Combination of Anterior and Posterior Vaginal Mesh Implants and Delorme Procedure in a 94-year-old female with Pelvic Organ Prolapse.

Pelvic organ prolapse refers to the descent of pelvic floor organs resulting from the weakening of pelvic muscles, fascia and connective tissue. The overall prevalence of pelvic organ prolapse is approximately 41%, including bladder prolapse (25%-34%), uterine prolapse (4%-14%) and rectal prolapse (13%-19%). Various methods are currently employed to repair damaged structures and improve patient symptoms, consequently enhancing their quality of life. This report focuses on a 94-year-old female diagnosed with pelvic organ prolapse, specifically Grade 3 bladder prolapse, Grade 3 uterine prolapse and complete rectal prolapse. A comprehensive surgical treatment was carried out to repair the pelvic organs on all three levels (rectum, uterus and bladder) by combining the Delorme procedure with synthetic graft implants. The surgical outcomes were good, illustrating immediate improvement in symptoms without early complications. A multispeciality approach helps functionally repair pelvic organ prolapse while preserving structural integrity.

Comparison of transvaginal natural orifice transluminal endoscopic surgery versus conventional surgery for uterosacral ligament suspension in patients who had concomitant vaginal hysterectomy for subtotal uterine prolapse.

INTRODUCTION: The study aimed to compare the short-term outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for uterosacral ligament suspension (USLS) versus nonendoscopic USLS in patients with subtotal uterine prolapse who had a concomitant vaginal hysterectomy. METHODS: There were 51 patients who underwent vNOTES USLS, whereas the nonendoscopic conventional USLS group had 49 patients. The information about patient demographics, and perioperative data including the operative duration, blood loss, intraoperative and postoperative complications, and length of postoperative hospital stay were determined from the patients' files. Postoperative follow-up visits were scheduled at the first week and 1 month after surgery. RESULTS: The demographic variables including age, body mass index, menopausal status, and parity were comparable, and no significant differences were found. A total of 90.2% of the patients in the vNOTES group and 69.4% of the patients in the shull group were at menopause (p = .09). Operation time was significantly shorter in the shull group (p < .001), and the hospitalization period (p = .029) was significantly shorter in the vNOTES group. Ba, Bp, and D points and total vaginal length (TVL) were significantly behind the hymenal ring in patients who had vNOTES USLS procedure (p < .001). None of the patients who had intraoperative significant blood loss required transfusion. One patient in the vNOTES and two patients in the shull group had a postoperative cuff hematoma. CONCLUSION: vNOTES USLS has a good safety profile, higher percentage of adnexal surgeries with better improvement on POP-Q points Ba, Bp, D, and TVL compared with classic USLS in patients with subtotal uterine prolapse. Studies evaluating short- and long-term results of vNOTES versus conventional USLS are needed.

A review of vaginal hysterectomies in the gynaecology department of a tertiary care hospital.

This retrospective cohort study analysed the trends and complications of vaginal hysterectomy conducted at Services Hospital, Lahore, from January 1, 2015 to December 31, 2020. Demographics, indications, surgery duration, complications (haemorrhage, urological or rectal problems, infection), and hospital stay were recorded. Out of 819 hysterectomies performed for benign gynaecological conditions, 112 (13.68%) were vaginal hysterectomies. Non-descent vaginal hysterectomy (NDVH) accounted for 33(29.46%) and uterine prolapse for 79(70.53%) of the cases. Mean age was 52.35±8.74 years, parity was 5.01±1.32, intraoperative haemorrhage was 796.87±450.1 ml, surgery duration was 48.61±12.28 minutes, and hospital stay was 2.58±0.41 days. Complications occurred in 19(16.97%) of the cases, while 93(83.03%) cases had no complications. Outcomes were comparable between NDVH and vaginal hysterectomy for prolapse (p=0.552). This indicates that vaginal hysterectomy is a safe procedure with minimal complications and quick recovery for uterine prolapse and non-descent uterus. However, a declining trend was observed over the study period.

