Sacral colpopexy versus transvaginal mesh colpopexy in obese patients.

OBJECTIVES: Obesity can predispose women to pelvic organ prolapse and can also affect the success of pelvic organ prolapse surgery. The purpose of this study was to compare the postoperative anatomical outcomes following sacral colpopexy (SC) and transvaginal mesh colpopexy in a group of obese women with pelvic organ prolapse. METHODS: We conducted a retrospective cohort study of obese women who underwent SC (n = 56) or transvaginal mesh colpopexy (n = 35). Follow-up ranged from 6 to 12 months. Preoperative, perioperative, and postoperative variables were compared using Student t, Mann-Whitney U, and Fisher exact tests, and by analysis of covariance. RESULTS: The women in the SC group had significantly higher mean apical vaginal measurements (P < 0.05), and significantly fewer stage II recurrences than women in the transvaginal mesh colpopexy group. There were no significant differences between the groups for other postoperative outcomes, including mesh erosion, recurrent prolapse symptoms, dyspareunia, and surgical satisfaction (P > 0.05). CONCLUSION: In these 91 obese patients with pelvic organ prolapse, SC resulted in better anatomical outcomes than transvaginal mesh colpopexy. However, the two procedures had similar outcomes with regard to recurrent symptoms and surgical satisfaction.

Objectifs : L'obésité peut prédisposer les femmes au prolapsus des organes pelviens et peut également affecter la réussite de la chirurgie visant à rectifier ce dernier. Cette étude avait pour objectif de comparer, chez un groupe de femmes obèses présentant un prolapsus des organes pelviens, les issues anatomiques postopératoires constatées à la suite d'une colpopexie sacrée (CS) à celles qui sont constatées à la suite d'une colpopexie par treillis transvaginal. Méthodes : Nous avons mené une étude de cohorte rétrospective portant sur des femmes obèses qui ont subi une CS (n = 56) ou une colpopexie par treillis transvaginal (n = 35). Le suivi a été d'une durée allant de six à douze mois. Les variables préopératoires, périopératoires et postopératoires ont été comparées au moyen des tests t de Student, U de Mann­Whitney et exact de Fisher, ainsi qu'au moyen d'une analyse de covariance. Résultats : Les femmes du groupe « CS ¼ présentaient des mesures vaginales apicales moyennes considérablement plus élevées (P < 0,05) et des récurrences de stade II considérablement moins fréquentes que les femmes du groupe « colpopexie par treillis transvaginal ¼. Aucune différence significative n'a été constatée entre les groupes en ce qui concerne d'autres issues postopératoires, y compris l'érosion du treillis, les symptômes récurrents de prolapsus, la dyspareunie et la satisfaction chirurgicale (P > 0,05). Conclusion : Chez ces 91 patientes obèses présentant un prolapsus des organes pelviens, la CS s'est soldée en de meilleures issues anatomiques que la colpopexie par treillis transvaginal. Toutefois, ces deux interventions ont obtenu des issues similaires pour ce qui est des symptômes récurrents et de la satisfaction chirurgicale.

Recurrence of prolapse after transvaginal mesh excision.

OBJECTIVE: Recurrence of pelvic organ prolapse (POP) is a potential complication after mesh removal. We evaluated anatomical and functional outcomes preoperatively and postoperatively in patients undergoing mesh excision. MATERIALS AND METHODS: We conducted a retrospective cohort analysis of consecutive patients who underwent mesh excision from years 2005 to 2009. Anatomical outcomes were evaluated using the POP quantification (POP-Q) system. Recurrence of prolapse was defined as stage II or higher-stage prolapse on the POP-Q system, reoperation for prolapse, or postoperative use of a pessary for prolapse reduction. Functional outcomes were assessed using the pelvic floor distress inventory and pelvic floor impact questionnaire scores. RESULTS: Data were analyzed from 71 patients who underwent either partial or complete mesh excision. Most (44/70 [63%]) of the patients underwent partial mesh excision, and 26 patients (37%) underwent total mesh removal. Nineteen patients (26.7%) had preoperative prolapse and 27 (38.0%) of the 71 patients underwent concomitant native tissue prolapse repair. Overall change in POP-Q stage in women who underwent partial removal (median, 0 [-1 to 2]) was less advanced than in women with total excision. (median, -1 [-3 to 0]; P = 0.006) at 1 year postoperatively. Four patients prolapsed to the hymen, with all patients having defects in the anterior compartment. No patients required a second surgery, and one patient was treated with a pessary.Total pelvic floor distress inventory and pelvic floor impact questionnaire scores before mesh excision were significantly improved 6 months after mesh removal (P < 0.05). Dyspareunia improved significantly after mesh excision (P = 0.034). CONCLUSION: In our patient population, total and partial mesh excision is associated with re-treatment of POP in 1.4% of the patients. Patient functional outcomes significantly improved after mesh removal.

