Analysis of long-term structural failure after native tissue prolapse surgery: a 3D stress MRI-based study.

INTRODUCTION AND HYPOTHESIS: We sought to identify postoperative structural failure sites associated with long-term prolapse recurrence and their association with symptoms and satisfaction. METHODS: Women who had a research MRI prior to native-tissue prolapse surgery were recruited for examination, 3D stress MRI, and questionnaires. Recurrence was defined by Pelvic Organ Prolapse Quantification System (POP-Q)Ba/Bp > 0 or C > -4. Measurements were performed at rest and maximum Valsalva ("strain") including vaginal length, apex location, urogenital hiatus (UGH), and levator hiatus (LH). Measures were compared between subjects and to women with normal support. Failure frequency was the proportion of women with measurements outside the normal range. Symptoms and satisfaction were measured using validated questionnaires. RESULTS: Thirty-one women participated 12.7 years after surgery-58% with long-term success and 42% with recurrence. Failure site comparisons between success and failure were: impaired mid-vaginal paravaginal support (62% vs. 28%, p = 0.01), longer vaginal length (54% vs. 22%, p = 0.03), and enlarged urogenital hiatus (54% vs. 22%, p = 0.03). Apical paravaginal location had the lowest failure frequency (recurrence: 15% vs. success: 7%, p = 0.37). Patient satisfaction was high (recurrence: 5.0 vs. success: 5.0, p = 0.86). Women with bothersome bulge symptoms had a 33% larger UGH strain on POP-Q (p = 0.01), 8.7% larger resting UGH (p = 0.046), 11.5% larger straining LH (p = 0.01), and 9.3% larger resting LH (p = 0.01). CONCLUSIONS: Abnormal low mid-vaginal paravaginal location (Level II), long vaginal length (Level II), and large UGH (Level III) were associated with long-term prolapse recurrence. Patient satisfaction was high and unrelated to anatomical recurrence. Bothersome bulge symptoms were associated with hiatus enlargement.

A new 3D stress MRI measurement strategy to quantify surgical correction of prolapse in three support systems.

AIMS: The aim of this study was to develop and test the feasibility of a magnetic resonance imaging (MRI)-based measurement strategy to evaluate the effectiveness of surgical procedures in restoring normal anatomy in all three systems of pelvic floor support and quantify the structural changes induced by prolapse surgery. METHODS: Patients underwent clinical examination and stress MRI preoperatively and again 3 months postoperatively. Preoperative and postoperative measures of three MRI-based structural support systems were made: (1) vaginal wall, (2) apical and paravaginal support, and (3) hiatal closure system. Preoperative to postoperative structural changes were calculated and compared to normal values, and bivariate associations were determined. RESULTS: The three structural support systems were successfully quantified for both preoperative and postoperative MRIs regardless of operative approaches in all 15 women in the pilot group. Apical support was restored to normal in 11 of 12 patients who underwent an apical suspension procedure and 9 of 14 patients with a posterior repair had normalization of genital hiatus size. Mid-vaginal paravaginal location was elevated an average of 2.5 ± 2.0 cm despite no paravaginal repairs being performed. Paravaginal location improvements were also significantly correlated with apical elevation (r values 0.99-0.87, p < 0.001). CONCLUSIONS: A strategy that quantifies structural-specific preoperative impairments and improvements after prolapse surgery was successfully developed. Early findings reveal that prolapse surgery is more successful in restoring normal anatomy at Level I than Level III. Improvement in paravaginal location is significantly correlated with apical elevation.

A 20-Centimeter Peritoneal Inclusion Cyst Presenting as Vaginal Prolapse.

This video shows the surgical excision of a 20-cm peritoneal inclusion cyst with laparoscopic repair of pelvic floor defects caused by the mass effect of the cyst. A 44-year-old woman presented with bulge symptoms and a reducible posterior prolapse extending 4 cm beyond the introitus inconsistent with an enterocele/rectocele. Dynamic MRI revealed a 20-cm cystic mass surrounding the uterine fundus extending down the posterior wall of the vagina, anterior to the rectum. Robotic-assisted laparoscopy revealed stage-IV endometriosis and a large peritoneal inclusion cyst extending from the pelvic brim to the rectovaginal septum. The cyst was mobilized through retroperitoneal dissection. Redundant peritoneum was excised down to the perineal body, and the distended posterior vaginal wall was plicated laparoscopically. The peritoneum was closed in a purse-string fashion, obliterating any potential space. Resolution of the prolapse was confirmed along with restoration of normal anatomy. We managed a unique case of a large peritoneal inclusion cyst presenting as vaginal prolapse. To correct defects after cystectomy, laparoscopic repair was performed similarly to closing an enterocele. Repair of a high posterior defect can be performed laparoscopically when working abdominally to avoid vaginal incisions, allowing for excellent visualization and access.

