mesh exposures or extrusions. CONCLUSIONS: This standardized LLS is safe and effective with no mesh complications after 3-year follow-up.

Long term outcomes of laparoscopic sacro/colpo-hysteropexy with and without rectopexy for the treatment of prolapse.

INTRODUCTION AND HYPOTHESIS: Laparoscopic sacrohysteropexy (LSH), sacrocolpopexy (LSC) and ventral rectopexy (LVR) with mesh are advocated for surgical treatment of pelvic and rectal prolapse. Our study aims at showing the feasibility of concomitant laparoscopic prolapse repair by comparing perioperative and long-term outcomes of LSH or LSC with and without LVR. METHODS: This is a retrospective study carried out on 348 women operated on between July 2009 and July 2019. Patients were divided into four groups: (1) LSH only, (2) LSC only, (3) LSH + LVR and (4) LSC + LVR. POP-Q scores and satisfaction questionnaires were recorded at baseline and then annually. Outcomes were defined as subjective failure (vaginal/rectal prolapse symptoms), objective failure (prolapse to/beyond the hymen, full thickness rectal prolapse) or retreatment for prolapse. Complications were collected and graded according to the Clavien-Dindo classification. RESULTS: Three hundred forty-eight women underwent laparoscopic repair for pelvic and rectal prolapse (219, 44, 66 and 19 in group 1, 2, 3 and 4, respectively). Median follow-up was 24 (4-174) months. Success rate for both rectal and pelvic prolapse was 90.2%. Recurrence rates were not significantly different between the groups (12.3%, 6.8%, 9.1% and 10.5% for groups 1, 2, 3 and 4, respectively). Significant improvement was noticed in satisfaction questionnaires in all groups. There was no difference in perioperative and late complications. CONCLUSION: The combined laparoscopic procedure appears to be safe and efficient in treating pelvic and rectal prolapse. Appropriate patient selection and available surgical expertise should determine whether to perform these procedures combined or separately.

Laparoscopic Sacral Mesh Fixation for Ventral Rectopexy: Clinical Implications From a Cadaver Study.

