Predictors for Pelvic Organ Prolapse Recurrence After Sacrocolpopexy: A Matched Case-Control Study.

OBJECTIVE: This study aimed to identify risk factors for prolapse recurrence after sacrocolpopexy. METHODS: This was a retrospective chart review with cross-sectional follow-up survey of 709 patients who underwent sacrocolpopexy of any modality from 2004 to 2014. Cases were defined as those with a composite failure, defined as having subjective bulge symptoms, retreatment, or anatomic prolapse (≥stage 2 prolapse on the Pelvic Organ Prolapse Quantification system). Controls were patients without composite failure. The cases and controls were matched by surgeon and by date of surgery in a 1:4 ratio. RESULTS: We identified 153 cases and matched them to 487 controls. The overall incidence of prolapse recurrence was 21.6% (95% confidence interval [CI], 18.2%-24.1%). Of the recurrence cases, 34 (22.2%) underwent surgical retreatment; the most common surgical retreatment was a posterior colporrhaphy (n = 16 [47.1%]). On multivariable logistic regression, a preoperative genital hiatus size ≥4 cm (adjusted odds ratio [adjOR], 1.95; 95% CI, 1.18-3.25) and concurrent anterior colporrhaphy (adjOR, 2.11; 95% CI, 1.06-4.18) were associated with increased odds of having a composite failure. Patients who had a concurrent posterior colporrhaphy had lower odds of experiencing a failure (adjOR, 0.62; 95% CI, 0.42-0.94). CONCLUSIONS: In this large retrospective chart review of women who underwent sacrocolpopexy with a cross-sectional survey follow-up time frame of nearly 7 years, patients with a preoperative genital hiatus of 4 cm or greater and need for concurrent anterior colporrhaphy at the time of their index surgery had higher odds of prolapse recurrence. Conversely, women who underwent a concurrent posterior colporrhaphy had lower odds of a recurrence.

Long-term pelvic organ prolapse recurrence and mesh exposure following sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Large, long-term studies are needed to compare pelvic organ prolapse (POP) recurrence and mesh exposure following all modes of sacrocolpopexy (open, robotic, and laparoscopic). We hypothesized that the prevalence of recurrent POP and mesh exposure does not differ between modes of sacrocolpopexy. METHODS: This is a retrospective cohort study with a cross-sectional, prospective survey. Participants were surveyed regarding complications, retreatments, and symptoms following sacrocolpopexy. Baseline characteristics, POP recurrence, mesh exposure, and survey responses were compared. RESULTS: A total of 709 participants met the criteria. Median time from sacrocolpopexy to last follow-up for all participants was 0.5 years (2 days to 13.4 years). 15.0% experienced recurrent stage 2 or greater POP or underwent retreatment (open 11.7% [95% CI 7.8-17.2%]; robotic 21.1% [95% CI 15.6-27.9%]; laparoscopic 13.8% [95% CI 10.6-17.9%]; p = 0.03). After adjusting for baseline differences there was no significant difference among groups (p = 0.30). 5.3% experienced mesh and/or suture exposure (mesh n = 19, suture n = 10, mesh and suture n = 8) with no significant difference among groups (open 7.7% [95% CI 4.6-12.5%]; robotic 3.6% [95% CI 1.7-7.6%]; laparoscopic 4.9% [95% CI 3.1-7.7%]; p = 0.20). Median time from sacrocolpopexy to survey completion was 6.5 (1.6-13.4) years. 9.2% reported evaluation or treatment for recurrent POP (open 6.3% [95% CI 2.1-16.8%]; robotic 12.5% [95% CI 6.9-21.5%]; laparoscopic 8.5% [5.1-13.8%]; p = 0.44). 6.9% reported evaluation or treatment for mesh exposure (open 6.0% [95% CI 2.1-16.2%]; robotic 3.9% [95% CI 1.3-10.7%]; laparoscopic 8.6% [5.2-13.9%]; p = 0.38). CONCLUSIONS: Objective and patient-reported long-term prevalence of POP recurrence and mesh exposure are low following all modes of sacrocolpopexy.

Does concurrent posterior repair for an asymptomatic rectocele reduce the risk of surgical failure in patients undergoing sacrocolpopexy?

PURPOSE: To determine if a concurrent posterior repair for an asymptomatic rectocele at the time of sacrocolpopexy reduces the incidence of surgical failure. METHODS: This is a retrospective chart review with a cross-sectional follow-up survey of all patients who underwent sacrocolpopexy from 2004 to 2014. Demographic and operative data were collected from the medical record. For the cross-sectional portion, patients were contacted to obtain information on symptoms and retreatment after surgery. In this study, we included patients with an asymptomatic rectocele on examination, defined as Ap or Bp ≥ -1 on POP-Q without defecatory dysfunction, which was defined as constipation based on the Rome III criteria, dyschezia, excessive straining and/or splinting to have a bowel movement. The primary outcome was a composite score of subjective bulge symptoms or retreatment for prolapse. RESULTS: Three hundred forty-four patients met the inclusion criteria: 185 (53.8%) had a sacrocolpopexy only (SCP) and 159 (46.2%) had a concurrent posterior repair (SCP + PR). The composite failure rate was 10.2% (95% CI = 7.4-13.8%), with a 13.5% (25) failure rate in the SCP group compared with 6.3% (10) in the SCP + PR group (p = 0.03). On multivariable logistic regression, the adjusted odds of failure was 2.79 in the SCP compared with the SCP + PR group (CI 1.25-6.23; P = 0.01). The rates of de novo defecatory dysfunction following surgery were low (SCP = 5.6% vs. SCP + PR = 7.5%, p = 0.55). CONCLUSIONS: For patients with asymptomatic rectoceles, a concurrent posterior repair at the time of sacrocolpopexy reduces the odds of composite patient-centered failure without an increased rate of dyspareunia or de novo defecatory dysfunction.