Analysis of the impact of obesity on recurrence rates of stress urinary incontinence after urethrolysis or sling revision.

OBJECTIVE: The impact of obesity on the recurrence rates of stress urinary incontinence (SUI) after urethrolysis/sling revision was analyzed. STUDY DESIGN: A retrospective analysis was conducted of patients who underwent urethrolysis or sling revision from January 2004 to November 2010. RESULTS: Data from 74 patients were included. The mean body mass index (BMI) was 29.8 kg/m (SD, 6.3) and 37/74 (50%) women were obese (BMI ≥ 30 kg/m) with a mean length of follow-up of 27 weeks (range, 6-132 weeks). The following urethrolysis/sling revision surgical techniques were varied: partial transvaginal urethrolysis, complete transvaginal urethrolysis, abdominal urethrolysis, sling transection, and transvaginal sling stretching.Of the 74 cases, 25 (33.8%) had recurrent SUI after urethrolysis or sling revision. The BMI did not differ between those who did and did not have a recurrence (t test P = 0.68); 25/49 (51%) women who did not have a recurrence were obese and 12/25 (48%) women with recurrence were obese. CONCLUSIONS: Obesity was not associated with increased rates of SUI recurrence after urethrolysis/sling revision.

Use of suprapubic tube to assess voiding function after synthetic midurethral slings.

INTRODUCTION: Up to 50% of patients are unable to void immediately after midurethral sling (MUS) procedures. The objective of this study was to present our case series of use of suprapubic tube (SPT) to assess voiding function after MUS procedures. METHODS: This was a retrospective cohort study of patients who underwent MUS procedures along with insertion of SPT between January 2007 and August 2010. RESULTS: A total of 123 patients were identified. Among the patients who met criteria for SPT removal within 4 weeks, the mean number of days of SPT use was 6 (4.6) days. One major complication involved a urinoma after SPT removal. CONCLUSION: The use of SPT after MUS procedures is practical. In our cohort of patients, it took up to 1 week for voiding function to return to normal.

High uterosacral ligament vaginal vault suspension: comparison of absorbable vs. permanent suture for apical fixation.

INTRODUCTION AND HYPOTHESIS: The primary objective of this study was to compare outcomes of absorbable and permanent suture for apical support with high uterosacral ligament vaginal vault suspension (HUSLS). The secondary objective was to investigate the rate of suture erosion. METHODS: This was a retrospective study of patients who underwent HUSLS with delayed absorbable and primarily permanent suture. Apical support was calculated as a new variable: Percent of Perfect Ratio (POP-R). This variable measures apical support as the position of the apex in relation to vaginal length. RESULTS: At 1-year follow-up, there was no significant difference in apical support between the two groups. The number of patients who suffered from suture erosion in the cohort that received permanent suture was 11 (22%). CONCLUSIONS: Permanent suture, in comparison with delayed absorbable suture, for HUSLS does not offer significantly better apical support at short-term follow-up. It is also associated with a high rate of suture erosion.

Use of preoperative prolapse reduction stress testing and the risk of a second surgery for urinary symptoms following laparoscopic sacral colpoperineopexy.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to determine the reoperation rate for sling placement or revision in patients who had primary continence procedures based on prolapse reduction stress testing (RST) prior to laparoscopic sacral colpoperineopexy (LSCP). METHODS: This was a retrospective cohort study of women who had RST prior to LSCP for symptomatic pelvic organ prolapse. Patients with positive test (Pos RST) had a concomitant midurethral sling procedure and those with negative test (Neg RST) did not. Variables were compared with either Student's t test or Fisher's exact test. RESULTS: In Neg RST group (n = 70), the rate of surgery for de novo urodynamic stress incontinence was 18.6%. In Pos RST group (n = 82), the rate of sling revision for bladder outlet obstruction was 7.3%. Overall, 88% of patients did not require a second surgery. CONCLUSIONS: The use of RST to recommend concomitant continence procedures during LSCP results in a single surgery for the majority of our patients.

