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Evaluatıon of the effectıveness of laparoscopıc pectopexy ın advanced stage apıcal prolapse
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To compare the clinical efficacy of laparoscopic pectopexy and laparoscopic high uterosacral ligament suspension in women suffering from apical prolapse. The clinical data of 170 patients with apical prolapse (POP-Q score ≥ II) treated in the Third Affiliated Hospital of Zhengzhou University from January 2018 to July 2020 were retrospectively analyzed to assess the clinical efficacy of three surgical methods [laparoscopic pectopexy with uterine preservation, laparoscopic pectopexy with hysterectomy, laparoscopic high uterosacral ligament suspension (LHUSLS) with hysterectomy]. Patients were divided into three groups depending on Surgical methods: laparoscopic uterine pectopexy group (n = 23), laparoscopic pectopexy with hysterectomy group (n = 78) and LHUSLS with hysterectomy group (n = 69). The POP-Q points before and after operation were analyzed. The operation-related indices, perioperative periods and post-operative complications were compared. 1. The operation time of laparoscopic uterine pectopexy group was the shortest (p < 0.05). There was no significant difference in the incidence of apical prolapse and new stress urinary incontinence among the three groups during the follow-up period (p > 0.05). 2. The POP-Q points (Aa, Ba, C) in the three groups were better than those before operation (p < 0.05). Laparoscopic pectopexy with hysterectomy group had better Ap, Bp and C points and a longer TVL than LHUSLS with hysterectomy group (p < 0.05). 3. The postoperative PFDI-20, PFIQ-7 and PISQ-12 scores of the three groups were significantly improved than those before operation (p < 0.05). The PISQ-12 scores in laparoscopic uterine pectopexy group were significantly higher than that in the other two groups one year after operation (p < 0.05). The study concludes that laparoscopic pectopexy and LHUSLS can significantly improve the quality of life and sexual function for patients with apical prolapse. One year after operation, laparoscopic pectopexy has a more satisfactory anatomical reduction than LHUSLS with hysterectomy. The laparoscopic uterine pectopexy group had lower postoperative complications and better sexual function than that with hysterectomy group. Laparoscopic pectopexy should be used for the treatment of apical prolapse (POP-Q score ≥ II) patients who aim to better clinical efficacy and sexual function improvement.
Background:
Laparoscopic pectopexy is an alternative to sacrocolpopexy that was first reported in 2010. This procedure has been performed at our hospital since 2019 in patients with contraindications to sacrocolpopexy.
Objective:
This study aimed to compare the outcomes of 50 cases of pectopexy with historical outcomes data for sacrocolpopexy.
Study design:
This was a retrospective review of 50 laparoscopic pectopexies performed from July 2020 to July 2022 at an academic tertiary referral center; this was the second reported use of this technique in North America. The outcomes from laparoscopic pectopexy were compared with laparoscopic sacrocolpopexy performed at the same institution by the same surgeons (n=207). The primary outcomes were complication rate, rate of recurrent prolapse (stage II or greater), and reoperation.
Results:
Overall complication rates were 6.0% for pectopexy and 16.5% for sacrocolpopexy (relative risk, 0.79; P=.65). Recurrent prolapse was seen among 2.0% of patients who underwent pectopexy and 6.3% of patients who underwent sacrocolpopexy at most recent follow-up (relative risk, 1.27; P=.66). The rates of reoperation were 2.0% for pectopexy and 3.9% for sacrocolpopexy (relative risk, 1.04; P=.96). The average operative times were 138 minutes for pectopexy and 158 minutes for sacrocolpopexy. The average lengths of follow-up were 88.1 days for pectopexy and 325.5 for sacrocolpopexy.
Conclusion:
Although pectopexy was typically employed in patients with extensive pelvic adhesions or other conditions that placed them at higher risk of complications, both the success rate and the adverse event rate were similar to those in the historical cohort who underwent sacrocolpopexy. Although sacrocolpopexy remains the gold standard operation for apical prolapse, our data suggest that pectopexy can be employed to offer similar outcomes in many patients with contraindications to sacral fixation. These data give us increasing confidence that we can counsel our patients that this operation is likely to produce an outcome similar to a sacrocolpopexy.
Objective:
Apical prolapse constitutes an important part of pelvic organ prolapse. In this study, our aim was to investigate the effectiveness of laparoscopic pectopexy that we made by preserving the uterus in the surgical treatment of apical prolapse.
Methods:
A total of 36 patients with apical prolapse who wanted to preserve their uterus underwent laparoscopic rectopexy. Apical prolapse and sexual function of the patients were evaluated preoperatively and 12 months after surgery using the Pelvic Organ Prolapse Quantification (POP-Q) scale and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) sexual questionnaire form. Preoperative medical records and postoperative clinical results were recorded.
Results:
There were no intraoperative or postoperative complications in the patients who underwent laparoscopic pectopexy. The average duration of surgery was 48.7 ± 9.8 min. Two patients had a recurrence of apical prolapse. In the Aa, Ba, C, and D points in the POP-Q staging, significant changes were observed. Postoperative PISQ-12 scores improved significantly (p < 0.05).