BACKGROUND: Correct tack placement at the sacral promontory for mesh fixation in ventral mesh rectopexy is crucial to avoid bleeding, nerve dysfunction, and spondylodiscitis. OBJECTIVE: The present cadaver study was designed to assess the true location of tacks after mesh fixation during laparoscopic ventral mesh rectopexy in relation to vascular and nerve structures and bony landmarks. DESIGN: This was an interventional cadaver study. SETTING: This study was conducted after laparoscopic mesh fixation detailed pelvic dissection was performed following a standardized protocol. In addition, 64-row multidetector computed tomography was conducted to further define lumbosacral anatomy and tack positioning. PATIENTS: Eighteen fresh cadavers (10 female, 8 male) were included in this study. MAIN OUTCOME MEASURES: True tack position and vascular and neuronal involvement served as outcome measures. RESULTS: A total of 52 tacks were deployed (median 3, range 2-3 tacks). Median tack distance to the midsacral promontory was 16.1 mm (0.0-54.2). Only a total of 22 tacks (42.3%) were found on the right surface of the S1 vertebra, correlating with the planned deployment area. In 7 cadavers (38.8%), all tacks were deployed on the planned deployment area. The median distance to the major vessels was 10.5 mm (0.0-35.0), which was the internal iliac artery in half of the cases. Median distance of tacks to the right ureter was 32.1 mm (7.5-46.1). Neither major vessels nor the ureter was injured. Dissection of the hypogastric plexus was undertaken in 14 cadavers, and in each cadaver, tacks affected the hypogastric nerve plexus. LIMITATIONS: This study was limited by the moderate number of cadavers. CONCLUSIONS: Tack placement showed significant variation in our specimen, emphasising the need for reliable anatomic landmarks and sufficient exposure during ventral mesh rectopexy. Hypogastric nerve plexus involvement is common, thus detailed functional assessment after surgery is required. It also points out the importance of cadaver studies before implementing new surgical techniques into clinical practice. See Video Abstract at http://links.lww.com/DCR/B827. FIJACIN LAPAROSCPICA DE MALLA SACRA PARA RECTOPEXIA VENTRAL IMPLICACIONES CLNICAS DE UN ESTUDIO SOBRE CADAVERS: ANTECEDENTES:La colocación correcta de la tachuela en el promontorio sacro para la fijación de la malla en la rectopexia con malla ventral es crucial para evitar hemorragias, disfunción nerviosa y espondilodiscitis.OBJETIVO:El presente estudio en cadáveres fue diseñado para evaluar la verdadera ubicación de las tachuelas después de la fijación de la malla durante la rectopexia laparoscópica con malla ventral en relación con las estructuras vasculares y nerviosas y los puntos de referencia óseos.DISEÑO:Estudio intervencionista de cadáveres.AJUSTE:Después de la fijación laparoscópica de la malla, se realizó una disección pélvica detallada siguiendo un protocolo estandarizado. Además, se realizó una tomografía computarizada multidetector de 64 cortes para definir mejor la anatomía lumbosacra y la posición de la tachuela.PACIENTES:Se incluyeron en este estudio dieciocho cadáveres frescos (10 mujeres, 8 hombres).PRINCIPALES MEDIDAS DE RESULTADO:Posición real de tachuela y compromiso vascular y neuronal.RESULTADOS:Se utilizaron un total de 52 tachuelas (mediana 3, 2-3 tachuelas). La distancia media de tachuela al promontorio sacro medio fue de 16,1 mm (0,0-54,2). Solo se encontraron un total de 22 tachuelas (42,3%) en la superficie derecha de la vértebra S1, correlacionándose con el área planificada. En siete cadáveres (38,8%) todas las tachuelas se utilizaron en el área de planificada. La distancia media a los vasos principales fue de 10,5 mm (0,0-35,0), que era la arteria ilíaca interna en la mitad de los casos. La distancia media de las tachuelas al uréter derecho fue de 32,1 mm (7,5-46,1). No se lesionó ni los grandes vasos ni el uréter. La disección del plexo hipogástrico se realizó en 14 cadáveres y en cada cadáver, las tachuelas afectaron el plexo nervioso hipogástrico.LIMITACIONES:Número moderado de cadáveres incluidos en el estudio.CONCLUSIONES:La colocación de tachuelas mostró una variación significativa en nuestra muestra, enfatizando la necesidad de puntos de referencia anatómicos confiables y una exposición suficiente durante la rectopexia con malla ventral. La afectación del plexo nervioso hipogástrico es común, por lo que se requiere una evaluación funcional detallada después de la cirugía. También destaca la importancia de los estudios sobre cadáveres antes de implementar nuevas técnicas quirúrgicas en la práctica clínica. Consulte Video Resumen en http://links.lww.com/DCR/B827. (Traducción-Dr Yolanda Colorado).

Physical activity and urinary incontinence during pregnancy and postpartum: A systematic review and meta-analysis.

To assess the association of physical activity and urinary incontinence, or its recovery, during pregnancy and postpartum. A search of publications indexed in five major electronic databases (CENTRAL, PubMed, EMBASE, CINAHL and PEDro) was performed from their respective inception dates to the 30 March 2020 with a combination of keywords to identify studies of interest. Google Scholar was used for non-indexed literature. All studies comparing physical activity with standard care in pregnant and postpartum women were selected. Two reviewers independently selected studies, assessed quality and extracted data. Odds ratios with 95% confidence intervals were calculated using fixed effects or random effects models, for low and moderate heterogeneity between studies, respectively. Seven studies (n = 12479) were included. Data of four studies could be pooled for meta-analyses; subgroup and sensitivity analyses were not possible. Physical activity, either during pregnancy or postpartum, is not associated with urinary incontinence, OR 0.90 (95% CI: 0.69-1.18) and OR 1.31 (95% CI: 0.74-2.34), respectively. Due to a lack of available data, urinary incontinence recovering could not be assessed. The available low evidence does not show that physical activity during pregnancy or postpartum is associated with urinary incontinence. Moderate physical activity should therefore be encouraged for the evidence-based benefits on other obstetrical outcomes.