Uterovaginal prolapse complicated by urogenital myiasis.

Urogenital myiasis is a rare entity that is usually manifested in women belonging to lower socioeconomic status residing in tropical or subtropical nations with poor hygiene or intellectual disability. It is caused by fly larvae capable of penetrating body orifices and healthy or necrotic tissue. The larvae penetrate the skin, forming painful, inflammatory nodules that can form fistula to the internal organs or the skin's surface. Serous and haemorrhagic exudation, along with crawling larvae, are encountered. Some complications, such as secondary infection and tetanus, have been documented. The prognosis is generally good, and treatment consists of removing the parasitic larvae and thoroughly cleansing the affected area.We present a case of a postmenopausal woman with parity 3 and live issue 1 in her early 50s from lower socioeconomic status diagnosed with uterovaginal prolapse complicated by myiasis. The patient was managed successfully with systemic antibiotics, manual removal of myiasis and hysterectomy.

A randomized, prospective, controlled study comparing uterine preserving laparoscopic lateral suspension with mesh versus laparoscopic sacrohysteropexy in the treatment of uterine prolapse.

OBJECTIVES: Pelvic organ prolapse (POP) significantly affects women's quality of life, occurring in 20-30% of females aged over 20 globally. With aging populations, demand for pelvic reconstructive surgery is rising. Patients seek anatomical restoration while preserving uterus and sexual function. Sacrohysteropexy is the gold standard for apical prolapse, but carries risks. Lateral suspension, offers safer apical and anterior correction especially for obese, sexually active women. Our prospective study compares laparoscopic sacrohysteropexy and lateral suspension objectively and subjectively. STUDY DESIGN: The study included patients who had laparoscopic lateral suspension (n = 22) or laparoscopic sacrohysteropexy (n = 22) for symptomatic stage 2 apical prolapse. Groups randomized with using block design. Anatomical cure was based on measurements taken by the same physician, unaware of intervention, before and at 12 months using POP-Q score. Pelvic floor ultrasound also used for objective rates. Subjective comparison used Prolapse Quality of Life (P-QoL), Pelvic Organ Prolapse-Symptom Score (POP-SS), Female Sexual Function Index (FSFI), Visual Analog Score (VAS), and Michigan Incontinence Severity Index (M-ISI). RESULTS: Age, BMI, parity, menopause, sexual activity, complications, showed no significant difference between groups (p > 0.05). Surgical procedure duration significantly varied between groups lateral suspension group was shorter. There was no significant difference in post operative complications. No significant differences in posterior/enterocele stages.) Anterior staging showed no significant difference in sacrouteropexy (p = 0.130), but significant difference in lateral suspension group (p < 0.001). No significant differences in pre-op and post-op PQOL, POP-SS, FSFI, and M-ISI scores between the two groups. CONCLUSION: Both methods effectively managed apical prolapse with similar outcomes. Objective measurements showed lateral suspension's superiority in reducing bladder descent.

Transvaginal mesh or grafts or native tissue repair for vaginal prolapse.

