Pilsner Modification of Mesh Sacrohysterocolpopexy (PiMMS): An Initial Report on Safety and Efficacy.

INTRODUCTION AND HYPOTHESIS: It is reported that up to 60% of women would prefer to spare their uterus during pelvic organ prolapse (POP) repair surgery. A reliable hysteropexy technique is therefore crucial. We aimed to describe the safety profile and initial core patient-reported and clinical outcomes of the Pilsner modification of laparoscopic mesh sacrohysterocolpopexy (PiMMS) in comparison with the laparoscopic sacrohysterocolpopexy technique (standard laparoscopic sacrohysterocolpopexy [sLSH]) previously used in our unit. METHODS: This was a retrospective cohort study conducted in a single tertiary referral urogynecological center. All patients who underwent laparoscopic mesh sacrohysterocolpopexy between 1 January 2015, and 31 January 2022 were included in the study. Follow-up clinical, patient-reported, and imaging outcomes at the 12-month follow-up time point are presented. RESULTS: A total of 87 patients were included. Of these, 49 (56.3%) and 38 (43.7%) underwent sLSH and PiMMS respectively. Low numbers of perioperative complications were found in both groups with no mesh-related complications reported following PiMMS up to 12 months postoperatively. There were no apical compartment failures in either group. There were 8 (17.0%) vs 1 (2.7%) anterior compartment failures (Ba ≤ -1) in the sLSH and PiMMS groups respectively (p = 0.07) at 12 months. At the 1-year follow-up, 42 (89.4%) patients reported a Patient Global Impression of Improvement score of ≤ 2 in the sLSH groups compared with 35 (94.6%) patients following PiMMS. CONCLUSIONS: The PiMMS technique seems to have comparable safety profile and patient-reported outcomes with the sLSH technique. However, there is a trend toward reduced anterior compartment failures with this modification. The findings of this preliminary report need to be re-evaluated in a well-powered prospective study.

A Comprehensive Evaluation of Sexual Life in Women After Laparoscopic Sacrocolpopexy using PISQ-IR.

INTRODUCTION AND HYPOTHESIS: Although laparoscopic sacrocolpopexy is a recommended procedure for sexually active women, its full impact on sexual life remains underexplored. This study is aimed at comprehensively assessing changes in the quality of sexual life and the prevalence of dyspareunia in women 1 year after laparoscopic sacrocolpopexy. METHODS: This prospective observational study enrolled women undergoing laparoscopic sacrocolpopexy for pelvic organ prolapse stage≥ 2. Included were women with a completed Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA Revised (PISQ-IR) questionnaire before and at 1 year after surgery. Individual domains of the PISQ-IR were compared separately. Dyspareunia, single summary PISQ-IR and PISQ-12 scores were additionally compared in sexually active women. Statistical analyses included paired signed rank, Wilcoxon, Median, Chi-squared, and Fisher tests (p < 0.05). RESULTS: Between February 2015 and December 2019, a total of 333 women were included. Mean age was 61.0 ± 11.2 and 141 (42%) reported being sexually active at baseline. At 12 months postoperatively, sexual activity was preserved in 110 (78%) of these women and an additional 26 women (14%) became sexually active. Both single-summary PISQ-IR (3.4 vs 3.6, p < 0.01) and PISQ-12 (36.0 vs 38.1, p < 0.01) scores increased significantly. The only variable that was associated with deteriorated scores postoperatively was a higher BMI. Individual domain analyses revealed significant improvement in condition-specific and condition-impact domains, except for the desire domain, which deteriorated. Prevalence of dyspareunia decreased post-surgery from 21.8% to 16.4%, p < 0.05. Newly sexually active women were older, had shorter vaginal length preoperatively, but lower PISQ-IR scores postoperatively than sexually inactive women pre- and postoperatively. Women ceasing sexual activity were older and had lower preoperative PISQ-IR scores than sexually active women pre- and postoperatively. CONCLUSIONS: Although the overall rate of sexually active women and sexual desire declined 12 months after sacrocolpopexy, overall sexual function scores improved and the prevalence of dyspareunia decreased.

Importance of vaginal packing after laparoscopic sacrocolpopexy - retrospective study.