Wide Variation in Post-Void Residual Management after Urogynecologic Surgery: A Survey of Urogynecologists' Practices.

To date there is no standardized regimen or evidence-based practical guideline concerning post-void residual (PVR) measurement after urogynecologic surgeries. This survey aimed to evaluate current practice patterns and the approach taken among urogynecologists surrounding PVR measurement. An online survey was sent to members of several urogynecologic societies assessing pre- and postoperative management of patients undergoing urogynecologic surgery. A total of 204 urogynecologists from 21 countries participated in the survey. The vast majority of urogynecologists perform some kind of voiding trial to assess voiding function postoperatively. The cut-off values to perform catheterization, the methods of measurement, and the number of successfully passed voiding showed strong differences. Only 34.4% of the respondents consider routine PVR measurement after urogynecologic surgery to be evidence-based. PVR measurement after urogynecologic surgeries is widely performed and if pathological, it almost always provokes invasive treatment. However, there is a wide variation of implemented strategies, methods, and cut-off values. Scientific societies are challenged to devise a standardized regimen based on evidence for the management of urinary retention after urogynecologic surgery.

Benefit of a nurse-led telephone-based intervention prior to the first urogynecology outpatient visit: a randomized-controlled trial.

INTRODUCTION AND HYPOTHESIS: Triage has become a valid tool to reduce workload during the first consultation in a specialized clinic. A nurse-led telephone intervention prior to the first urogynecologic visit reduces visit duration and increases patients' and physicians' satisfaction. METHODS: All patients scheduled for their very first visit were recruited. They were randomized into an intervention group (prior contact by a specialized urogynecology nurse) and a control group (no contact). The intervention included a questionnaire about history and symptoms. Patients were prompted to complete a bladder diary. Primary outcome was duration of the consultation; secondary outcomes were patients' and physicians' satisfaction with the intervention. RESULTS: Fifty-five patients were allocated to the intervention group and 53 to the control group with no difference regarding age, BMI, parity, menopausal status and primary diagnosis. Mean duration of the telephone call was 10.8 min (SD 4.4). The consultation was significantly shorter in the intervention group than in the control group (mean difference: 4 min and 8 s, p = 0.017). In the intervention group, 79% of the patients found the consultation quality "excellent," 86% would return, and 77% would recommend our clinic to a relative or friend compared with 68%, 67% and 66%, respectively, in the control group. Physicians were "very satisfied" or "satisfied" with the patient preparation. CONCLUSIONS: A nurse-led intervention reduces the duration of the first uroynecologic consultation and is associated with high patient and physician satisfaction. Further research should evaluate whether it also decreases the number of follow-up visits and further referrals.

Basic Laparoscopic Skills Training Is Equally Effective Using 2D Compared to 3D Visualization: A Randomized Controlled Trial.

Reduced depth perception due to two-dimensional (2D) visualization of a three-dimensional (3D) space represents a main challenge in acquiring basic laparoscopic skills (BLS); 3D visualization might increase training efficiency. This study aimed to assess whether BLS training on a standard box trainer using 2D is at least equally effective compared to 3D. Medical students were randomized to training of Fundamentals of Laparoscopic Surgery (FLS) tasks using either 2D or 3D for four weeks. Baseline and post-training tests were performed using the assigned visualization modality. Data of 31 participants were analyzed (n = 16 2D, n = 15 3D). Baseline test scores did not differ significantly between groups; only at the peg transfer task and total scores, the 3D group performed better than the 2D group. All scores improved significantly in both groups, with post training scores not differing significantly between groups. Non-inferiority of 2D compared to 3D was demonstrated for total score improvement and improvement in all individual FLS tasks except for suturing with extracorporeal knot tying. Post training test performance did not change significantly when changing to the unfamiliar modality. In conclusion, BLS training using standard 2D is at least equally effective as with 3D, without significant disadvantages when changing to the other modality.