BACKGROUND: Pelvic organ prolapse is the descent of one or more of the pelvic organs (uterus, vaginal apex, bladder, or bowel) into the vagina. In recent years, surgeons have increasingly used grafts in transvaginal repairs. Graft material can be synthetic or biological. The aim is to reduce prolapse recurrence and surpass the effectiveness of traditional native tissue repair (colporrhaphy) for vaginal prolapse. This is a review update; the previous version was published in 2016. OBJECTIVES: To determine the safety and effectiveness of transvaginal mesh or biological grafts compared to native tissue repair or other grafts in the surgical treatment of vaginal prolapse. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and two clinical trials registers (March 2022). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing different types of vaginal repair (mesh, biological graft, or native tissue). DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed risk of bias, and extracted data. The primary outcomes were awareness of prolapse, repeat surgery, and recurrent prolapse on examination. MAIN RESULTS: We included 51 RCTs (7846 women). The certainty of the evidence was largely moderate (ranging from very low to moderate). Transvaginal permanent mesh versus native tissue repair Awareness of prolapse at six months to seven years was less likely after mesh repair (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.73 to 0.95; I2 = 34%; 17 studies, 2932 women; moderate-certainty evidence). This suggests that if 23% of women are aware of prolapse after native tissue repair, between 17% and 22% will be aware of prolapse after permanent mesh repair. Rates of repeat surgery for prolapse were lower in the mesh group (RR 0.71, 95% CI 0.53 to 0.95; I2 = 35%; 17 studies, 2485 women; moderate-certainty evidence). There was no evidence of a difference between the groups in rates of repeat surgery for incontinence (RR 1.03, 95% CI 0.67 to 1.59; I2 = 0%; 13 studies, 2206 women; moderate-certainty evidence). However, more women in the mesh group required repeat surgery for the combined outcome of prolapse, stress incontinence, or mesh exposure (RR 1.56, 95% CI 1.07 to 2.26; I2 = 54%; 27 studies, 3916 women; low-certainty evidence). This suggests that if 7.1% of women require repeat surgery after native tissue repair, between 7.6% and 16% will require repeat surgery after permanent mesh repair. The rate of mesh exposure was 11.8% and surgery for mesh exposure was 6.1% in women who had mesh repairs. Recurrent prolapse on examination was less likely after mesh repair (RR 0.42, 95% CI 0.32 to 0.55; I2 = 84%; 25 studies, 3680 women; very low-certainty evidence). Permanent transvaginal mesh was associated with higher rates of de novo stress incontinence (RR 1.50, 95% CI 1.19 to 1.88; I2 = 0%; 17 studies, 2001 women; moderate-certainty evidence) and bladder injury (RR 3.67, 95% CI 1.63 to 8.28; I2 = 0%; 14 studies, 1997 women; moderate-certainty evidence). There was no evidence of a difference between the groups in rates of de novo dyspareunia (RR 1.22, 95% CI 0.83 to 1.79; I2 = 27%; 16 studies, 1308 women; moderate-certainty evidence). There was no evidence of a difference in quality of life outcomes; however, there was substantial heterogeneity in the data. Transvaginal absorbable mesh versus native tissue repair There was no evidence of a difference between the two methods of repair at two years for the rate of awareness of prolapse (RR 1.05, 95% CI 0.77 to 1.44; 1 study, 54 women), rate of repeat surgery for prolapse (RR 0.47, 95% CI 0.09 to 2.40; 1 study, 66 women), or recurrent prolapse on examination (RR 0.53, 95% CI 0.10 to 2.70; 1 study, 66 women). The effect of either form of repair was uncertain for bladder-related outcomes, dyspareunia, and quality of life. Transvaginal biological graft versus native tissue repair There was no evidence of a difference between the groups at one to three years for the outcome awareness of prolapse (RR 1.06, 95% CI 0.73 to 1.56; I2 = 0%; 8 studies, 1374 women; moderate-certainty evidence), repeat surgery for prolapse (RR 1.15, 95% CI 0.75 to 1.77; I2 = 0%; 6 studies, 899 women; moderate-certainty evidence), and recurrent prolapse on examination (RR 0.96, 95% CI 0.71 to 1.29; I2 = 53%; 9 studies, 1278 women; low-certainty evidence). There was no evidence of a difference between the groups for dyspareunia or quality of life. Transvaginal permanent mesh versus any other permanent mesh or biological graft vaginal repair Sparse reporting of primary outcomes in both comparisons significantly limited any meaningful analysis. AUTHORS' CONCLUSIONS: While transvaginal permanent mesh is associated with lower rates of awareness of prolapse, repeat surgery for prolapse, and prolapse on examination than native tissue repair, it is also associated with higher rates of total repeat surgery (for prolapse, stress urinary incontinence, or mesh exposure), bladder injury, and de novo stress urinary incontinence. While the direction of effects and effect sizes are relatively unchanged from the 2016 version of this review, the certainty and precision of the findings have all improved with a larger sample size. In addition, the clinical relevance of these data has improved, with 10 trials reporting 3- to 10-year outcomes. The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. Data on the management of recurrent prolapse are of limited quality. Given the risk-benefit profile, we recommend that any use of permanent transvaginal mesh should be conducted under the oversight of the local ethics committee in compliance with local regulatory recommendations. Data are not supportive of absorbable meshes or biological grafts for the management of transvaginal prolapse.