OBJECTIVE: To compare the subjective and objective results of laparoscopic sacrocolpopexy (LSC) with and without the introduction of a vaginal packing one year after surgery. Methodology: This is a retrospective cohort study of 125 women after laparoscopic sacrocolpopexy operated on in 2013-2016 with complete annual follow-up. Patients with a total hysterectomy were excluded from the study. Basic patient characteristics, preoperative POP-Q and surgery data were collected. The subjective outcome of the surgery was assessed using the PGI-I (patient global impression of improvement). The anatomic outcome of the surgery was evaluated using the composite definition of surgical failure based on POP-Q (Ba ≥ -1, C ≥ -3, Bp ≥ -1). Patients were divided into two groups according to whether or not they had vaginal packing after surgery. Statistical analysis was performed using c2, Wilcoxon and Fischer test according to the distribution of normality. Results: A total of 125 women were enrolled in the study; 48 (38.4%) after LSC, 58 (46.4%) with concomitant supracervical hysterectomy and 19 (15.2%) after sacrohysterocolpopexy. Vaginal packing was introduced for 24-48 hours after surgery in 86 (68.8%) women. The groups did not differ in age, body mass index, smoking or preoperative pelvic organ prolapse quantification system. We did not observe statistically significant differences in PGI-I first year after surgery. The difference in anatomic surgical failure did not reach statistical significance, although more failures were observed in the group without packing (12.8 vs. 3.5%; P = 0.09). The mean C-point value one year after surgery was lower in the non-tamponade group (-7 vs. -7.5; P < 0.009). No mesh extrusion or serious complications were recorded in the monitored group. Conclusion: Vaginal packing after LSC probably does not affect patient satisfaction after surgery, however, it may be associated with better anatomical outcome one year after the surgery. The results of the study must be confirmed by a more detailed prospective evaluation.

Laparoscopic sacrocolpopexy in the management of recurrent pelvic organ prolapse.

OBJECTIVES: We set out to assess long-term anatomical and functional outcomes in women after laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse. METHODS: All women with a history of pelvic organ prolapse surgery operated between 2005 and 2022 were enrolled in this retrospective observational study. The indication for recurrent POP surgery was a symptomatic stage II and above pelvic organ prolapse. The data from objective urogynecologic examination and subjective patient assessment using validated questionnaires were collected. The last follow-up information was evaluated. The outcomes were compared with preoperative state using Student t-test and Wilcoxon test, p<0.05 was considered significant. RESULTS: 39 women were enrolled in the study. The rate of perioperative complications was very low; no significant hemorrhage, ureteral damage or conversion to laparotomy were observed. The mean follow-up was 40 ± 26.8 months. The postoperative course was not complicated by bowel incarceration, pelvic infection or mesh exposure. We observed a statistically significant elevation of all POP-Q points and decrease in all mean scores of PFDI, PFIQ, Wexner and VAS prolapse bother postoperatively. Improvement in stress urinary incontinence, anal incontinence and constipation was found. CONCLUSIONS: Laparoscopic sacrocolpopexy for recurrent pelvic organ prolapse is a safe and effective surgery regardless of the type of the original repair performed. It provides good subjective and anatomical outcomes with a lasting effect on the quality of life in a long-term follow-up.

Impact of laparoscopic sacrocolpopexy (LSC) on sexual function in women with advanced stages of pelvic organ prolapse (POP): A five-year prospective study.

OBJECTIVE: To compare patients undergoing laparoscopic sacrocolpopexy (LSC) for pelvic organ prolapse (POP), in terms of sexual function and surgical anatomical outcomes more than 5-years follow up period. STUDY DESIGN: This is a cohort study of prospectively collected data that includes all women who underwent LSC between July 2005 and December 2021 at a tertiary care center. A total of 228 women were enrolled in this study. Patients completed a validated quality of life questionnaires and were evaluated using the POP-Q, the PFDI-20, PFIQ-7 and the PISQ-12 scores. Patients were divided preoperatively if they are sexually active or not and postoperatively according to the sexual improvement after POP surgery. RESULTS: There was a statistically significant improvement in the PFDI, PFIQ and POPQ score. There was no significant improvement in the PISQ-12 score with more than 5 years follow-up. 76.1 % of patients who were not sexually active preoperatively resumed their sexual activity after the surgery. CONCLUSION: The anatomical correction of a pelvic organ prolapse and pelvic floor disorders by laparoscopic sacrocolpopexy allowed a significant proportion (over ¾) of the women to resume sexual activity whom had not previously been sexually active. However, PISQ 12 scores did not alter significantly in those who were sexually active prior to surgery. Sexual function is a very complex issue affected by multitude of factors among which prolapse seems to be less important.