Route of hysterectomy during minimally invasive sacrocolpopexy does not affect postoperative outcomes.

INTRODUCTION AND HYPOTHESIS: Hysterectomy can be performed during sacrocolpopexy, but there are limited studies comparing the effect of route of hysterectomy on adverse events. We hypothesized there would be no difference in adverse events or patient-reported outcomes in women who underwent minimally invasive sacrocolpopexy with either vaginal or supracervical hysterectomy. METHODS: This was a retrospective chart review with a cross-sectional survey component sent to all consenting patients. Patients were identified by procedure code for sacrocolpopexy and hysterectomy from January 2005 to June 2016. RESULTS: Of the 161 subjects meeting the inclusion criteria, 116 underwent supracervical and 45 vaginal hysterectomy. Overall incidence of perioperative adverse events was low. Vaginal hysterectomy cases were faster (276 vs. 324 min, p < 0.001) and had higher rates of postoperative stress incontinence (22 vs. 9%, p = 0.03). Thirty-one (19%) of all subjects had recurrent prolapse; 10 (6%) underwent repeat surgery. Three (1%) subjects had a mesh exposure (no difference between groups), all treated conservatively. Ninety-six (60%) subjects responded to the survey with a median follow-up of 56 (9-134) months. Ninety-one percent (87) of respondents reported being better since surgery, and 91% (87) reported they would choose the surgery again. Twenty-eight percent (27) reported a surgery-related complication including pain, urinary and bowel symptoms; 8% (8) reported evaluation for recurrent prolapse symptoms, all treated conservatively; 4% (4) of respondents reported a mesh exposure. CONCLUSIONS: Incidence of adverse events is low and not different between patients undergoing minimally invasive sacrocolpopexy with concurrent supracervical or vaginal hysterectomy. One in three patients report pelvic floor symptoms postoperatively, but long-term satisfaction is high.

Surgical Pain After Transobturator and Retropubic Midurethral Sling Placement.

OBJECTIVE: To compare prevalence and severity of any surgical pain between transobturator and retropubic slings; secondary aims were to compare pain at anatomic locations, pain medication use, and pain resolution between transobturator and retropubic slings and to compare pain between types of transobturator slings. METHODS: This is a secondary analysis of the Trial of Mid-Urethral Slings, which compared retropubic and transobturator sling outcomes and included 597 participants from 2006 to 2008. Postoperative assessments included body maps, visual analog scales, Surgical Pain Scales, and medication inventories for 30 days, at 6 weeks, and 6, 12, and 24 months. Postoperative pain prevalence and severity were compared. Mixed models compared pain resolution and severity over time. Regression models compared pain prevalence and severity between types of transobturator slings. Eighty percent power was provided for the primary outcome pain prevalence and 95% power was provided for the primary outcome pain severity. RESULTS: Postoperative prevalence of any surgical pain, pain severity, and pain medication was not different between retropubic and transobturator slings. Retropubic sling was associated with greater prevalence of suprapubic pain at 2 weeks (proportion difference 10.6%; 95% confidence interval [CI] 4.6-16.4%; P<.001). Transobturator sling was associated with greater prevalence of groin pain at 2 weeks (proportion difference 12.0%; 95% CI 7.1-16.8%; P<.001). There was no difference in pain resolution (odds ratio [OR] 1.11, 95% CI 0.88-1.40; P=.38). Between types of transobturator slings, the odds of surgical pain were similar at 2 (OR 2.39, 95% CI 0.51-11.31; P=.27) and 6 weeks (OR 0.46, 95% CI 0.02-9.20; P=.61). CONCLUSION: Transobturator and retropubic slings are associated with low prevalence of any surgical pain. Transobturator sling was associated with greater prevalence of groin pain at 2 weeks, and retropubic sling was associated with greater prevalence of suprapubic pain at 2 weeks. Surgical pain resolved quickly in both groups.

Perceptions of posthysterectomy cystoscopy training in obstetrics and gynecology residency programs.

OBJECTIVE: The objective of this study was to characterize the training practices of obstetrics and gynecology (OG) residency programs regarding posthysterectomy cystoscopy. METHODS: Two separate electronic surveys were sent to program directors and residents at American Council of Graduate Medical Education-accredited OG programs. Measures included the type of cystoscopy training available, estimates on indications and how often posthysterectomy cystoscopy is performed, and exposure to female pelvic medicine and reconstructive surgery (FPMRS). RESULTS: Sixty-one (26%) of 235 program directors and 394 (29.7%) of 1325 residents completed the survey. The majority of residents (95%) who received training reported having experience with cystoscopy in the operating room. Residents with FPMRS fellowships were more likely to perform routine cystoscopy after hysterectomy during their training compared with residents without fellowships (39% vs 27%, P = 0.01). Residents graduating from programs with FMPRS fellowships reported they planned to always perform routine cystoscopy more often than did those without a fellowship program (30.3% vs 17%, P = 0.01).Program directors most frequently defined competency as direct observation of the procedure (95%), followed by the number performed (53%) and a competency checklist (45%). No significant differences were noted in the reported use of routine cystoscopy by program directors after hysterectomy, with or without a fellowship program (62% vs 48%, P = 0.38). CONCLUSIONS: Residents in OG programs are receiving cystoscopy training, most commonly in the operating room, less often with simulation. Nineteen percent reported receiving no training. Graduating residents exposed to FPMRS fellowships more frequently reported planning to always perform cystoscopy after hysterectomy than did those without fellowship exposure.