Robotic Vaginal Hernia Repair for Recurrent Vaginal Prolapse Status Post-Radical Cystectomy with an Indiana Pouch.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse following a radical cystectomy is challenging to treat and recurrence of prolapse after primary repair is common owing to compromised pelvic floor support and tissue quality. Vaginal prolapse repairs are often preferred because of concern for patients' complex intraabdominal pathological conditions. However, for those with recurrent prolapse following colpocleisis, limited definitive treatment options exist. METHODS: This surgical video presents a 64-year-old G4P4 with a history of radical cystectomy with an Indiana Pouch for invasive urothelial carcinoma who presented with recurrent stage IV vaginal prolapse two years following colpocleisis. Owing to thin vaginal tissue, a sacrocolpopexy with vaginal mesh could not be performed, thus, the patient underwent robotic-assisted vaginal hernia repair with a polypropylene-reinforced ovine tissue matrix attached to Cooper's ligament and the levator ani muscles. RESULTS: The surgery was free from complications and her postoperative Pelvic Organ Prolapse Quantification examination revealed a leading vaginal tissue remnant at the level of the hymen. The patient reported overall improved health and quality of life following surgery and recovery on postoperative validated questionnaires. CONCLUSIONS: Vaginal and pelvic floor hernia repair with a polypropylene-reinforced tissue matrix is a feasible definitive surgical treatment for patients with prior radical cystectomy in whom colpocleisis has failed.

Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes. DATA SOURCES: PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared. METHODS OF STUDY SELECTION: In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39). CONCLUSION: Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022326255.

Uterine horn intussusception in immediate post-partum in a Pomeranian Spitz dog.

A 2-year-old Pomeranian-Spitz dog (5.8 kg) was admitted with symptoms of uterine prolapse and lethargy 1 day after whelping three puppies. The prolapsed uterus was corrected, but the next day, prolapse reoccurred. To fix the cervix to the abdominal wall, the dog underwent a surgery operation where intussusception in the left horn of the uterus was found. Ovariohysterectomy was performed as the treatment of choice. The diagnosis of intussusception is challenging, and exploratory laparotomy is the reliable diagnostic approach. Although uterine intussusception is rare, it should be one of the important considerations in dogs within the post-partum period.

A case report of vaginal delivery in the second trimester of severe uterine prolapse complicated with cervical incarceration.

BACKGROUND: Uterine prolapse is a rare complication of pregnancy, and there is still no consensus on the choice of delivery method. METHODS: The patient's reproductive history included an abortion and eutocic delivery of a girl weighing 3200 g; the current pregnancy was the third pregnancy. Her cervical region was outside the vaginal opening and was red in color, with evident enlargement (6 × 4 cm) and a broken surface. The cervical area also showed white discharge. According to her Transvaginal ultrasonography revealed a fetus in the uterine cavity at approximately 19 weeks of gestation. Gynecological examination revealed prolapse of both the anterior and posterior vaginal walls. Evaluation of the pelvic organ prolapse-Q scores showed that the patient had uterine prolapse at stage IV. RESULTS: Vaginal delivery was performed smoothly after oral administration mifepristone and misoprostol tablets for a few days, obtaining a dead female fetus in cephalic, 25 cm in length. The cervix of the pregnant woman did not prolapse during the delivery. CONCLUSION: For pregnancy with uterine prolapse and cervical incarceration, transvaginal delivery is a potential treatment option. Maintenance of cervical retraction and oral mifepristone administration with misoprostol tablets is crucial during this delivery. This treatment can minimize the risk of cervical lacerations and uterine rupture, helping surgeons to complete the operation successfully.