Long-term development of surgical outcome of laparoscopic sacrohysteropexy with anterior and posterior mesh extension.

INTRODUCTION AND HYPOTHESIS: Long-term durability and functional outcome of laparoscopic sacrohysteropexy (LSH) remains to be confirmed. We set out to assess the development of surgical outcome in women with increasing minimal follow-up. METHODS: All women after LSH with anterior and posterior mesh extension operated for advanced apical uterine prolapse at Geoffroy Saint-Hilaire clinic from July 2005 to June 2020 were enrolled in this retrospective study. Last known follow-up information was used for the analysis and allocation into groups. The surgical success was defined as no prolapse beyond hymen, no symptomatic recurrence or no retreatment. Functional outcome was evaluated from validated questionnaires and presence of pelvic floor disorders. The outcomes were compared with preoperative state using chi-square and Fisher's test; p < 0.05 was considered significant. RESULTS: In total, 270 patients after LSH with a follow-up of up to 14.5 years were enrolled and divided into groups according to their last follow-up length: ≥ 1 year 242, ≥ 3 years 112, ≥ 5 years 76, ≥ 7 years 45 and ≥ 10 years 18 women. Increase of minimal follow-up was associated with gradual decrease in surgical success. Rates of stress urinary incontinence were unchanged by the surgery, while anal incontinence and constipation rates decreased significantly; 14.5% of women were operated on for SUI in the follow-up. The PFDI-20, PFIQ-7 and VAS bother scores decreased significantly regardless of minimal follow-up length. CONCLUSIONS: LSH with anterior and posterior mesh extension is a safe, effective and durable surgery with a positive long-term effect on quality of life. Although the surgical success gradually decreases, LSH remains a surgical success in most women.

Relationship between urethrovesical junction mobility changes and postoperative progression of stress urinary incontinence following sacrospinous ligament fixation - a subanalysis of a multicentre randomized study.

OBJECTIVES: The study aimed to assess the relationship between urethrovesical junction (UVJ) descent and development of de novo stress urinary incontinence (SUI) and postoperative progression of preexisting SUI following surgery for pelvic organ floor prolapse using the method of sacrospinal fixation (SSF). This was a secondary analysis of the SAME prospective randomized multicentre study (reg. no. NCT03053479) comparing three approaches to surgery for apical defects - sacropexy, SSF and transvaginal mesh. METHODS: The subanalysis included 81 patients with apical defects managed by SSF, either right-sided (N = 14, 17.3%) or bilateral (N = 67, 82.7%). Postoperative follow-up was assessed at 3 months (N = 59), 12 months (N = 47) and 24 months (N = 30). UVJ mobility at rest and with maximum effort, the Valsalva manoeuvre was determined using a standardized 3D/ 4D transperineal ultrasound protocol proposed by Dietz et al. De novo SUI and postoperative progression of preexisting SUI were ascertained from history. RESULTS: Preoperative demographic data (N = 81) were as follows: BMI 27.3 kg/ m2 (16.8-44.5), age 67.0 years (31-85), and parity 2 (1-6). Concomitant anterior repair was performed in 65.4%. Postoperative progression of SUI was 45.8% at 3 months, 21.3% at 12 months, and 23.3% at 24 months. There were significant differences between preoperative and postoperative UVJ descent values at 3, 12 and 24 months (P < 0.0001). Correlations between UVJ descent at 3, 12 and 24 months postoperatively and de novo SUI or progression of preexisting SUI at 3, 12 and 24 months postoperatively were not statistically significant (P = 0.051-0.883). Correlations between differences (preoperative UVJ descent minus UVJ descent at 3, 12 and 24 months postoperatively) and de novo SUI or progression of preexisting SUI at 3, 12 and 24 months postoperatively were not statistically significant (P = 0.691-0.779). CONCLUSIONS: The study showed significant changes in UVJ descent values preoperatively and at 3, 12 and 24 months after SSF. There were no significant correlations between UVJ descent and de novo SUI and postoperative progression of preexisting SUI following surgery for pelvic organ floor prolapse at 3-, 12- and 24-month follow-up. There were no signifi cant correlations between differences (preoperative UVJ descent minus UVJ descent at 3, 12 and 24 months postoperatively and de novo SUI and postoperative progression of preexisting SUI following surgery for pelvic organ floor prolapse at 3-, 12- and 24-month follow-up.