Conclusion:
Uterine-preserving laparoscopic pectopexy is a safe, feasible, and effective method for treating pelvic organ prolapse. It also improved the PISQ-12 and POP-Q scores in POP patients. Laparoscopic pectopexy may increase a surgeon's technical perspective for pelvic organ prolapse surgery.
Pelvic organ prolapse affects 30–50% of the female population. For definitive treatment surgery is unavoidable. Sacrocolpopexy has been the gold standard for anatomical correction of pelvic organ prolapse since the 1990s. Recently, pectopexy has been introduced as a new surgical procedure to correct apical prolapse. We have translated the laparoscopic pectopexy into a robotic procedure. The charts of the first 30 consecutive patients who underwent robotic pectopexy at the department for robotic and pelvic floor surgery were reviewed. All patients were analyzed for estimated blood loss, operation time, as well as complications. Treatment success was evaluated after 3–6 months using a composite endpoint including anatomical and subjective components. Of the 30 patients analyzed, 18 underwent hysteropectopexy (n = 18), 6 patients underwent vaginopectopexy and 6 patients underwent cervicopectopexy. Additional procedures were performed in 14 patients, and this influenced operation time and intraoperative blood loss. No intraoperative complications were noted and no conversions were necessary. Treatment success according to the primary composite endpoint was achieved in 30 (100%) patients. Furthermore, neither de novo urgency nor obstructive bowel symptoms were noted in any of the patients treated with robotic pectopexy. Similar to SCP, pectopexy is designed for prolapse repair. The robotic technique for pectopexy capitalizes on the advantages of robotic surgery as compared to conventional laparoscopy since it allows for anatomical preparation and simplification of applying sutures and mesh material, reducing operating time and minimizing surgical trauma. The technique is safe, and anatomical outcomes are excellent.
Objective: We sought to compare the surgical outcomes, safety, effectiveness, and mid-term outcomes in patients who had undergone laparoscopic hysterosacropexy and laparoscopic pectopexy due to apical prolapse.
Materials and Methods: This prospective randomized study was conducted on a total of 62 women who underwent apical prolapse surgery (32 undergoing a pectopexy and 30 undergoing a sacrohysteropexy) between June 2015 and June 2017. Patients with symptomatic uterine or vaginal vault prolapse with stage 2 or worse were included in the sudy. Before and after the operation, we used the Pelvic Organ Prolapse Quantification System (POP-Q) and questionnaires, which are the Prolapse Quality of Life Questionnaire (P-QOL) and Female Sexual Function Index (FSFI), to evaluated cases. Baseline characteristics, perioperative and postoperative complications, and follow-up results at 12 months were also evaluated.
Results: All domains of POP-Q, P-QOL, and FSFI scores improved significantly after surgery both in pectopexy and sacrohysteropexy group. The postoperative complications of both procedures were similar except for constipation after surgery (3.2% in the pectopexy group and 20% in the hysterosacropexy group [P = 0.036]).
Conclusion: Both sacrohysteropexy and pectopexy are effective surgical options for apical prolapse patients. The pectopexy is an acceptable alternative to laparoscopic sacrohysteropexy because of its less complexity and not reducing pelvic space for the rectum to exist. We suggest that the laparoscopic pectopexy may be widely used in clinical routine.
Pelvic organ prolapse (POP) is the herniation or bulging of the pelvic organs to or beyond the vaginal introitus. POP is a common condition affecting more than half of parous women. We recently performed POP surgery and repair in 37 patients using laparoscopic pectopexy, a new technique for apical prolapse surgery, in women with advanced POP. The surgery was performed by a single surgeon at a single institute. The methods of operation were divided into total laparoscopic hysterectomy with pectopexy, supracervical hysterectomy with pectopexy or pectopexy alone, with additional anterior or posterior colporrhaphy selectively performed. All patients were analyzed in terms of age, body mass index, parity, estimated blood loss (EBL), operation time, intraoperative complications, and postoperative complications. The patients were followed up for at least 6 months after surgery, and the short-term clinical outcomes were analyzed. All operations were performed successfully and without severe intraoperative or postoperative complications. The mean EBL was 84 mL, and the mean operation time was 121 minutes. The operation satisfaction rates were high in most patients. All patients had no recurrence of apical prolapse, de novo urgency, frequency, incontinence, de novo constipation, or ileus. In our experience, laparoscopic pectopexy is a feasible method for apical prolapse repair as it does not have severe intraoperative or postoperative complications and de novo gastrointestinal complications. Considerable follow-up period for possible postoperative events is warranted.
Objective:
To investigate differences in perioperative complications and short-term outcomes of patients who underwent abdominal sacrocolpopexy / sacrohysteropexy, laparoscopic sa-crocolpopexy / sacrohysteropexy, or laparoscopic pectopexy due to apical prolapse.
Materials and methods:
A retrospective cohort study was performed on 110 patients who underwent apical prolapse surgery between January 1, 2011, and July 31, 2017. Only symp-tomatic uterine or vaginal vault prolapse patients with stage 2-4, according to the pelvic organ prolapse quantification system, were included. Baseline and intraoperative variables of groups; perioperative complications, including hemorrhage, urinary, and wound complications, blood transfusion, ileus, and short-term outcomes were compared.