What Is Uterine Prolapse?

This JAMA Patient Page describes the condition of uterine prolapse and its risk factors, symptoms, and treatment options.

Comparison of outcomes between preservation or division of the uterine round ligament in laparoscopic groin hernia repair in females: a meta-analysis and trial sequential analysis.

PURPOSE: The purpose of this study was to perform a meta-analysis comparing the short-term and long-term outcomes in laparoscopic groin hernia repair with or without preservation of the uterine round ligament (URL) in females. METHODS: We searched several databases including PubMed, Web of Science, Cochrane Library, and and CNKI databases. This meta-analysis included randomized clinical trials, and retrospective comparative studies regarding preservation or division of the URL in laparoscopic groin hernia repair in females. Outcomes of interest were age, BMI, type of hernia, type of surgery, operating time, estimated blood loss, time of hospitalization, seroma, concomitant injury, mesh infection, recurrence, uterine prolapse, foreign body sensation, chronic pain, and pregnancy. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3 and TSA software, respectively. RESULTS: Of 192 potentially eligible articles, 9 studies with 1104 participants met the eligibility criteria and were included in the meta-analysis. There were no significant difference in age (MD-6.58, 95% CI - 13.41 to 0.24; P = 0.06), BMI (MD 0.05, 95%CI - 0.31 to 0.40; P = 0.81), blood loss (MD-0.04, 95% CI - 0.75 to 0.66; P = 0.90), time of hospitalization (MD-0.22, 95% CI-1.13 to 0.69; P = 0.64), seroma (OR 0.71, 95% CI 0.41 to 1.24; P = 0.23), concomitant injury (OR 0.32, 95% CI 0.01 to 8.24; P = 0.68), mesh infection (OR 0.13, 95% CI 0.01 to 2.61; P = 0.18), recurrence (OR 1.13, 95% CI 0.18 to 7.25; P = 0.90), uterine prolapse(OR 0.71, 95% CI 0.07 to 6.94; P = 0.77), foreign body sensation (OR 1.95, 95% CI 0.53 to 7.23; P = 0.32) and chronic pain(OR 1.03 95% CI 0.4 to 2.69; P = 0.95). However, this meta-analysis demonstrated a statistically significant difference in operating time (MD 6.62, 95% CI 2.20 to 11.04; P = 0.0003) between the preservation group and division group. Trial sequential analysis showed that the cumulative Z value of the operating time crossed the traditional boundary value and the TSA boundary value in the third study, and the cumulative sample size had reached the required information size (RIS), indicating that the current conclusion was stable. CONCLUSION: In summary, laparoscopic groin hernia repair in women with the preservation of the round uterine ligament requires a longer operating time, but there was no advantage in short-term or long-term complications, and there was no clear evidence on whether it causes infertility and uterine prolapse.

Effect of different surgical techniques on postoperative wound infection in patients with uterine prolapse: A meta-analysis.

The assumption is that a number of controlled trials have been conducted to assess the impact of uterus retaining or hysterectomy on wound and haemorrhage, but there is no indication as to which method would be more beneficial for wound healing. This research is intended to provide a comprehensive overview of the availability of wound healing in case studies of both operative methods. From inception to October 2023, four databases were reviewed. The odds ratio (OR) and the mean difference (MD) for both groups were computed with a random effect model, as well as the corresponding 95% confidence intervals. A total of five studies were carried out in the overall design and enrolled 16 972 patients. No statistical significance was found in the rate of postoperative wound infection among the two treatments (OR,1.46; 95% CI,0.66,3.22 p = 0.35); The rates of bleeding after surgery did not differ significantly from one procedure to another (OR,1.41; 95% CI,0.91,2.17 p = 0.12); two studies demonstrated no statistical significance for the rate of incisional hernia after surgery (OR,2.58; 95% CI,0.37,18.05 p = 0.34). Our findings indicate that there is a similar risk between uterine preservation and hysterectomies for the incidence of wound infection, haemorrhage and protrusion of incision.