Can we harness the placebo effect to improve care in lower urinary tract dysfunction? ICI-RS 2019.

The proposal "Can we harness the placebo effect to improve care in lower urinary tract dysfunction?" was discussed at the International Consultation on Incontinence-Research Society (ICI-RS) 2019 meeting. The placebo effect can change the treatment outcome whether the treatment is an active treatment or placebo. The total active treatment outcome is a combination of the placebo and the active treatment effect which is seen in placebo-controlled trials. The placebo effect plays an important role in the treatment of lower urinary tract dysfunction in overactive bladder, bladder pain syndrome, and stress urinary incontinence. In clinical practice, a number of factors can be employed to use the placebo effect to maximize its effect on patients receiving an active treatment, such as having the same environment for review such as the same appointment time, same room, and same clinician. Clinicians should also be aware of the nocebo effect which is increased with an overemphasis on side effects or negative outcomes.

Laparoscopic management of pelvic organ prolapse recurrence after open sacrocervicopexy.

In this narrated video we present a case of pelvic organ prolapse (POP) recurrence 12 years after sacrocervicopexy, outline our management and suggest an optimal laparoscopic surgical technique that may reduce the risk of future recurrence. A 71-year-old patient, who had undergone an open sub-total hysterectomy with sacrocervicopexy 12 years previously, complained of a bulging sensation in her vagina, of 12 months' duration. On physical examination, a Pelvic Organ Prolapse Quantification (POP-Q) stage III prolapse was diagnosed, with marked apical, anterior and posterior compartment prolapse. On laparoscopy we identified the old mesh attached to the promontory and to the vaginal apex, without any fixation of the vaginal walls. Complete mesh excision was performed, followed by vaginal dissection to facilitate implantation of two new meshes and performing a new sacrocolpopexy. No postoperative complications occurred. Over 6 weeks of post-operative follow-up, there was no pelvic pain, dysuria or dyschezia. A good anatomical result was noted without any prolapse. Laparoscopy appears to be an effective approach to complete mesh excision. For the treatment of prolapse recurrence, complete excision of the old mesh with new pelvic mesh-augmented reconstruction is recommended. Thorough dissection of the vesico-vaginal and recto-vaginal spaces followed by mesh fixation to the relevant vaginal walls may reduce recurrence.

Is there enough evidence to justify the use of laser and other thermal therapies in female lower urinary tract dysfunction? Report from the ICI-RS 2019.

AIMS: There is increasing evidence to suggest that thermomodulation may have a role in the management of women with lower urinary tract dysfunction (LUTD) and there has been widespread adoption of laser and radiofrequency (RF) therapies within clinical practice. However, in many areas of LUTD, the data are still limited and there remains a need for further evaluation of the safety and efficacy of thermal therapy. The aim of this study proposal is to report the findings of the International Consultation on Incontinence Research Society to clarify our current knowledge regarding the evidence for thermal therapy in LUTD and to set research priorities for the future. METHODS: Literature review based on the search terms: "laser," "radiofrequency," "genitourinary syndrome of the menopause" or "urogenital atrophy," "stress urinary incontinence (SUI)," "pelvic organ prolapse," "OAB" or "overactive bladder," and "urinary tract infection." RESULTS: The current available evidence, though of low or very low quality, appears promising for the use of laser therapy in the management of genitourinary syndrome of the menopause, there are some data to suggest a possible role in SUI although very little evidence for urogenital prolapse. At present, the evidence supporting the use of laser in OAB and recurrent urinary tract infection is limited or lacking, while the available evidence for RF in the management of all forms of LUTD is much less robust. CONCLUSIONS: Laser and RF are being introduced clinically as a minimally invasive, low-risk interventions for women with LUTD although at present, the evidence supporting usage is limited. Consequently, there is an urgent need to demonstrate the safety and efficacy with prospective long-term studies including sham studies and comparative studies with current standard therapy.