Results:
A total of 68 abdominal sacrocolpopexies (44 sacrocolpopexies and 24 sa-crohysteropexies), 14 laparoscopic sacrocolpopexies (10 sacrocolpopexies and 4 sa-crohysteropexies), and 28 laparoscopic pectopexies (16 pectopexies and 12 pectohys-teropexies) were analyzed. Baseline characteristics and intraoperative variables were similar. However, the mean operating time was significantly shorter in the laparoscopic pectopexy group (74.9 min) when compared with that of the other groups (p < 0.01). During the six-month follow-up period, no prolapse recurrence and mesh erosion / exposure were observed in any group. De-novo stress urinary incontinence, urgency, and defecation problems, as well as perioperative complication rates, were not statistically significantly different between the groups.
Conclusions:
Although the complication rates and short-term outcomes were not significantly different between the groups, minimally invasive approaches were associated with reduced procedural-related morbidity. Laparoscopic pectopexy is a promising endoscopic prolapse surgery and can be an alternative technique to sacrocolpopexy.
Purpose:
The purpose of the study was to compare the outcome of laparoscopic sacral colpocervicopexy with laparoscopic pectopexy. Our aim was to show that the safety and effectiveness of the new technique is similar to the traditional technique. We expected differences regarding defecation disorders.
Patients and methods:
We randomly assigned patients to two treatment groups: 44 in the pectopexy and 41 in the sacropexy group. If necessary, the operative procedures were planned in a so-called multicompartment setting regarding the different pelvic floor disorders. All defects were managed at the same time. Eighty-one patients were examined 12 to 37 months after treatment (mean follow-up 20.67 months).
Results:
The long-term follow-up (21.8 months for pectopexy and 19.5 months for sacropexy) showed a clear difference regarding de novo defecation disorders (0% in the pectopexy vs 19.5% in the sacropexy group). The incidence of de novo stress urinary incontinence was 4.8% (pectopexy) vs 4.9% (sacropexy). The incidence of rectoceles (9.5% vs 9.8%) was similar in both groups. No de novo lateral defect cystoceles were found after pectopexy, whereas 12.5% were found after sacropexy. The apical descensus relapse rates, 2.3% for pectopexy vs 9.8% for sacropexy, were not statistically significant. The occurrence of de novo anterior defect cystoceles and rectoceles revealed no significant differences.
Conclusion:
Laparoscopic pectopexy is a novel method of vaginal prolapse therapy that offers clear practical advantages compared with laparoscopic sacropexy. Because laparoscopic pectopexy does not reduce the pelvic space, it results in a zero percentage of defecation disorders.
To develop a simple, valid, reliable questionnaire to assess the severity of symptoms and their impact on the quality of life in women with urogenital prolapse. Women recruited from gynaecology outpatient clinics were asked to complete a prolapse quality of life questionnaire (P-QOL) before their hospital visit. At the time of the visit, they were examined supine using the International Continence Society (ICS) prolapse score (POP-Q). A second P-QOL was posted and completed by patients 2 weeks later. The validity was assessed by measuring levels of missing data, comparing symptom scores between affected and asymptomatic women and comparing symptom scores with objective prolapse stages. The internal reliability was assessed by measuring the Cronbach alpha coefficient; 155 symptomatic and 80 asymptomatic women were studied. Severity according to P-QOL strongly correlated with the vaginal examination findings (p < 0.01, rho > 0.5). The total scores for each P-QOL domain were significantly different between symptomatic and asymptomatic women (p < 0.001). All items achieved a Cronbach alpha greater than 0.80 showing good inter-rater reliability. The test-retest reliability confirmed a highly significant correlation between the total scores for each domain. A P-QOL questionnaire for English-speaking patients has been developed which is reliable and valid.
To validate the Turkish translated version of the prolapse quality of life questionnaire (P-QOL).
After establishing the test-retest reliability and internal consistency in a pilot study, 310 patients were enrolled in the study and general and subscale scores of the questionnaires were calculated. All participants underwent the International Continence Society (ICS) prolapse score (POP-Q).
One hundred and forty-five (49.7%) women were symptomatic and 147 (50.3%) were asymptomatic. The level of missing data ranged from 0 to 2.2%. For the test-retest reliability, Spearman's rho was from 0.91 to 1.00 for all domains (p<0.001). The severity of P-QOL was strongly correlated with the vaginal examination findings among the symptomatic group (p<0.001). Items correlated with the objective vaginal examination findings. The total and domain scores for P-QOL of symptomatic and asymptomatic women were found to be statistically significant (p<0.001).
The Turkish translated version of the P-QOL is reliable, consistent and valid instrument for assessing symptom severity, impact on quality of life in women with uterovaginal prolapse. It is easy to understand may be easily administered and self-completed by the women.
Background:
Apical vaginal prolapse is the descent of the uterus or vaginal vault (post-hysterectomy). Various surgical treatments are available, but there are no guidelines to recommend which is the best.
Objectives:
To evaluate the safety and efficacy of any surgical intervention compared to another intervention for the management of apical vaginal prolapse.
Search methods:
We searched the Cochrane Incontinence Group's Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings and ClinicalTrials.gov (searched 14 March 2022).
Selection criteria:
We included randomised controlled trials (RCTs).
Data collection and analysis:
We used Cochrane methods. Our primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse (any site).