Determinants of Dissatisfaction After Laparoscopic Cure of Vaginal and/or Rectal Prolapse using Mesh: a Comprehensive Retrospective Cohort Study.

INTRODUCTION AND HYPOTHESIS: The primary objective is to identify determinants of dissatisfaction after surgical treatment of vaginal prolapse ± rectal prolapse, using laparoscopic mesh sacrohysteropexy (LSH) or sacrocolpopexy (LSC) ± ventral mesh rectopexy (VMR). The secondary objective is the evaluation of complications and objective/subjective recurrence rates. METHODS: The study performed was a single-surgeon retrospective review of prospectively collected data. LSH/LSC ± VMR were performed between July 2005 and September 2022. Primary investigated outcome was patients' satisfaction, assessed using the Patient Global Impression of Improvement (PGI-I) score and the bother visual analog scale (VAS) obtained postoperatively (at a 1-month interval and on a 6-month/yearly basis thereafter). We looked for a correlation between the level of satisfaction (as reflected by the VAS) and potential determinants. RESULTS: There were 355 patients with a mean age of 62 ±12 years. Nearly all the patients (94.3%) had a stage 3 or 4 prolapse according to the POP-Q classification. The mean postoperative bother VAS was 1.8, with only 12.7% of patients reporting a bother VAS score ≥ 3/10, indicating a dissatisfaction. PGI-I showed improvement in the vast majority of patients (96.4% scoring 1 to 3). Patients with anal incontinence preoperatively scored higher on the bother VAS postoperatively (r=0.175, p < 0.05). The use of a posterior arm mesh (for posterior vaginal prolapse) correlated with better satisfaction overall (r= -0.178, p = 0.001), whereas the performance of VMR was associated with a bothering sensation (r = 0.232, p < 0.001). A regression analysis confirmed the impact of posterior mesh and VMR on satisfaction levels, with odds of dissatisfaction being 2.18 higher when VMR was combined with LSH/LSC. CONCLUSIONS: Posterior mesh use improves patient satisfaction when the posterior compartment is affected. In patients with concomitant vaginal and rectal prolapse, combining VMR with anterior LSC/LSH appears to negatively impact patients' satisfaction. Preoperative anal incontinence was demonstrated to be a risk factor for postoperative dissatisfaction.

Vaginal hysteropexy compared with vaginal hysterectomy with apical suspension for the treatment of pelvic organ prolapse: A 5-year cost-effectiveness Markov model.