Outcomes of sacrocolpopexy/sacrohysteropexy with mesh placement targeted to affected compartment.

OBJECTIVE: No recommendation regarding the number of meshes to be implanted in laparoscopic genital prolapse surgery exists. Is it necessary to implant a mesh into a compartment that is not affected to prevent its prolapse in the follow-up? Our objective was to compare the long-term outcomes of laparoscopic sacrocolpopexy according to compartments where mesh was implanted. STUDY DESIGN: This is a retrospective cohort study of 328 patients after laparoscopic sacrocolpopexy at our centre in 7/2005 - 3/2021. 294 patients with perioperative data and POP-Q and/or prolapse symptoms in mean follow-up of 42.8 months was available for the outcome analysis. Surgical failure was defined as prolapse beyond hymen, subjective recurrence or retreatment. The women were divided into four groups depending on compartments, where the mesh was implanted. Group A - anterior, group P - posterior, Group AP - compound of patients with anterior or posterior single arm mesh placement and (B), with anterior and posterior arm placement. Groups AP and B were compared for feasibility of single compartment mesh implantation. Comparison of groups A and P allowed assessment of non-inferiority of single anterior vs. posterior compartment placement. The data were compared using Wilcoxon Two Sample test, Chi-square test or Fishers Exact test, p-value < 0.05 was considered statistically significant. RESULTS: A single compartment mesh implantation was associated with shorter operating time and hospital stay and comparable incidence of complications. A statistically significant difference in all POP-Q points in favour of group B was observed, however, with comparable rate of prolapse beyond hymen(6.3%AP vs. 7.8%B). Similar frequency of surgical failure (17.5%AP vs. 13.8%B) and incidence of de novo pelvic floor disorders or pain was observed. Comparison of groups A and P showed higher suspension of point C in group P(-2.6 vs. -4.0, p < 0.05) with no difference in points Ba, Bp, surgical failure rate and de novo pelvic floor disorders. CONCLUSION: Implantation of a single sheet of mesh was not associated with inferior outcome to implantation of mesh to both compartments. Laparoscopic sacrocolpopexy with a single mesh arm placed into the affected compartment along with apical suspension does not induce a de novo prolapse in unoperated compartment.

Contribution of ultrasound examination in the detection of unexpected uterine and adnexal findings in reconstructive surgery for pelvic organ prolapse.

Objective: Current urogynaecology practice allows preservation of the uterus in pelvic organ prolapse (POP) surgery, thus not reducing oncologic risk. AIM: The aim of the study was to evaluate the efficacy of ultrasound (USG) in dia-gnosing unexpected uterine and adnexal pathologies in women referred for POP. Furthermore, the benefit of USG examination by a specialist in gynaecology-oncology ultrasound was assessed. MATERIALS AND METHODS: All women after a hysterectomy with or without adnexectomy in the course of a POP surgery at our tertiary centre in 2013-2018 with preoperative USG were enrolled in the study. Women with recurrent uterine bleeding, abnormal cytology, using tamoxifen, or women with already dia-gnosed uterine or adnexal pathology were excluded. RESULTS: 289 women were enrolled in the study - 157 (54.3%) expert USG vs. 132 (45.7%) non-expert USG. Abnormal findings were observed on the cervix in one case (non-expert USG), the endometrium 30 (10.4%) cases - 13 (8.3%) expert vs. 17 (12.9%) non-expert USG, the adnexa three (2.3%) cases (all non-expert USG), and no suspicion of malignancy on myometrium was observed. USG was false negative in four (1.4%) cases - two (1.3%) expert vs. two (1.5%) non-expert USG. Conversely, the examination was false positive in 34 (11.8%) cases - 13 (8.3%) expert vs. 21 (15.9%) non-expert USG. CONCLUSION: The risk of unexpected uterine or adnexal pathologies in POP surgery was 1.4%. The agreement between USG and histopathological benign, abnormal or malign findings was 87.2%. A sonographer specialized in oncologic sonography is able to reduce the number of false positive findings; however, this does not increase the sensitivity of the ultrasound.

Laparoscopic synthetic mesh explantation after sacrohysteropexy.