Main results:
We included 59 RCTs (6705 women) comparing surgical procedures for apical vaginal prolapse. Evidence certainty ranged from very low to moderate. Limitations included imprecision, poor methodology, and inconsistency. Vaginal procedures compared to sacral colpopexy for vault prolapse (seven RCTs, n=613; six months to f four-year review) Awareness of prolapse was more common after vaginal procedures (risk ratio (RR) 2.31, 95% confidence interval (CI) 1.27 to 4.21, 4 RCTs, n = 346, I2 = 0%, moderate-certainty evidence). If 8% of women are aware of prolapse after sacral colpopexy, 18% (10% to 32%) are likely to be aware after vaginal procedures. Surgery for recurrent prolapse was more common after vaginal procedures (RR 2.33, 95% CI 1.34 to 4.04; 6 RCTs, n = 497, I2 = 0%, moderate-certainty evidence). The confidence interval suggests that if 6% of women require repeat prolapse surgery after sacral colpopexy, 14% (8% to 25%) are likely to require it after vaginal procedures. Prolapse on examination is probably more common after vaginal procedures (RR 1.87, 95% CI 1.32 to 2.65; 5 RCTs, n = 422; I2 = 24%, moderate-certainty evidence). If 18% of women have recurrent prolapse after sacral colpopexy, between 23% and 47% are likely to do so after vaginal procedures. Other outcomes: Stress urinary incontinence (SUI) was more common after vaginal procedures (RR 1.86, 95% CI 1.17 to 2.94; 3 RCTs, n = 263; I2 = 0%, moderate-certainty evidence). The effect of vaginal procedures on dyspareunia was uncertain (RR 3.44, 95% CI 0.61 to 19.53; 3 RCTs, n = 106, I2 = 65%, low-certainty evidence). Vaginal hysterectomy compared to sacral hysteropexy/cervicopexy (six RCTS, 554 women, one to seven year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.01 95% CI 0.10 to 9.98; 2 RCTs, n = 200, very low-certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 0.85, 95% CI 0.47 to 1.54; 5 RCTs, n = 403; I2 = 9%, low-certainty evidence). Prolapse on examination- there was little or no difference between the groups for this outcome (RR 0.78, 95% CI 0.54 to 1.11; 2 RCTs n = 230; I2 = 9%, moderate-certainty evidence). Vaginal hysteropexy compared to sacral hysteropexy/cervicopexy (two RCTs, n = 388, 1-four-year review) Awareness of prolapse - No difference between the groups for this outcome (RR 0.55 95% CI 0.21 to 1.44; 1 RCT n = 257, low-certainty evidence). Surgery for recurrent prolapse - No difference between the groups for this outcome (RR 1.34, 95% CI 0.52 to 3.44; 2 RCTs, n = 345; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 0.99, 95% CI 0.83 to 1.19; 2 RCTs n =367; I2 =9%, moderate-certainty evidence). Vaginal hysterectomy compared to vaginal hysteropexy (four RCTs, n = 620, 6 months to five-year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.0 95% CI 0.44 to 2.24; 2 RCTs, n = 365, I2 = 0% moderate-quality certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 1.32, 95% CI 0.67 to 2.60; 3 RCTs, n = 443; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 1.44, 95% CI 0.79 to 2.61; 2 RCTs n =361; I2 =74%, low-certainty evidence). Other outcomes: Total vaginal length (TVL) was shorter after vaginal hysterectomy (mean difference (MD) 0.89cm 95% CI 0.49 to 1.28cm shorter; 3 RCTs, n=413, low-certainty evidence). There is probably little or no difference between the groups in terms of operating time, dyspareunia and stress urinary incontinence. Other analyses There were no differences identified for any of our primary review outcomes between different types of vaginal native tissue repair (4 RCTs), comparisons of graft materials for vaginal support (3 RCTs), pectopexy versus other apical suspensions (5 RCTs), continuous versus interrupted sutures at sacral colpopexy (2 RCTs), absorbable versus permanent sutures at apical suspensions (5 RCTs) or different routes of sacral colpopexy. Laparoscopic sacral colpopexy is associated with shorter admission time than open approach (3 RCTs) and quicker operating time than robotic approach (3 RCTs). Transvaginal mesh does not confer any advantage over native tissue repair, however is associated with a 17.5% rate of mesh exposure (7 RCTs).
Authors' conclusions:
Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, and postoperative SUI than a variety of vaginal interventions. The limited evidence does not support the use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse. There were no differences in primary outcomes for different routes of sacral colpopexy. However, the laparoscopic approach is associated with a shorter operating time than robotic approach, and shorter admission than open approach. There were no significant differences between vaginal hysteropexy and vaginal hysterectomy for uterine prolapse nor between vaginal hysteropexy and abdominal hysteropexy/cervicopexy. There were no differences detected between absorbable and non absorbable sutures however, the certainty of evidence for mesh exposure and dyspareunia was low.
Study objective:
To evaluate the clinical benefits of laparoscopic pectopexy versus laparoscopic sacrocolpopexy in women with pelvic organ prolapse (POP).
Design:
Prospective cohort study.
Setting:
A tertiary hospital.
Patients:
We included 203 patients with POP.
Interventions:
Laparoscopic pectopexy or laparoscopic sacrocolpopexy.
