Sacral colpopexy versus transvaginal mesh colpopexy in obese patients.

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

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

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

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

Female pelvic floor symptoms before and after bariatric surgery.

BACKGROUND: Obesity is a risk factor for female pelvic floor disorders. The study objective was to determine whether there was a difference in the subjective reporting of pelvic symptoms before and after bariatric surgery. METHODS: This was a prospective cohort study of female patients that underwent bariatric surgery. Patients completed a demographic questionnaire, the Pelvic Floor Distress Inventory-20 (PFDI-20), and the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) before surgery and at 6 and 12 months following surgery. Body mass index (BMI) was compared between time points using Student's t tests (P < 0.05 significant). Symptom and impact on quality of life prevalence were compared using McNemar's test and questionnaire scores were compared using the Wilcoxon matched pairs test (P < 0.025 significant). RESULTS: At 12 months after surgery, 63 patients had completed the study. Even with significant weight loss (BMI, 43.7 kg/m(2) to BMI, 29 kg/m(2); P < 0.001), there was no significant difference in the prevalence of pelvic floor symptoms before and after surgery (94% to 81%, P = 0.2). Prevalence of pelvic floor symptom impact on quality of life did significantly decrease after surgery (56% to 30%; P = 0.004). Baseline PFDI-20 and PFIQ-7 scores were low; however, there was still a significant reduction in PFDI-20 and PFIQ-7 scores after surgery (P < 0.001). CONCLUSIONS: Prevalence of pelvic floor symptoms did not vary greatly after surgery; however, significant weight reduction did improve the degree of bother and quality of life related to these symptoms.

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

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

Surgical outcomes following total Prolift: colpopexy versus hysteropexy.

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

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

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

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

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

Pelvic magnetic resonance imaging for assessment of the efficacy of the Prolift system for pelvic organ prolapse.

OBJECTIVE: The purpose of this study was to compare pre- and postoperative pelvic organ prolapse-quantification (POP-Q) and magnetic resonance imaging (MRI) measurements in patients who undergo total Prolift (Ethicon, Inc, Somerville, NJ) colpopexy. STUDY DESIGN: Pre- and postoperative MRI and POP-Q examinations were performed on patients with stage 2 or greater prolapse who underwent the Prolift procedure. MRI measurements were taken at maximum descent. Correlations between changes in MRI and POP-Q measurements were determined. RESULTS: Ten subjects were enrolled. On MRI, statistically significant changes were seen with cystocele, enterocele, and apex. Statistically significant changes were seen on POP-Q measurements for Aa, Ba, C, Ap, Bp, and GH. Positive correlations were demonstrated between POP-Q and MRI changes. Minimal tissue reaction was seen on MRI. CONCLUSION: The Prolift system is effective in the surgical management of pelvic organ prolapse as measured by POP-Q and MRI. Postoperative MRIs support the inert nature of polypropylene mesh.

Surgery for extratemporal nonlesional epilepsy in adults: an outcome meta-analysis.

PURPOSE: To better evaluate surgery for extratemporal lobe epilepsy (ETLE) in adults, we conducted a meta-analysis of previous studies that analyzed postoperative seizure outcomes for ETLE. METHODS: After searching PubMed for appropriate studies, patient data were reviewed, and data on patients who fit the authors' criteria were extracted. Statistical analysis compared each variable with surgical outcome to determine if an association existed. RESULTS: For the 131 patients who were included in the analysis, the age at surgery, age of seizure onset, and duration of epilepsy were not found to be statistically and significantly related to seizure outcome. Similarly, seizure semiology, abnormality on magnetic resonance imaging, lateralization of the seizures, the need for intracranial monitoring, pathological findings, and the type and location of surgery did not appear to be associated with outcome. CONCLUSIONS: This meta-analysis confirms the findings of other centers: ETLE surgical outcomes are less desirable than those for temporal lobe epilepsy. None of the factors studied in adults showed significant association with outcome. Contrary to some reports, shortening the duration of epilepsy by pursuing surgery as early as possible also does not appear to improve outcomes. The creation of standard protocols among epilepsy centers is needed to allow for a detailed evaluation of outcomes across different centers and, ultimately, to better assess the factors associated with improved outcomes.

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

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

Surgery for extratemporal nonlesional epilepsy in children: a meta-analysis.