INTRODUCTION: In this video, we present a case of rectal and bladder injury, which occurred during laparoscopic mesh removal following sacrohysteropexy treated 6 months later with a laparoscopic pectopexy. METHODS: We present the case of a 66-year-old woman with a prolapse recurrence after sacrohysteropexy. During the laparoscopic explantation of the mesh, we detected a fixation of the mesh to the bladder and the rectum rather than a fixation to the vaginal walls. Consequently, bladder and rectal injuries occurred during the dissection and were diagnosed and repaired immediately. Due to bowel injury, the treatment of the prolapse was postponed. Six months later, a laparoscopic pectopexy was performed to avoid complications during the repeated dissection of the promontory. The postoperative recovery after the pectopexy was uncomplicated with no short-term prolapse recurrence or postoperative complications. CONCLUSION: Laparoscopy appears to be an efficient approach to mesh explantation. Futhermore, laparoscopic pectopexy seems to be a good approach to secondary prolapse reconstruction after sacrohysteropexy mesh explantation avoiding complications during repeated dissection of the promontory.

Effect of Age on Complications Rate and Surgical Outcomes in Women Undergoing Laparoscopic Sacrohysteropexy and Sacrocolpopexy.

STUDY OBJECTIVE: To compare perioperative and long-term outcomes of laparoscopic sacrohysteropexy/sacrocolpopexy in different groups of age. DESIGN: This was a retrospective cohort study. Patients were evaluated preoperatively and postoperatively (starting from 1 month after surgery and then annually). SETTING: The department of functional pelvic surgery and oncology, a tertiary care center. PATIENTS: All patients who underwent laparoscopic sacrohysteropexy/sacrocolpopexy, between July 2005 and December 2019. INTERVENTIONS: Laparoscopic sacrohysteropexy/sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: The study population was divided into 3 groups, according to age at the time of surgery: group 1, <65 years; group 2, between 65 and 75 years, and group 3, >75 years. The primary outcome was the rate of perioperative complications. The secondary outcome was the comparison of long-term results among the groups. A total of 330 patients were included: in group 1, 183 patients (mean age 53.4 ± 8.2), in group 2, 92 patients (mean age 69.2 ± 2.9), and in group 3, 55 patients (mean age 79.3 ± 3.5). The overall perioperative complications rate (up to 30 days after surgery) was 5.7%. No differences among the groups in operative details and rates of perioperative complications were observed. During the follow-up period, 37 patients (11.2%) presented with prolapse recurrence (objective and/or subjective); the rates of prolapse recurrence and long-term complications were similar among the groups. Similarly, the groups did not differ in postoperative functional results except for postoperative stress urinary incontinence. A surgery for stress urinary incontinence was more common among patients in group 3 (group 1, 13.4%; group 2, 11.9%; group 3, 31.3%; p = .008). CONCLUSION: Laparoscopic sacrohysteropexy/sacrocolpopexy is associated with low rates of perioperative and long-term complications. We did not find a difference in rates of complications and/or long-term outcomes, between different age groups.

Pelvic organ prolapse and uterine preservation: a cohort study (POP-UP study).

BACKGROUND: Abdominal and laparoscopic sacro-colpopexy (LSC) is considered the standard surgical option for the management of a symptomatic apical pelvic organ prolapse (POP). Women who have their uterus, and for whom an LSC is indicated, can have a laparoscopic sacro-hysteropexy (LSH), a laparoscopic supra-cervical hysterectomy and laparoscopic sacro-cervicopexy (LSCH + LSC) or a total laparoscopic hysterectomy and laparoscopic sacro-colpopexy (TLH + LSC). The main aim of this study was to compare clinical and patient reported outcomes of uterine sparing versus concomitant hysterectomy LSC procedures. METHODS: A retrospective analysis of clinical, imaging and patient reported outcomes at baseline, 3 and 12 months after LSH versus either LSCH + LSC or TLH + LSC between January 2015 and January 2019 in a tertiary referral urogynecology center in Pilsen, the Czech Republic. RESULTS: In total, 294 women were included in this analysis (LSH n = 43, LSCH + LSC n = 208 and TLH + LSC n = 43). There were no differences in the incidence of perioperative injuries and complications. There were no statistically significant differences between the concomitant hysterectomy and the uterine sparing groups in any of the operative, clinical or patient reported outcomes except for a significantly lower anterior compartment failure rate (p = 0.017) and higher optimal mesh placement rate at 12 months in women who had concomitant hysterectomy procedures (p = 0.006). CONCLUSION: LSH seems to be associated with higher incidence of anterior compartment failures and suboptimal mesh placement based on postoperative imaging techniques compared to LSC with concomitant hysterectomy.