Measurements and main results:
Anatomical effectiveness was measured using the POP-quantification (POP-Q) system, both pre- and post-operation. Functional recovery effectiveness was evaluated using complications and recurrence rates within one year. Quality of life (QOL) was assessed by the Pelvic Floor Distress Inventory-20 (PFDI-20) and Incontinence Quality of Life (I-QOL) questionnaires at enrollment and postoperative months 3, 6, and 12. Comparisons between groups were performed using t-test, Chi-square test, and mixed-effects model with repeated measures. The analysis included 203 eligible patients (sacrocolpopexy 101; pectopexy 102). The proportion of robotic-assisted surgeries was lower in the pectopexy group than in the sacrocolpopexy group (15.7% vs. 41.6%, p<0.001). The average operation time of pectopexy was shorter than that of sacrocolpopexy (174.2 vs. 187.7 mins) with a mean difference of 13.5 min (95%CI, 3.9-23.0; p=0.006). Differences of intraoperative blood loss, length of hospital stay and postoperative 7-day complications between groups were not significant. Anatomical successes were obtained in both groups with similar improvement in POP-Q scores. The rate of urinary symptoms recurrence was higher in the pectopexy group (13.7%) than in the sacrocolpexy group (5.0%) at the one-year follow-up (OR, 3.1; 95% CI, 1.1-8.8, p=0.032). The PFDI-20 and I-QOL scores were better improved at postoperative months 3, 6 and 12 for laparoscopic pectopexy than for sacrocolpopexy.
Conclusion:
Laparoscopic pectopexy revealed comparable anatomical success, shorter operation time, and better improvement in QOL scores of prolapse, colorectal-anal and urinary symptoms at 1-year follow-up, possibly being an alternative when sacrocolpopexy is not practicable. However, clinicians should pay more attention to the recurrence of urinary symptoms after pectopexy.
Background
Several authors have recently compared the outcomes and complications of surgical procedures that preserve or remove the uterus in the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Following the publication of several high quality randomized control trials on this topic we performed a new systematic review and meta analysis of this data.
Methods
We performed a systematic literature search in ClinicalTrials.gov, PubMed, Scopus, Ovid, EBSCO host, Science Direct, Web of Science, and Cochrane CENTRAL for randomized controlled and cohort trials of uterine sparing prolapse repair (hysteropexy) versus hysterectomy with suspension. A total of 1285 patients from 14 studies were included in our systematic review and meta-analysis.
Results
Uterine sparing procedures (hysteropexy) were comparable to hysterectomy with suspension for recurrence rates (RR = 0.908, 95% CI [0.385, 2.143]), reoperation rates (RR = 1.517, 95% CI [0.802, 2.868]), length of hospital stay, (SMD = − 0.159 days, 95% CI [−0.375, 0.057]), voiding dysfunction (RR = 1.089, 95% CI [0.695, 1.706]), and intraoperative blood loss (SMD = − 0.339, 95% CI [−0.631, 0.047]). However, hysteropexy had shorter operative time than hysterectomy with suspension (SMD = − 1.191 h, 95% CI [−1.836, −0.545]), and fewer visceral injuries (RR = 0.421, 95% CI [0.244, 0.725]).
Conclusion
We found no significant differences in the outcomes or major complications of uterine preserving surgical procedures versus those which include hysterectomy in the treatment of POP. Hysteropexy procedures may be associated with a shorter operative time and fewer visceral injuries. This is consistent with older analyses.
The technique of laparoscopic pectopexy was published in 2010. A subsequent randomized trial focused on pectopexy versus sacropexy revealed no new risks for patients and significant advantages in terms of operating time and de novo defecation disorders compared to sacrocolpopexy. The present international multicenter trial was performed to evaluate the applicability of the technique in clinical routine.
Material and method:
Eleven clinics and 13 surgeons in four European counties participated in the trial. To ensure a standardized approach and obtain comparable data, all surgeons followed the same rules in placing the apical tape, no further mesh was used. Data were collected for 14 months on a secured server; 501 surgeries were documented and evaluated.
Results:
Patients treated at the leading center (2 surgeons) contributed 44 % of the patient population. We made a distinction between high-volume (48-135 surgeries annually) (n = 4), intermediate-volume (28-37 surgeries annually) (n = 4), and low-volume (7-22 surgeries annually) (n = 5) surgeons. 97.3 % of the patients (n = 501) had delivered children; 5.6 % had had a Caesarian section. 29.7 % of the patients had undergone a hysterectomy. The operating time for pectopexy was less than 60 min in 79 % of cases. The procedures were completed in less than 159 min in 71 % of cases. Severe complications (n = 5) included four cases of organ damage (related to concomitant surgeries or adhesions) and one case of relevant bleeding. De novo incontinence was registered in two cases and voiding dysfunction in three. No intestinal obstruction or defecation disorder was observed. Two complicated infections were noted. Urinary infection occurred in 2 % of patients.
Conclusion:
In clinical routine severe complications occurred in 1 %. The latter were unrelated to pectopexy, but occurred due to concomitant procedures or adhesions. The overall operating time as well as the operating time for pectopexy were similar to those reported in published studies on sacrocolpopexy.