Surgical outcomes of abdominal versus laparoscopic sacral colpopexy related to body mass index.

OBJECTIVE: Obesity can predispose women to pelvic organ prolapse and can also affect the success of prolapse surgery. Sacral colpopexy is a common surgical approach used to treat significant prolapse, and may be performed by laparotomy or laparoscopy. The objective of this study was to determine whether surgical outcomes following abdominal sacral colpopexy (ASC) and laparoscopic sacral colpopexy (LSC) varied according to BMI. METHODS: We conducted a retrospective cohort study of women who had undergone ASC (n = 90) and LSC (n = 150). Preoperative, perioperative, and postoperative information was collected from patient charts and entered into a database according to BMI category (normal weight 18.5 to 24.9 kg/m², overweight = 25 to 29.9 kg/m², obese ≥ 30 kg/m²). Within each BMI group, outcomes were compared between ASC and LSC patients using Student t, Mann-Whitney U, and Fisher exact tests, and analyses of covariance. RESULTS: In normal weight patients, postoperative apical measurements were worse in ASC patients (P = 0.01). In overweight patients, the ASC group had worse posterior measurements (P = 0.05) and fewer mesh/suture erosions (P = 0.03) but more recurrent prolapse symptoms (P = 0.007). In obese patients, the ASC group had better anterior measurements (P = 0.008). There were no differences in any BMI category for prolapse stage, surgical satisfaction, or classification of surgical success or failure (P > 0.05). CONCLUSION: Differences between ASC and LSC were identified when patients were categorized according to BMI. These findings may be useful in counselling patients and planning the appropriate surgical approach for sacral colpopexy based on BMI.

De novo stress urinary incontinence after negative prolapse reduction stress testing for total vaginal mesh procedures: incidence and risk factors.

OBJECTIVE: The primary objective was to estimate the incidence of de novo stress urinary incontinence after total vaginal mesh procedures in women with negative preoperative urodynamics with prolapse reduction. Secondary objective was to identify associated risk factors. STUDY DESIGN: A retrospective cohort study with a nested case-control study of women who underwent total vaginal mesh procedures without midurethral sling after a negative preoperative urodynamics. RESULT: Sixty patients were included in the final analysis. Fifteen (25%) patients were diagnosed with de novo stress urinary incontinence. Although no significant associated risk factors were identified, there was a trend for higher gravidity and better anterior wall support among women who had stress urinary incontinence develop. CONCLUSION: The incidence of de novo stress urinary incontinence after total vaginal mesh procedures in this cohort was 25%. Patients should be appropriately counseled regarding the same.

Surgical outcomes following total Prolift: colpopexy versus hysteropexy.

BACKGROUND: Total Prolift(®) is a pelvic floor repair system that is performed transvaginally and can be carried out with or without the uterus in situ. AIM: To compare surgical outcomes following total Prolift colpopexy (TPC) and total Prolift hysteropexy (TPH). METHODS: This was a retrospective cohort study of women that underwent TPC (n = 65) or TPH (n = 24). Outcomes were compared between groups using Student's t-test, ANCOVA and Fisher's exact tests (P ≤ 0.05). RESULTS: There were no significant differences between TPC and TPH for all peri-operative variables. Patients were followed 6-12 months after surgery. Post-operatively, TPC patients had significantly higher pelvic organ prolapse-quantification (POP-Q) point C measurements (P = 0.05); however, all other POP-Q measurements were similar, including POP-Q apical stage of prolapse, with 99% in the TPC group and 92% in the TPH group at stage I or less. Post-operative mesh erosion, prolapse symptoms, surgical satisfaction, sexual activity and dyspareunia rates did not significantly differ between groups. CONCLUSIONS: This study showed that TPC and TPH have similar surgical outcomes, except for vaginal vault measurements reflected by POP-Q point C.