Is polypropylene mesh material fundamentally safe for use as a reconstructive material in vaginal surgery: ICI-RS 2019?

Polypropylene (PP) mesh has been used as a primary or adjuvant material for vaginal reconstruction for both stress urinary incontinence (SUI) and pelvic organ prolapse (POP) for decades. Whether polypropylene is the optimal material for such indications has been called into question by clinicians, regulatory agencies and the public in several countries around the world. This paper is a report of presentations and subsequent discussion at the annual International Consultation on Incontinence Research Society (ICI-RS) Meeting in June 2019 in Bristol, UK on the proposal "Is polypropylene mesh material fundamentally safe for use as a reconstructive material in vaginal surgery?" in which several of the salient issues were presented and discussed.

Laparoscopic sacrocolpopexy: A comprehensive literature review on current practice.

Sacrocolpopexy is considered the preferred treatment for vaginal vault. However, numerous technical variants are being practiced. We aimed to summarize the recent literature in relation to technical aspects of laparoscopic sacrocolpopexy (LSC). We focused on surgical technique, mesh type, concomitant surgeries, and training aspects. We performed 2 independent literature searches in Medline, Scopus, the Cochrane library, and Embase electronic databases including the keywords: 'sacrocolpopexy', 'sacral colpopexy' and 'promontofixation'. Full text English-language studies of human patients, who underwent LSC, published from January 1, 2008 to February 26, 2019, were included. Levels of evidence using the modified Oxford grading system were assessed in order to establish a report of the available literature of highest level of evidence. Initially, 953 articles were identified. After excluding duplicates and abstracts screening, 35 articles were included. Vaginal fixation of the mesh can be performed with barbed or non-barbed (level 1), absorbable or non-absorbable sutures (level 2). Fixation of the mesh to the promontory can be performed with non-absorbable sutures or non-absorbable tackers (level 2). The current literature supports using type 1 mesh (level 2). Ventral mesh rectopexy can safely be performed with LSC while concurrent posterior repair has no additional benefit (level 2). There is no consensus regarding the preferred type of hysterectomy or the benefit of an additional anti urinary incontinence procedure. A structured learning program, as well as the number of procedures needed in order to be qualified for performing LSC is yet to be established. There are numerous variants for performing LSC. For many of its technical aspects there is little consensus.

Rectal injury during laparoscopic mesh removal after sacrocervicopexy.

In this video we present a case of rectal injury, which occurred during laparoscopic mesh removal following sacrocervicopexy. Four years after sub-total hysterectomy with laparoscopic sacrocervicopexy, a 64-year-old patient still suffered from intense proctalgia and pain while sitting. On physical examination, intense pain could be triggered by palpating the left aspect of the levator ani muscle, raising the suspicion of an association with the mesh and leading to the decision for its removal. The left posterior arm of the mesh was removed completely laparoscopically. During this procedure, a rectal lesion was diagnosed and immediately repaired by a double layer of interrupted sutures. There was an immediate and complete resolution of the symptoms after surgery, with no short-term prolapse recurrence or postoperative complications. Laparoscopy appears to be an efficient approach to mesh excision. A high level of alertness to recognize intraoperative injuries is warranted.

How can we improve the diagnosis and management of bladder pain syndrome? Part 2:ICI-RS 2018.

BACKGROUND: This paper summarises the discussion in a think tank at the International Consultation on Incontinence-Research Society (ICI-RS) 2018 about the treatment of bladder pain syndrome. AIMS: To review the treatments of bladder pain syndrome from behavioural treatments to surgical interventions. MATERIALS AND METHODS: Review the literature in the light of the think tank discussions. RESULTS: All guidelines recommend different levels of treatment starting with conservative behavioral treatments then introducing oral treatments followed by intravesical instillations. If these treatments fail then more invasive treatments such as botulinum toxin injections, neuromodulation, or surgery could be suggested. CONCLUSION: Unfortunately for all treatments, the numbers are limited and, therefore, the evidence base is not strong. Further suggestions for research are suggested.