Aims:
Apical defect is a pelvic organ prolapse disorder, with 5%-15% prevalence. The aim of the study was to investigate methods of laparoscopic repair of apical defect and compare them with other techniques (open, vaginal, and robotic).
Methods:
A systematic search of the literature was conducted in MEDLINE/PubMed and ClinicalTrials.gov databases using the following key words: apical prolapse and treatment procedures. The search was limited by using the humans filters. Only articles published in English between 2010 and 2018 were considered. Two independent authors reviewed the publications for inclusion on the basis of the following criteria: (a) use of laparoscopic techniques, and (b) apical support loss as indication for surgery.
Results:
A total of 1002 papers were initially identified; 24 studies fulfilled the inclusion criteria. Four main laparoscopic procedures were found. The reported anatomical success rate (POP-Q < II stage) was 77%-100%, with patient satisfaction for pectopexy, laparoscopic sacropexy (LS), lateral ligament suspension and laparoscopic uterosacral ligament suspension (LUSLS) of 96.4%-97.6%, 71.0%-100%, 66.7%-87.8%, and 95%-95.5%, respectively. Major complications included hemorrhage, bladder, ureter, and/or bowel injuries were rare. Prolapse recurrences after LUSLS and LS were reported in 13.2% and 10.4% of patients, respectively; with reoperation rate for LS 2.2%-12.8%.
Conclusions:
Most studies reported anatomical and subjective outcomes, with follow-up ranging from 1 month to >7 years. Success rates for laparoscopic and abdominal corrections of apical defect were similar; laparoscopy was superior in terms of perioperative blood loss, length of hospital stay, and recovery.
Introduction and hypothesis
The apical compartment is a keystone in POP treatment. Sacrospinous fixation, suggested half a century ago, today is still one of the most popular and efficient methods of colpo-hysteropexy. However, it has specific side effects: chronic pain syndrome, dyspareunia and а high rate of cystocele de novo. We aimed to evaluate the efficacy and safety of unilateral sacrospinous hysteropexy with a synthetic apical sling combined with anterior subfascial colporrhaphy.
Methods
Following the suggested technique, 174 women with anterior-apical prolapse underwent surgery. The follow-up period took 12 months. Pre- and postoperative examination included: urogynecological examination (POP-Q), uroflowmetry, ultrasound of the bladder and filling in of validated questionnaires (PFDI-20, PISQ-12).
Results
The mean surgery time was 26 ± 7.84 min. No cases of damage of the bladder or rectum or of intraoperative clinically significant bleeding were noted. At the 12-month follow-up, the recurrence rate in the apical compartment was 0.7% (1/147) and in the anterior compartment 7.4% (11/147). The efficacy of the surgery reached 96.5%. During 12 months of follow-up, no cases of mesh exposure or chronic pelvic pain syndrome were detected. The incidence of dyspareunia de novo was observed in just one patient.
Conclusions
A unilateral sacrospinous fixation with a synthetic mesh (apical sling) combined with anterior subfascial colporrhaphy enhances the anatomical efficacy of surgery. It also helps to avoid specific side effects of traditional sacrospinous fixation.
Introduction and hypothesis:
This study examined the early outcomes of laparoscopic (LS) pectopexy and evaluated its effects on female sexual function and quality of life (QoL).
Methods:
Twenty-two patients with apical prolapse who underwent LS pectopexy were included. Outcomes of the procedure were noted; the Female Sexual Function (FSFI) and Prolapse Quality of Life (P-QOL) questionnaires were completed preoperatively and 6 months postoperatively.
Results:
There was no evidence of recurrent prolapse or constipation; the percentages of exacerbation of cystocele, rectocele, de novo stress urinary incontinence (SUI), and de novo urgency (UUI) were 4.5%, 9.0%, 4.5%, and 4.5%, respectively (mean follow-up 10.41 months). FSFI and P-QOL scores improved significantly (p < 0.05) postoperatively.
Conclusions:
LS pectopexy shows promising results for pelvic organ prolapse (POP) surgery with comparable outcomes. It also improved the FSFI and P-QOL scores in POP patients.
Laparoscopic sacrocolpopexy (LSC) is attracting increasing attention as a minimally invasive surgery that provides excellent therapeutic effects on apical vaginal prolapse. However, its therapeutic effects on multi-compartmental pelvic organ prolapse (POP) remain unclear. Therefore, the aim of this review was to evaluate the efficacy of LSC on multi-compartmental POP compared with abdominal sacrocolpopexy (ASC). We extracted three articles on randomized controlled trials that compared LSC and ASC. A total of 247 patients (123 for LSC, 124 for ASC) were evaluated. There was no evidence of recurrence or reoperation in either group for the apical vaginal compartment. Regarding recurrence within the anterior vaginal compartment, there were no significant between-group differences in either of the two randomized controlled trials targeting vaginal vault prolapse. In contrast, in the randomized controlled trial targeting POP including cases with uteruses, there were more recurrent POP with grade II or more in the LSC group than in the ASC group (11/60 [18.3%] vs 1/60 [1.6%], P = 0.004). Reoperation for the posterior vaginal compartment was performed in three cases (2.5%) in the LSC group and in one case (0.8%) in the ASC group. The combined repeat surgery and mesh removal surgery rate was higher in the LSC group (8/119 [6.7%]) than in the ASC group (2/121 [1.7%], P = 0.049). LSC has an excellent therapeutic effect and is comparable to ASC for the treatment of apical prolapse. However, cystocele recurrence, repeat surgery of the posterior compartment, and mesh-related complications were more frequent in patients who had undergone LSC.