Laparoscopic sacral colpoperineopexy: abdominal versus abdominal-vaginal posterior graft attachment.

INTRODUCTION AND HYPOTHESIS: Laparoscopic sacral colpoperineopexy (LSCP) involves posterior graft extension to the perineum for improved posterior support. The objective of this study was to determine whether posterior measurements differed between those that had graft extension done abdominally (A-LSCP) or abdomino-vaginally (AV-LSCP). METHODS: This was a retrospective cohort study of patients that underwent A-LSCP (n = 17) and AV-LSCP (n = 51). Pre-, peri-, and postoperative variables were compared using Student's t, Fisher's exact, and analysis of covariance tests. RESULTS: Follow-up was 6 to 12 months. There were no differences between A-LSCP and AV-LSCP for any vaginal measurements or stage of prolapse (P > 0.05). Although not statistically different, A-LSCP patients had lower rates of mesh erosion and dyspareunia (P > 0.05). AV-LSCP patients had fewer prolapse symptoms (P = 0.01), but both groups had similar surgical satisfaction (P= 0.8). CONCLUSIONS: A-LSCP and AV-LSCP had comparable effects on posterior vaginal measurements; however, mesh erosion and subjective outcomes differed between the two approaches.

The effect of tension-free vaginal tape placement on distal anterior vaginal wall support at the time of laparoscopic sacral colpoperineopexy.

PURPOSE: The occurrence of stress urinary incontinence and pelvic organ prolapse can often coexist resulting in the need for concomitant surgical procedures to treat both conditions. The purpose of this study was to determine if tension-free vaginal tape (TVT) at the time of laparoscopic sacral colpoperineopexy (LSCP) had an effect on distal anterior vaginal wall support. METHODS: This was a retrospective cohort study of patients that had LSCP between January 2005 and December 2007 (n = 121). These patients were divided according to those with (n = 63) and without TVT (n = 58) at the time of LSCP. Pre- and postoperative information was compared between groups using Student's t tests, ANCOVA, and Fisher's exact tests (P ≤ 0.05). RESULTS: Preoperatively, there were no significant differences between groups for all demographic and anatomic variables (P > 0.05). Patients were followed-up until 12 months after surgery. Patients with and without TVT had similar postoperative anterior vaginal wall measurements (points Aa and Ba) and stage of prolapse (P > 0.05). There were also no differences between groups with regard to recurrent prolapse symptoms or surgical satisfaction (P > 0.05). CONCLUSIONS: Tension-free vaginal tape at the time of LSCP did not improve postoperative distal anterior vaginal support.

Does tension-free vaginal tape placement at the time of total prolift colpopexy affect distal anterior vaginal support?

OBJECTIVES: : Pelvic organ prolapse (POP) and stress urinary incontinence often require concomitant procedures to treat both conditions. The purpose of this study was to determine whether tension-free vaginal tape (TVT) at the time of total Prolift colpopexy (TPC) affected distal anterior vaginal wall support. METHODS: : This was a retrospective cohort study of women that had TPC (n = 62) between January 2005 and December 2007. All patients had no uterus and underwent TPC with mesh placement in the anterior and posterior vaginal compartments. A concomitant TVT was placed only in those who had a preoperative diagnosis of urodynamic stress urinary incontinence with prolapse reduction. Patients were subdivided into those with (n = 26) and without TVT (n = 36). Data were compared between groups using Student t, Wilcoxon rank sum, and Fisher exact tests (P ≤ 0.05). RESULTS: : There were no significant differences between groups for all preoperative variables. Patients were observed for 6 to 12 months after TPC. Postoperatively, those with and without TVT had similar anterior POP quantification measurements (points Aa and Ba; P > 0.05), although the group with TVT had significantly more patients with anterior stage 2 and 3 recurrences (23%) when compared with the group without TVT (5%, P = 0.04). CONCLUSIONS: : Tension-free vaginal tape does not provide additional distal anterior vaginal wall support for patients undergoing TPC.

Risk of mesh erosion after abdominal sacral colpoperineopexy with concomitant hysterectomy.