Pelvic organ prolapse and uterine preservation: a survey of female gynecologists (POP-UP survey).

BACKGROUND: The aim of this study was to explore the personal views of female gynecologists regarding the management of POP with a particular focus on the issue of uterine sparing surgery. METHODS: A questionnaire based survey of practicing female gynecologists in the Czech Republic, Slovenia and Slovakia. RESULTS: A total of 140 female gynecologists from 81 units responded to our questionnaire. The majority of respondents stated they would rely on a urogynecologist to aid them with their choice of POP management options. The most preferred options for POP management were sacrocolpopexy and physiotherapy. Almost 2/3 of respondents opted for a hysterectomy together with POP surgery, if they were menopausal, even if the anatomical outcome was similar to uterine sparing POP surgery. Moreover, 81.4% of respondents, who initially opted for a uterine sparing procedure, changed their mind if the anatomical success of POP surgery with concomitant hysterectomy was superior. Discussing uterine cancer risk in relation to other organs had a less significant impact on their choices. CONCLUSIONS: The majority of female gynecologists in our study opted for hysterectomy if they were postmenopausal at the time of POP surgery. However, variation in information provision had an impact on their choice.

Trans-obturator cystocele repair of level 2 paravaginal defect.

INTRODUCTION AND HYPOTHESIS: It is reported that almost one in five women will need some form of pelvic organ prolapse surgery in their lifetime, with anterior wall repair accounting for nearly half of these. Cystoceles occur secondary to defect(s) in one or more of the vaginal wall support mechanisms, including its lateral paravaginal attachments. Paravaginal defects are very common in women presenting with cystocele, thus highlighting the importance of paravaginal defect repair for optimal cystocele correction in the majority of cases. Although there are several paravaginal defect repair procedures, some entail complex techniques, whereas others rely on the use of transvaginal mesh, which is currently not permitted in many countries. METHODS: In this video article we present a novel trans-obturator native tissue paravaginal defect repair for the management of cystocele. RESULTS: This procedure has the advantages of avoiding complex transabdominal paravaginal defect repair, the controversial use of transvaginal mesh, or a single-point fixation to an arcus tendineus fasciae pelvis that might be difficult to identify. CONCLUSION: We believe that the trans-obturator cystocele repair procedure offers several advantages over existing paravaginal defect repair alternatives.

Diagnostic Reliability, Accuracy and Safety of Ultrasound-guided Biopsy and Ascites Puncture in Primarily Inoperable Ovarian Tumours.

BACKGROUND/AIM: To compare the diagnostic reliability, accuracy and safety of ultrasound-guided biopsy (Tru-Cut biopsy) and ascites puncture in patients with a primarily inoperable malignant ovarian tumor. PATIENTS AND METHODS: This is a retrospective analysis of the studied methods in consecutively examined patients and a prospective validation of these methods. 79 women with a suspected primarily inoperable ovarian tumor underwent Tru-Cut biopsies and were included in the ultrasound-guided biopsy group. In addition, 55 patients after ascites puncture were enrolled in the comparison group. Both procedures were performed in 48 patients for the prospective validation. RESULTS: Significant differences in favour of ultrasound-guided biopsy were found in all studied variables (malignancy confirmation 72.9% vs. 95.8%, tumor origin 52.1% vs. 89.6%, histologic subtype 43.8% vs. 85.4% and accuracy, i.e. agreement of preoperative and definitive diagnosis 43.7% vs. 95.4%). CONCLUSION: Ultrasound-guided biopsy is an accurate, reliable, safe and minimally invasive method. Owing to the high reliability and accuracy, it has the capacity to replace ascites puncture with cytologic examination or a more invasive method (laparoscopy, laparotomy) for adequate tumor sampling.

Laparoscopic sacrohysteropexy: the Pilsner modification.