Objective:
We aimed to systematically review the literature on apical pelvic organ prolapse surgery with uterine preservation compared with prolapse surgeries including hysterectomy and provide evidence-based guidelines.
Data sources:
The sources for our data were MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to January 2017.
Study eligibility criteria:
We accepted randomized and nonrandomized studies of uterine-preserving prolapse surgeries compared with those involving hysterectomy.
Study appraisal and synthesis methods:
Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality. If 3 or more studies compared the same surgeries and reported the same outcome, a meta-analysis was performed.
Results:
We screened 4467 abstracts and identified 94 eligible studies, 53 comparing uterine preservation to hysterectomy in prolapse surgery. Evidence was of moderate quality overall. Compared with hysterectomy plus mesh sacrocolpopexy, uterine preservation with sacrohysteropexy reduces mesh exposure, operative time, blood loss, and surgical cost without differences in prolapse recurrence. Compared with vaginal hysterectomy with uterosacral suspension, uterine preservation in the form of laparoscopic sacrohysteropexy improves the C point and vaginal length on the pelvic organ prolapse quantification exam, estimated blood loss, postoperative pain and functioning, and hospital stay, but open abdominal sacrohysteropexy worsens bothersome urinary symptoms, operative time, and quality of life. Transvaginal mesh hysteropexy (vs with hysterectomy) decreases mesh exposure, reoperation for mesh exposure, postoperative bleeding, and estimated blood loss and improves posterior pelvic organ prolapse quantification measurement. Transvaginal uterosacral or sacrospinous hysteropexy or the Manchester procedure compared with vaginal hysterectomy with native tissue suspension both showed improved operative time and estimated blood loss and no worsening of prolapse outcomes with uterine preservation. However, there is a significant lack of data on prolapse outcomes >3 years after surgery, the role of uterine preservation in obliterative procedures, and longer-term risk of uterine pathology after uterine preservation.
Conclusion:
Uterine-preserving prolapse surgeries improve operating time, blood loss, and risk of mesh exposure compared with similar surgical routes with concomitant hysterectomy and do not significantly change short-term prolapse outcomes. Surgeons may offer uterine preservation as an option to appropriate women who desire this choice during apical prolapse repair.
Objective:
Laparoscopic sacrocolpopexy is becoming an increasingly popular surgical approach for repair of apical vaginal prolapse. The aim of this study was to document the postoperative anterior mesh position after laparoscopic sacrocolpopexy and to investigate the relationship between mesh location and anterior compartment support.
Methods:
This was an external audit of patients who underwent laparoscopic sacrocolpopexy for apical prolapse ≥ Stage 2 or advanced prolapse ≥ Stage 3, between January 2005 and June 2012. All patients were assessed with a standardized interview, clinical assessment using the International Continence Society Pelvic Organ Prolapse quantification and four-dimensional transperineal ultrasound to evaluate pelvic organ support and mesh location. Mesh position was assessed with respect to the symphysis pubis whilst distal mesh mobility was assessed using the formula √[(XValsalva - Xrest )(2) + (YValsalva - Yrest )(2) ], where X is the horizontal distance and Y is the vertical distance between the mesh and the inferior symphyseal margin, measured at rest and on Valsalva.
Results:
Ninety-seven women were assessed at a mean follow-up of 3.01 (range, 0.13-6.87) years after laparoscopic sacrocolpopexy, 88% (85/97) of whom considered themselves to be cured or improved, and none had required reoperation. On clinical examination, prolapse recurrence in the apical compartment was not diagnosed in any patient; however, 60 (62%) had recurrence in the anterior compartment and 43 (44%) in the posterior compartment. On ultrasound examination, mesh was visualized in the anterior compartment in 60 patients. Both mesh position and mobility on Valsalva were significantly associated with recurrent cystocele on clinical and on ultrasound assessment (all P < 0.01). For every mm that the mesh was located further from the bladder neck on Valsalva, the likelihood of cystocele recurrence increased by 6-7%.
Conclusion:
At an average follow-up of 3 years, laparoscopic sacrocolpopexy was highly effective for apical support; however, cystocele recurrence was common despite an emphasis on anterior mesh extension. Prolapse recurrence seemed to be related to mesh position and mobility, suggesting that the lower the mesh is from the bladder neck, the lower the likelihood of anterior compartment prolapse recurrence. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
Purpose:
Recent studies showing a correlation between descent of the anterior and apical vaginal compartments suggest that cystoceles may recur if associated apical prolapse is not corrected. However, to date the anatomical relationship of apical prolapse with respect to cystocele has been incompletely reported. We present the predictive value of a cystocele for clinically significant vaginal apical prolapse.
Materials and methods:
We retrospectively reviewed the records of all new patient visits to a urogynecology clinic in a 30-month period. Women with a point Ba value of -1 or greater (stage 2 cystocele and above) were included in analysis. Predictive values of clinically significant apical prolapse, defined as point C -3 or greater, were calculated and stratified by cystocele stage.