OBJECTIVE: The purpose of this study was to evaluate the effect of concomitant hysterectomy at the time of abdominal sacral colpoperineopexy on the risk of mesh erosion with the use of type 1 polypropylene mesh. STUDY DESIGN: This was a retrospective case control study. All cases of vaginal mesh erosion (n = 31) were compared with matched control cases (n = 93) in a 3:1 ratio. Demographic data, concomitant procedures, and postoperative complications were compared between groups with the use of 2-sample Student t test and Pearson chi(2) test. RESULTS: The odds ratio of a vaginal mesh erosion was no different for those who underwent a hysterectomy at the time of abdominal sacral colpoperineopexy (odds ratio, 0.95; 95% confidence interval, 0.41-2.18; P = .899) when potential confounders were similar between groups. CONCLUSION: Hysterectomy at the time of abdominal sacral colpoperineopexy is not a risk factor for vaginal mesh erosion with the use of type 1 polypropylene mesh.

Does the Prolift system cause dyspareunia?

OBJECTIVE: The purpose of this study was to determine the de novo dyspareunia rate with the Prolift procedure. STUDY DESIGN: All Prolift cases performed between August 2005 and August 2007 were evaluated. The rate of de novo dyspareunia was calculated by chart review. Type and degree of dyspareunia were assessed by self-administered questionnaire. Demographics, use of hormone therapy, failure rate, and willingness to have the surgery again were summarized using descriptive statistics. RESULTS: The rate of de novo dyspareunia was 16.7%. Over 75% of patients with de novo dyspareunia described the pain as mild or moderate. Most described dyspareunia with insertion. Eighty-three percent of respondents with de novo dyspareunia would have the procedure done again. CONCLUSION: The Prolift is associated with a 17% de novo dyspareunia rate. Despite this, most would have the surgery done again.

Tobacco use is a risk factor for mesh erosion after abdominal sacral colpoperineopexy.

OBJECTIVE: The purpose of this study was to evaluate the association between smoking and vaginal mesh erosion after abdominal sacral colpoperineopexy with the use of type 1 polypropylene mesh. STUDY DESIGN: All cases of mesh erosion (n = 27) that were diagnosed between October 2003 and June 2006 were identified and compared with matched control cases (n = 81). Control cases were matched for age, diabetes mellitus status, hypoestrogenic state (menopausal status, chronic steroid use, use of hormone therapy), abdominal-vaginal rectocele repair, culdoplasty, and concomitant hysterectomy. Demographic data, surgical characteristics, and postoperative complications were also compared between groups. Continuous data were compared using 2-sample Student t tests. Categoric data were compared with the use of Pearson Chi-square tests. RESULTS: The odds of experiencing mesh erosion was significantly greater in smokers than in nonsmokers (odds ratio, 4.4; 95% CI, 1.3, 14.4; P = .010) when potential confounders were similar between groups. CONCLUSION: Tobacco use is a risk factor for vaginal mesh erosion after abdominal sacral colpoperineopexy with the use of type 1 polypropylene mesh.

From the simple to the sublime: incorporating surgical models into your surgical curriculum.

Financial and time constraints have limited graduating residents' operative experience, making the use of models a necessary adjunct to a complete surgical curriculum. Models are useful tools to teaching surgical skills outside the operating room. They can be very realistic and complex, or they can be simple and economical. Models are developed to represent the anatomic arrangements seen in human patients, and to reproduce the biomechanical tasks necessary to complete a surgical case. Bench model laboratories are well-received by trainees and steepen the learning curve in the operating room.

Prevalence of severe pelvic organ prolapse in relation to job description and socioeconomic status: a multicenter cross-sectional study.

The aim of this study was to determine if certain occupations or socioeconomic levels are associated with pelvic organ prolapse. Investigators at six American sites performed pelvic organ prolapse quantification examinations on women presenting for routine gynecologic care. Between September 1999 and March 2002, 1,004 patients were examined. Severe pelvic organ prolapse was defined as the leading edge being 1 cm or more beyond the hymeneal ring. The data was analyzed with the Kruskal-Wallis analysis of variance, Bonferroni test, multiple logistic regression, and descriptive statistics. The prevalence of severe pelvic organ prolapse in our group was 4.3%. Women who were laborers/factory workers had significantly more severe prolapse than the other job categories (p < 0.001). Women with annual income of Dollars 10,000 or less had significantly more severe pelvic organ prolapse than other income groups (p < 0.001). These differences persisted even when controlling for age, race, number of deliveries, body mass index >30, and smoking status (all p < 0.001). Laborers/factory worker jobs and an annual household income of Dollars 10,000 or less are associated with severe pelvic organ prolapse.