Ventral rectopexy with biological mesh for recurrent disorders of the posterior pelvic organ compartment.

PURPOSE: Recurrent prolapse of the posterior pelvic organ compartment presents a management challenge, with the best surgical procedure remaining unclear. We present functional outcome and patient satisfaction after laparoscopic and robotic ventral mesh rectopexy (VMR) with biological mesh in patients with recurrence. METHODS: We analyzed data from 30 patients with recurrent posterior pelvic organ prolapse who underwent VMR with biological mesh from August 2012 to January 2018. Data included patient demographics and intra- and postoperative findings; functional outcome as assessed by Cleveland Clinic Constipation Score (CCCS), Obstructed Defecation Score Longo (ODS), and Cleveland Clinic Incontinence Score (CCIS); and patient satisfaction. RESULTS: CCCS, CCIS, and ODS were significantly improved at 6-12 months postoperatively and at last follow-up. Patient satisfaction (visual analog scale [VAS] 6.7 [0 to 10]), subjective symptoms (+ 3.4 [scale - 5 to + 5]), and quality of life improvement (+ 3.0 [scale from - 5 to + 5]) were high at last follow-up. The rates of morbidity and major complications were 13% and 3%, respectively. There were no mesh-related complications or deaths. Difference in type of previous surgery (abdominal or transanal/perineal) had no significant effect on results. CONCLUSIONS: VMR with biological mesh is a safe and effective option for patients with recurrent posterior pelvic organ prolapse. It reduces functional symptoms, has a low complication rate, and promotes patient satisfaction.

Pre-operative guided imagery in female pelvic medicine and reconstructive surgery: a randomized trial.

INTRODUCTION AND HYPOTHESIS: The purpose was to determine if pre-operative guided imagery (GIM) would help women to feel more prepared, less anxious, and have higher satisfaction scores 6 weeks after surgery compared with routine care. METHODS: Eligible women planning to undergo pelvic floor surgery were enrolled and randomized. The GIM group received an institution-specific CD that uses GIM to detail day of surgery (DOS) events and expectations. Participants were asked to listen to the CD once daily during the week before surgery. At three time points (surgical consent visit, DOS, and 6-weeks post-operatively), we measured anxiety using the State and Trait Anxiety Inventory for Adults (STADI), in addition to preparedness for surgery and overall satisfaction (ten-point Likert scales). Data were analyzed in SPSS 23 using two-tailed t tests. RESULTS: A total of 38 out of 44 (86%) enrolled participants completed the study (GIM: 18, control: 20). The GIM self-reported compliance rate was 72%, with an average use of 4.8 times (range = 3-8 times). Women in the GIM group reported a significant increase from baseline in preparedness for surgery on both DOS and 6 weeks post-operatively (7.32 ± 1.81 vs 9.11 ± 1.13, p = 0.001) and (7.32 ± 1.81 vs 9.22 ± 0.81, p = 0.001) respectively; a change that was not seen in the control group. Satisfaction was high in both the GIM and the control group (9.55 ± 0.85 and 9.05 ± 1.70, p = 0.263). In all patients, anxiety increased from baseline to DOS and dropped at 6 weeks post-operatively, and was not significantly different in the two groups. CONCLUSIONS: Guided imagery improved patient preparedness for pelvic floor surgery with an overnight stay on their DOS and 6 weeks post-operatively.

Fluoroscopic imaging of needle position in the tension-free vaginal mesh procedure for pelvic organ prolapse: two case reports.

The tension-free vaginal mesh (TVM) procedure has become one of the commonly used treatments for pelvic organ prolapse (POP) due to good clinical outcome. However, there are several technical difficulties associated with this procedure. We performed fluoroscopy for imaging of the surgical procedure on the TVM to resolve the technical problems regarding needle penetration. Fluoroscopic imaging with rectogram and cystogram demonstrated the positions of the needle, pelvic organs and index finger for needle guidance in the TVM procedure. Fluoroscopic imaging may be useful to understand the movement of surgical devices in the blind space, objectively evaluate the surgeon's skill, avoid injury to the pelvic organs, and detect any such injury immediately should it occur.

Pelvic floor ultrasound in prolapse: what's in it for the surgeon?

Pelvic reconstructive surgeons have suspected for over a century that childbirth-related trauma plays a major role in the aetiology of female pelvic organ prolapse. Modern imaging has recently allowed us to define and reliably diagnose some of this trauma. As a result, imaging is becoming increasingly important, since it allows us to identify patients at high risk of recurrence, and to define underlying problems rather than just surface anatomy. Ultrasound is the most appropriate form of imaging in urogynecology for reasons of cost, access and performance, and due to the fact that it provides information in real time. I will outline the main uses of this technology in pelvic reconstructive surgery and focus on areas in which the benefit to patients and clinicians is most evident. I will also try and give a perspective for the next 5 years, to consider how imaging may transform the way we deal with pelvic floor disorders.