Results:
A total of 385 women were included in study. Point Ba was the leading edge of prolapse in 83.9% of cases. The position of Ba strongly correlated with that of the vaginal apex (Spearman ρ = 0.769, p <0.001). Overall 59.7% of patients had a point C of -3 or greater. The finding of clinically significant apical prolapse increased significantly with increasing Ba values. Of patients with stage 2, 3 and 4 cystocele point C was -3 or greater in 42%, 85% and 100%, respectively.
Conclusions:
The finding of stage 2 or greater cystocele is highly suggestive of clinically significant apical vaginal descent to -3 or greater. Furthermore, as cystocele stage increases, the predictive value of apical prolapse also increases. Surgeons contemplating cystocele repair should have high suspicion for vaginal apical prolapse and consider concomitant repair.
Obesity is a chronic disease which affects a substantial number of patients. It also increases a person's risk of genital prolapse. Conventional techniques of prolapse repair (sacropexy, transvaginal meshes and sacrospinal fixation) are used in very adipose women, but the effectiveness of this technique is sometimes restricted due to the difficultly of performing the surgery.
Here we will describe a new method of endoscopic prolapse surgery, which is especially developed for obese patients. The lateral parts of the iliopectineal ligament are used for a bilateral mesh fixation of the descended structures. We have already used this method successfully in 12 patients without any complications.
This method provides a stable and durable repair. The laparoscopic access reduces morbidity. The operation time for this procedure is approximately 50 min.
To estimate the number of women who will have symptomatic pelvic floor disorders in the United States from 2010 to 2050.
We used population projections from the U.S. Census Bureau from 2010 to 2050 and published age-specific prevalence estimates for bothersome, symptomatic pelvic floor disorders (urinary incontinence [UI], fecal incontinence, and pelvic organ prolapse [POP]) from the 2005 National Health and Nutrition Examination Survey. We abstracted data regarding the number of women aged 20 years or older in 20-year age groups. We assumed that the age-specific prevalences for these disorders and the population distribution of risk factors remained unchanged thru 2050. We also conducted sensitivity analyses that varied both the prevalence estimates and the population projections.
The number of American women with at least one pelvic floor disorder will increase from 28.1 million in 2010 to 43.8 million in 2050. During this time period, the number of women with UI will increase 55% from 18.3 million to 28.4 million. For fecal incontinence, the number of affected women will increase 59% from 10.6 to 16.8 million, and the number of women with POP will increase 46% from 3.3 to 4.9 million. The highest projections for 2050 estimate that 58.2 million women will have at least one pelvic floor disorder, with 41.3 million with UI, 25.3 million with fecal incontinence, and 9.2 million with POP.
The prevalence of pelvic floor disorders will increase substantially given the changing demographics in the United States. This increase has important implications for public health and the field of gynecology.
III.
This article presents a standard system of terminology recently approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse and pelvic floor dysfunction. An objective site-specific system for describing, quantitating, and staging pelvic support in women is included. It has been developed to enhance both clinical and academic communication regarding individual patients and populations of patients. Clinicians and researchers caring for women with pelvic organ prolapse and pelvic floor dysfunction are encouraged to learn and use the system.
The purpose of this study was to determine whether the degree of anterior compartment (bladder) and apical compartment (cervix) prolapse are correlated, and whether 2 anterior compartment elements (urethra and bladder) are related at maximal Valsalva.
Women with a complete spectrum of pelvic support were recruited for a pelvic support study. Dynamic magnetic resonance scans were taken during Valsalva. A convenience sample of 153 women with a mean age of 53.3 +/- 12.5 (SD) years with a uterus in situ was studied. Anterior compartment status was assessed by the most caudal bladder point and the internal urinary meatus. The external cervical os was used to assess the apical compartment. The position of the bladder, urethra, and uterus were determined in 20 nulliparous women to determine their reference locations. The distances of each structure below the reference positions were calculated at maximum Valsalva.
Average distances of the bladder base, urethra, and uterus from the reference positions at maximal Valsalva were 4.1 +/- 2.4 cm, 3.1 +/- 1.3 cm, and 4.3 +/- 2.4 cm, respectively. The Pearson correlation coefficient of the relationship between the bladder base and uterine distances was r = 0.73 (r2 = 0.53). The Pearson correlation coefficient of the bladder distance and urethral distance was r = 0.82 (r2 = 0.67).
Half of the observed variation in anterior compartment support may be explained by apical support.
The objective of our study was to estimate the age-specific incidence and lifetime risk of surgically managed pelvic organ prolapse (POP) and urinary incontinence (UI). Women aged 20 and older who underwent primary surgical management of POP or UI in 1993 were identified from the database of a health maintenance organization using ICD-9 codes and confirmed through chart abstraction. From a population of 147,719 women, 135 were identified who underwent prolapse surgery only, 82 incontinence only, and 34 surgery for both conditions. From the age-specific incidence, we estimated the lifetime risk of undergoing an operation by age 80 to be 11.8%. Our findings agree with a previous estimate that approximately 11% of women will undergo surgery for POP or UI by age 80. POP and UI appear to be common problems, undoubtedly affecting an even larger proportion of the women than suggested by this high cumulative incidence of surgery.
Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity
- Hendrix