The effect of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence.

OBJECTIVE: The purpose of this study was to determine the relative effects of pregnancy and mode of delivery on the prevalence of urinary and fecal incontinence. STUDY DESIGN: This was a prospective, observational multicenter study of women presenting to 6 gynecology clinics. Demographic data collected included: height, weight, gravidity, parity, and number of vaginal deliveries. Patients were diagnosed with incontinence by questionnaire. Standard univariate logistic regression analyses' were performed to determine the contribution of pregnancy, mode of delivery, and BMI on the prevalence of urinary and fecal incontinence. RESULTS: One thousand and four women were enrolled over an 18-month period. Two hundred and thirty-seven and 128 subjects had urinary and fecal incontinence, respectively. Odds ratio (95% CI) calculated for the prevalence of urinary incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.46 (1.53-3.95), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.95 (0.99-3.80), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.53 (1.57-4.07), and any term pregnancy but no vaginal delivery (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 1.30 (0.77-3.95). Odds ratio (95% CI) calculated for the prevalence of fecal incontinence by pregnancy and mode of delivery were: any term pregnancy vs no term pregnancy was 2.26 (1.22-4.19), any term pregnancy but no vaginal deliveries (cesarean section only) vs no term pregnancy was 1.13 (0.43-2.96), any term pregnancy and at least 1 vaginal delivery vs no term pregnancy was 2.41 (1.30-4.49), and any term pregnancy but no vaginal deliveries (cesarean section only) vs any term pregnancy, and at least 1 vaginal delivery was 2.15 (0.97-4.77). BMI and age did not impact these results. CONCLUSION: Pregnancy increases the risk of urinary and fecal incontinence. Cesarean section does not decrease the risk of urinary or fecal incontinence compared to pregnancy with a vaginal delivery.

Pelvic Organ Support Study (POSST) and bowel symptoms: straining at stool is associated with perineal and anterior vaginal descent in a general gynecologic population.

OBJECTIVE: The purpose of this study was to evaluate the association of constipation symptoms and anal incontinence with vaginal wall and pelvic organ descent in a general gynecologic population. STUDY DESIGN: In this multicenter, cross-sectional study, 1004 women attending routine gynecologic healthcare underwent pelvic organ prolapse quantification (POPQ) measurements, and were surveyed regarding anal incontinence, digitation, < 2 bowel movements (BMs)/week, and > 25% frequency of: straining, hard/lumpy stools, and incomplete emptying. Constipation scores reflected the sum of positive responses. Associations between POPQ measurements (Ba, C, Bp, gh+pb), constipation scores, and anal incontinence were evaluated using multivariable regression. RESULTS: Of 119 women with Bp > or = -1.00, 47% reported no constipation symptoms. Hard/lumpy stools (26%), incomplete emptying (24%), and straining (24%) were more prevalent; fewer women reported < 2 BMs/week (15%) or digitation (7%). Constipation scores were weakly correlated with Bp, gh+pb (both r < .1, P < .02). Women reporting > or = 2 symptoms had greater gh+pb measurements than women reporting 0 or 1 symptom (P = .03). Women with anal incontinence had greater gh+pb and gh values than women without anal incontinence (P < .01). POPQ measurements were regressed separately onto (1) total constipation scores, (2) dichotomized scores, and (3) individual symptoms, with BMI, age, number of vaginal deliveries (NVD), weight of largest vaginal delivery (WLVD), race, hysterectomy, study site, and income included as covariates. Total constipation scores and dichotomized scores were nonsignificant in all models. With regard to individual symptoms, straining at stool was significant in the models for Ba and gh+pb, with greater Ba and gh+pb measurements among strainers relative to nonstrainers. CONCLUSION: Most associations between bowel symptoms and vaginal or pelvic organ descent were weak. After controlling for important covariates, straining at stool remained associated with anterior vaginal wall and perineal descent.