Recommendations and future research initiative to optimize bladder management in pregnancy and childbirth International Consultation on Incontinence - Research society 2018.

With increasing birth rates globally, obstetric bladder care and long term pelvic floor dysfunction continues to be a issue. This paper aims to provide an overview of the concerns in the antenatal, intrapartum an post partum periods and presents recommendation for the research requirements necessary and education to challenge current practice.

How can we improve the diagnosis and management of bladder pain syndrome? Part 1: ICI-RS 2018.

BACKGROUND: This paper summarizes the discussion in a think tank at the ICI-RS 2018 about the diagnosis of bladder pain syndrome (BPS). AIMS: To review the guidelines, investigations and subtypes of BPS. MATERIALS AND METHODS: Review of literature in the light of the think tank discussion. RESULTS: All guidelines recommend completing history, physical examination, urine analysis, urine culture, and urine cytology to define the BPS phenotype but there are differences on further investigations. In those guidelines which recommend cystoscopy, the identification of Hunner's lesions (HLs) is recommended as this changes the treatment plan and outcome. CONCLUSION: We propose that the differentiation of Hunner's ulcers is an important step in the assessment of these patients. Further suggestions for research are suggested.

Abnormal vaginal microbiome associated with vaginal mesh complications.

AIMS: To identify differences in the vaginal microbiomes of women after transvaginal mesh (TVM) surgery for pelvic organ prolapse with and without mesh-associated complications. METHODS: Patients with complications were eligible as cases, patients without as controls. DNA was isolated and the V1-2 region of the 16S ribosomal RNA gene was amplified and sequenced. Overall richness was quantified using Chao1. Overall diversity was expressed as Shannon diversity and screened for group differences using analysis of variance. Multivariate differences among groups were evaluated with functions from R. RESULTS: We recruited 14 patients after mesh exposure, 5 after contraction, and 21 as controls. The average number of operational taxonomic unit was 74.79 (SD ± 63.91) for controls, 57.13 (SD ± 58.74) after exposures, and 92.42 (SD ± 50.01) after contractions. Total 89.6% of bacteria in controls, 86.4% in previous exposures, and 81.3% in contractions were classified as either Firmicutes, Proteobacteria, or Actinobacteria (P < .001). Veillonella spp. was more abundant in patients after contraction (P = .045). The individual microbiomes varied, and we did not detect any significant differences in richness but a trend towards higher diversity with complications. CONCLUSIONS: The presence of Veillonella spp. could be associated with mesh contraction. Our study did not identify vaginal microbiotic dysbiosis as a factor associated with exposure. Larger cohort studies would be needed to distinguish the vaginal microbiome of women predisposed to mesh-related complications for targeted phenotyping of patients who could benefit from TVM surgery.

Midurethral slings for treatment of stress urinary incontinence review.

PURPOSE: The midurethral sling (MUS) has largely been regarded as the "gold standard" in treatment of stress urinary incontinence (SUI). Recently the safety and use of the MUS has come under scrutiny following concerns about the use of mesh implants. The aim of this review was to detail the background to SUI which has led to the development of MUS, to highlight the issues surrounding the use of mesh under the current climate of mesh controversies and to provide an update on current evidence on the use of MUS. MATERIALS AND METHODS: We conducted a review of the literature looking at the efficacy and safety of MUS. RESULTS: MUS has good rates of subjective cure in the short and into the longer term. The overall rates of complications are low including those associated with the use of mesh implants. When compared to other continence procedures, MUS is equally effective in regard to cure but has lower rates of complications and more favorable operative outcomes. The use of mesh has been supported by major Urogynaecological Societies along with the reports from government driven enquiries into the use of mesh. CONCLUSIONS: Overall, MUS have been shown to be an effective and safe surgical treatment for management of stress urinary incontinence.