PURPOSE: Previous small studies have demonstrated that seizure outcomes following surgery for extratemporal lobe epilepsy (ETLE) in children are worse than those for temporal lobe epilepsy. We have conducted a meta-analysis of the available literature to better understand ETLE surgical outcomes in children. METHODS: We searched PubMed (1990-2009) for appropriate studies using the following terms: ETLE, ETLE surgery, ETLE surgery outcome, frontal lobe epilepsy, occipital lobe epilepsy, and parietal lobe epilepsy. Our collected data included patient age at seizure onset and surgery, the cerebral lobe involved with epileptogenesis, MRI findings, predominant seizure semiology, intracranial monitoring use (electrode implantation), epileptic region histopathology, and postoperative seizure outcome. Statistical analysis was performed to determine associations among these variables and postoperative outcome. RESULTS: Ninety-five patients from 17 studies satisfied the inclusion criteria. Pathological findings (p = 0.039) and seizure type (p = 0.025) were significantly associated with outcome: A larger proportion of patients with cortical dysplasia and complex partial seizures experienced better outcomes. Age at surgery (p = 0.073) and the cerebral resection site (p = 0.059) were marginally associated with seizure outcome. CONCLUSIONS: This study confirms previous reports: Surgical outcomes for ETLE epilepsy are significantly worse than those for temporal lobe epilepsy. The reasons for this difference may include the diffuse nature of the pathology involved in ETLE, difficulty in localizing the seizure focus in young children, and involvement of "eloquent" nonresectable cortex in epileptogenesis. Because of the reporting variability among different epilepsy centers, more uniform protocols are necessary for fair evaluation and comparison of outcomes among the different centers.

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

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

Abdominovaginal sacral colpoperineopexy: patient perceptions, anatomical outcomes, and graft erosions.

This is a retrospective analysis of 169 consecutive patients who underwent the abdominovaginal sacral colpoperineopexy. POP-Q measurements, patient willingness to have the same surgery again, and mesh erosions were recorded during follow-up visits. Patients whose erosion responded to office excision were defined as having minor mesh erosion. Patients with persistent erosions requiring outpatient surgical excisions were defined as having major mesh erosion. For the 122 patients with 12-month follow-up, all POP-Q points improved (p<0.005) compared with preoperative measurements. The response to the question "Would you go through the same surgery again?" was "yes" 77.3% of the time and "no" 4.9% of the time. Minor mesh erosion rate was 5.9% (10/169). Major erosion rate was 0.6% (1/169). In conclusion, when combined with paravaginal defect repair and Burch urethropexy, the abdominovaginal sacral colpoperineopexy effectively addresses all support defects in patients with advanced prolapse. The procedure is associated with a high level of patient willingness to have the same surgery again, and it is achieved with low erosion rate.

Change in serum prostate specific antigen concentration after holmium laser enucleation of the prostate: a marker for completeness of adenoma resection?

BACKGROUND AND PURPOSE: Holmium laser enucleation of the prostate (HoLEP) is a well-established technique for the treatment of benign prostatic hyperplasia (BPH). To date, changes in serum prostate specific antigen (PSA) after HoLEP have not been published. We hypothesized that HoLEP produces a diminution in PSA similar to that produced by the gold-standard therapies for BPH. To test this hypothesis, we have examined PSA data before and after HoLEP from two institutions performing high volumes of this procedure. PATIENTS AND METHODS: Between August 1998 and September 2004, 509 HoLEPs were performed at two institutions for which complete PSA data were available. Preoperative demographic and transrectal ultrasonography (TRUS) volume measurements were recorded; postoperative pathology and TRUS volume were obtained. Change in PSA as a function of the weight of prostate resected and the relation of preoperative TRUS volume to PSA was determined. RESULTS: The average weight of adenoma resected was 49.8 g (range 5-300 g) in the McGill group and 90.4 g (range 7.9-312 g) in the Methodist Hospital group. The mean decrease in PSA was 81.7% in the McGill group (range 6.0-1.1 ng/mL; P < 0.0001) and 86.0% in the Methodist Hospital group (range 8.6-1.2 ng/mL; P < 0.0001). Log transformed preoperative PSA correlated well with TRUS volume (r = 0.45), as did the weight of adenoma resected with absolute change in PSA (r = 0.38). The TRUS volume decreased significantly, from 111.9 cc to 26.5 cc, in the Methodist Hospital group (P < 0.0001). CONCLUSION: The HoLEP procedure produces a significant diminution in PSA that correlates well with the weight of adenoma resected. Measurement of PSA may be a useful tool for the objective assessment of ablative therapies for BPH, as the reduction in PSA corresponds well with the amount of adenoma removed.