Pelvic floor ultrasound: a review.

Imaging currently plays a limited role in the investigation of pelvic floor disorders. It is obvious that magnetic resonance imaging has limitations in urogynecology and female urology at present due to cost and access limitations and due to the fact that it is generally a static, not a dynamic, method. However, none of those limitations apply to sonography, a diagnostic method that is very much part of general practice in obstetrics and gynecology. Translabial or transperineal ultrasound is helpful in determining residual urine; detrusor wall thickness; bladder neck mobility; urethral integrity; anterior, central, and posterior compartment prolapse; and levator anatomy and function. It is at least equivalent to other imaging methods in visualizing such diverse conditions as urethral diverticula, rectal intussusception, mesh dislodgment, and avulsion of the puborectalis muscle. Ultrasound is the only imaging method able to visualize modern mesh slings and implants and may predict who actually needs such implants. Delivery-related levator trauma is the most important known etiologic factor for pelvic organ prolapse and not difficult to diagnose on 3-/4-dimensional and even on 2-dimensional pelvic floor ultrasound. It is likely that this will be an important driver behind the universal use of this technology. This review gives an overview of the method and its main current uses in clinical assessment and research.

[Old wine in new bottles-proven open-surgical procedures for the treatment of pelvic organ prolapse]. / Alter Wein in neuen Schläuchen ­ bewährte offen-operative Verfahren zur Behandlung des Urogenitalprolaps.

Urinary incontinence and pelvic organ prolapse (POP) are increasing due to demographic factors. Increasing life expectancy and sociocultural demands of women require successful treatments that also have low complication rates. Classic open procedures such as colposuspension or colposacropexy (native tissue repair as well as mesh procedures) are experiencing a renaissance due to the current critical view of mesh-repair pelvic floor surgery and continue to be of great importance. With suitable patient selection, long-term results of abdominal procedures are on a par with minimally invasive techniques. Cosmetically acceptable results can be achieved with optimized incisions. The therapeutically relevant target for apical fixation is the elevation angle of the vagina (EAV). Minimally invasive mesh-based primary reconstructions and interventions for POP recurrence proved to be superior to conventional procedures due to good long-term results, lower recurrence rates and reduced early and late complication rates when anatomically correct and gentle surgery is performed with a critical selection of textile implants. Abdominal procedures are not inferior to minimally invasive techniques when instrumental suturing techniques and modern instruments are used. Adequate and critical information about surgical options and possible risks of complications should be provided in a timely manner. Education and training in modern diagnostics as well as in abdominal and current minimally invasive techniques and complication management should be implemented according to the guidelines and recommendations of professional societies, the Food and Drug Administration and the European Network of Information Centres.

Robotic-assisted laparoscopic apical suspension: description of the spiral technique.

This video's objective was to describe our spiral technique and surgical steps of robotic-assisted laparoscopic apical suspension (RALAS) in the treatment of patients with symptomatic apical vaginal prolapse. A 70-year-old Caucasian woman, gravida 3, para 2 had symptomatic pelvic organ prolapse (POP) apical/anterior stage III. At pelvic ultrasound evaluation, the uterus was small and normal appearing of adnexa bilaterally. She failed pessaries and is sexually active. The most relevant complaints were vaginal bulging and pressure. She denied urinary incontinence. During the surgery, we used (1) 3-0, V-Loc™ (Covidien) and we reinforced these absorbable sutures with (2) 2-0, GORE-TEX® Suture (Gore Medical). The Si da Vinci Surgical System was used with 4 arms and 5 trocars configuration, docked on the patient's left side. On the right/left apical support, we used V-Loc and Gore-Tex and these provided the initial 2 points suspension on the uterosacral ligaments (USL). We like to attach the left to the right USL. We then developed the space between the bladder and vagina and proceed with a plication of the pubocervical fascia with V-loc sutures. Two anterior apical support sutures were taken from the vagina to the transversalis fascia on the anterior abdominal wall and then hid behind the bladder peritoneum. The tension of these sutures was maintained with Hem-o-lock (TeleFlex) and LAPRA-TY (Ethicon). With the spiral technique, we secured these sutures through aponeurosis of abdominal muscle inside-outside-inside using a Carter-Thomason (Cooper Surgical) laparoscopic port closure system. This technique may provide a better long-term support for the anterior apical compartment.

Imaging of Pelvic Floor Reconstruction.

Stress urinary incontinence and pelvic organ prolapse are 2 common pelvic floor disorders that are important causes of pelvic pain and disability. Mesh and sling placement are some of the surgical treatment options available for treatment of these conditions. In addition to clinical assessment, imaging plays an important role in managing postoperative patients with complications such as recurrent organ prolapse and chronic pain. Role of high-resolution pelvic magnetic resonance imaging with additional advanced imaging techniques, such as magnetic resonance neurography that are invaluable in managing such patients, are discussed in this article.