OBJECTIVE: Our objective was to perform a 5-year cost-effectiveness analysis of transvaginal hysteropexy (HP) via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) versus vaginal hysterectomy (VH) with apical suspension via sacrospinous ligament fixation (SS) or uterosacral ligament suspension (US) for the treatment of uterine prolapse. DESIGN: A decision analytic model assessed the cost-effectiveness of the surgical intervention over a 5-year horizon. SETTING: This model was constructed using TreeAge® software. POPULATION OR SAMPLE: Healthy women undergoing surgery for uterine prolapse were modeled. METHODS: A Markov model was constructed to simulate the possible recurrence of prolapse. Recurrence rates, repeat surgery for surgical failures and complication rates were modeled. Base case, sensitivity analyses and probabilistic modeling were performed. MAIN OUTCOME MEASURES: The primary outcome was the incremental cost-effectiveness ratio (ICER) of <$100 000 per quality-adjusted life year (QALY). RESULTS: Using the available prolapse recurrence rates and repeat surgery rates in the literature, both HP-SS and HP-US are cost-effective at a willingness-to-pay (WTP) threshold of <$100 000 per QALY. The incremental cost-effectiveness ratio (ICER) for HP-US compared to HP-SS is $90 738.14, while VH-US and VH-SS are both dominated strategies. HP-US is the optimal cost-effective strategy but decays exponentially with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. The cost-effectiveness acceptability curve (CEAC) favors sacrospinous hysteropexy until reaching a WTP threshold between $90 000 and $100 000. CONCLUSION: Hysteropexy surgical strategies are cost-effective transvaginal surgical approaches for uterine prolapse. Vaginal hysterectomy with apical suspension becomes more cost-effective with increasing probability of prolapse recurrence and need for repeat surgery after failed hysteropexy. Given the variability of prolapse recurrence rates in the literature, more comparative studies are needed to understand the cost-effectiveness relationship between these different surgical approaches.

Vaginal morphology and position associated with prolapse recurrence after vaginal surgery: A secondary analysis of the DEMAND study.

OBJECTIVE: To identify vaginal morphology and position factors associated with prolapse recurrence following vaginal surgery. DESIGN: Secondary analysis of magnetic resonance images (MRI) of the Defining Mechanisms of Anterior Vaginal Wall Descent cross-sectional study. SETTING: Eight clinical sites in the US Pelvic Floor Disorders Network. POPULATION OR SAMPLE: Women who underwent vaginal mesh hysteropexy (hysteropexy) with sacrospinous fixation or vaginal hysterectomy with uterosacral ligament suspension (hysterectomy) for uterovaginal prolapse between April 2013 and February 2015. METHODS: The MRI (rest, strain) obtained 30-42 months after surgery, or earlier for participants with recurrence who desired reoperation before 30 months, were analysed. MRI-based prolapse recurrence was defined as prolapse beyond the hymen at strain on MRI. Vaginal segmentations (at rest) were used to create three-dimensional models placed in a morphometry algorithm to quantify and compare vaginal morphology (angulation, dimensions) and position. MAIN OUTCOME MEASURES: Vaginal angulation (upper, lower and upper-lower vaginal angles in the sagittal and coronal plane), dimensions (length, maximum transverse width, surface area, volume) and position (apex, mid-vagina) at rest. RESULTS: Of the 82 women analysed, 12/41 (29%) in the hysteropexy group and 22/41 (54%) in the hysterectomy group had prolapse recurrence. After hysteropexy, women with recurrence had a more laterally deviated upper vagina (p = 0.02) at rest than women with successful surgery. After hysterectomy, women with recurrence had a more inferiorly (lower) positioned vaginal apex (p = 0.01) and mid-vagina (p = 0.01) at rest than women with successful surgery. CONCLUSIONS: Vaginal angulation and position were associated with prolapse recurrence and suggestive of vaginal support mechanisms related to surgical technique and potential unaddressed anatomical defects. Future prospective studies in women before and after prolapse surgery may distinguish these two factors.

Characteristics Associated With Surgical Failure After Native Tissue Apical Prolapse Repair.

OBJECTIVE: To identify clinical and demographic characteristics associated with prolapse recurrence by 12 months after native tissue transvaginal repair. METHODS: This was a planned secondary analysis of a randomized trial including postmenopausal participants with stage 2 or greater apical or anterior vaginal prolapse scheduled for surgical repair at three U.S. sites. Participants underwent vaginal hysterectomy (if uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The intervention was perioperative (5 weeks or more preoperatively and 12 months postoperatively) vaginal estrogen compared with placebo cream. The primary outcome was time to failure by 12 months after surgery, defined by objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, symptomatic vaginal bulge, or retreatment. For this analysis, participants were grouped according to failure compared with success, and multiple factors were compared, including age, time since menopause, race and ethnicity, parity, body mass index (BMI), baseline genital hiatus measurement, prolapse stage and point of maximal prolapse, surgery type (uterosacral or sacrospinous ligament suspension), and concomitant procedures. Factors were assessed for association with the hazard of surgical failure using Cox proportional hazards models, adjusted for site and treatment group. Factors with P <.50 from this analysis were considered for inclusion in the final multivariable model; site and treatment group were kept in this model. RESULTS: One hundred eighty-six participants underwent surgery; 183 provided complete data. There were 30 failures (16.4%) and 153 successes (83.4%) at 12 months. On bivariate analysis, failure was associated with decreasing age, shorter duration since menopause, Latina ethnicity, and greater baseline genital hiatus. In the final multivariable model, which included age, BMI, and point of maximal prolapse, only age remained significantly associated with surgical failure (adjusted hazard ratio [per year] 0.92, 95% CI, 0.86-0.98, P =.016). CONCLUSION: Among postmenopausal women, younger age was associated with increased frequency of prolapse recurrence by 12 months after native tissue repair. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT02431897.

Maintaining the apex: a novel technique for vault suspension during vaginal hysterectomy.

INTRODUCTION AND HYPOTHESIS: Post-hysterectomy vault prolapse poses significant challenges to patients and surgeons alike. Despite numerous surgical interventions during initial vaginal hysterectomy to counteract this, a comparative analysis of their efficacy is limited. This study introduces a pioneering technique intended to avert vault prolapse during vaginal hysterectomy by harmoniously merging level 1 and level 2 support. METHODS: After obtaining informed consent, we recorded a variation of the McCall technique performed during vaginal hysterectomy and anterior repair. Patient follow-ups were conducted up to 6 months post-operation to evaluate anatomical outcomes and quality of life. RESULTS: A total of 46 women underwent the surgery. Anatomical evaluations at the 6-month mark were commendable, with no recurrence instances. Quality-of-life assessments, using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12), showcased substantial improvement. CONCLUSION: Our novel approach to vault suspension provides an uncomplicated, easily impartible, surgical procedure utilizing standard sutures. We believe that this approach is both enduring and safe.

Indigo carmine dye for detecting urinary track damage during vaginal surgery.

OBJECTIVE: Unrecognized ureteral and bladder injury increase morbidity and mortality in gynecologic surgery. The primary objective of this study is to analyze the efficiency of a systematic intra-venous (IV) injection of carmine indigo to detect bladder injury in gynecologic vaginal surgery for benign disease. The secondary objective is to analyze the cost and use of carmine indigo. STUDY DESIGN: A retrospective, monocentric study was conducted in a tertiary hospital between January 2018 and October 2021. All patients undergoing a vaginal surgery of hysterectomy for benign disease or anterior prolapse were systematically included. Patients can be systematically included by the automatic coding of surgery. After anesthesia, during the patient's installation, an intravenous injection of 5 mL of intravenous indigo carmine (Carmyne®) diluted in 100 mL of physiological serum was systematically administered by the anesthesia team. Intraoperative cystoscopy was performed only in cases of suspected associated ureteral injury. RESULTS: We recorded 443 vaginal hysterectomies for benign disease and 95 vaginal anterior prolapse surgeries. There were 6 (1,4%) bladder injuries during vaginal hysterectomies and 1 (1,1%) bladder injury during vaginal prolapse surgery. All bladder injuries were diagnosed intraoperatively. No ureteral injury was diagnosed in this series of patients. No complication related to IV indigo carmine injection was found. In this tertiary hospital, 1085 ampoules of carmine indigo were ordered during the same period, approximatively 270 per year. The total cost to the gynecology and obstetrics department was 19,600 euros, or about 4,900 euros per year. Half of the carmine indigo was used in vaginal surgery and half in laparotomy, caesarean section and endometriosis surgery for suspected bladder or ureteral injury.