INTRODUCTION AND HYPOTHESIS: Laparoscopic sacrocolpopexy is the preferred contemporary procedure for the surgical management of a significant apical pelvic organ prolapse. In the presence of a uterus it is possible for the patient to have subtotal hysterectomy and cervicopexy, total hysterectomy with colpopexy or uterine conservation and hysteropexy. However, hysteropexy seems to be associated with a higher risk of anterior compartment failure compared with cervicopexy or colpopexy. It is not uncommon for an asymmetrically large anterior compartment defect to co-exist with a symptomatic apical pelvic organ prolapse. In a cervicopexy or colpopexy, this asymmetry can be balanced by creating a de novo vaginal apex from the superior part of the anterior vaginal wall. However in a hysteropexy the attachment of the base of the anterior mesh to the vagina and cervical isthmus limits the ability to do this. METHODS: In this video we present a solution where the shape of the posterior mesh is modified to include two horizontal arms that are passed through openings in the broad ligament and attached to the cervical isthmus anteriorly. RESULTS: This frees the anterior Y-shaped mesh to be fixed to the anterior vaginal wall only and hence provides the required tension to create the de novo apex. CONCLUSION: Prior to wide adoption, this technique should be further investigated in the context of robustly designed comparative studies.

Laparoscopic sacrocolpopexy as the mainstay management for significant apical pelvic organ prolapse (LAP) study.

STUDY OBJECTIVES: The primary aim of this study was to assess the clinical feasibility of a policy where laparoscopic sacrocolpopexy (LSC) is the default procedure for the management of a significant apical pelvic organ prolapse (a-POP). As a secondary aim, we wanted to evaluate LSC outcomes in relation to women's preoperative assessment of their surgical fitness using the American Society of Anesthesiologists physical status (ASA-PS) categorization. DESIGN: Retrospective cohort study. SETTING: A university affiliated urogynecology center. METHODS: All women with symptomatic a-POP (C ≥ -1) who attended the urogynecology clinic between the 1st of January and the 31st of December 2016 and had their surgery by the 31st of May 2017 were included in the study. In our unit, routine follow-up appointments are arranged at 3 and 12 months post LSC. INTERVENTIONS: Perioperative and mesh-related complications were assessed based on the Dindo-Clavien and IUGA/ICS classifications respectively. The preoperative outcome measures included Pelvic Organ Prolapse Quantification (POP-Q) stage, Pelvic Floor Distress Inventory (PFDI) and ASA-PS score. At follow-up women were asked to complete a PFDI, Patient Global Impression of Improvement (PGI-I), had their POP-Q staging and ultrasonographic assessment of mesh position and placement. The above measures are routinely collected as part of our standard practice. A preoperative ASA-PS score of <3 was used as a cut-off to dichotomies participants into low and high risk. MAIN RESULTS: A total of 220 women attended our center during the study period because of POP. Of these, 146 women were diagnosed with a significant a-POP and 142 (97.2 %) women opted for a surgical repair. Of the 142 women, 128 (90.1 %) were deemed suitable for a type of LSC and 121 had their surgery before the 31st of May 2017. There were no statistically significant differences in any of our collected perioperative, clinical, patient reported or ultrasonographic outcome measures when comparing women with ASA-PS scores of <3 or ≥3. CONCLUSION: In a specialized urogynecology healthcare setting, it is feasible and safe to rely on LSC as the mainstay surgical procedure for the repair of a significant a-POP. However, it is imperative to ensure that technical skills and equipment requirements are fulfilled and maintained.

Obesity and its long-term impact on sacrocolpopexy key outcomes (OBELISK).

INTRODUCTION AND HYPOTHESIS: Sacrocolpopexy is the preferred contemporary approach to managing significant apical pelvic organ prolapse. Obesity is an established risk factor for several surgical procedures and can have a negative impact on outcomes. Our goal was to evaluate the impact of BMI on the safety and efficacy of laparoscopic sacrocolpopexy in women with pelvic organ prolapse. METHODS: A single-center retrospective observational study of women undergoing laparoscopic sacrocolpopexy between January 1, 2015, and December 31, 2017. RESULTS: We found 299 procedures: 82 (27.4%), 147 (49.2%) and 70 (23.4%) in women with BMI <25 (normal weight), BMI ≥ 25 - < 30 (overweight) and BMI ≥ 30 (obese), respectively. Perioperative and early postoperative complications were generally low and not statistically significantly different between the groups. At 12 months postoperatively, 81 (98.8%), 136 (92.5%) and 62 (88.6%) normal-weight, overweight and obese women attended their follow-up, respectively. All obese women attending the follow-up scored an overall Patient Global Impression of Improvement (PGI-I) of ≤ 3. The Pelvic Floor Distress Inventory (PFDI) scores showed a significant improvement in all domains and were similar between the study groups. In total, there was one (0.4%) anatomical apical compartment failure, three (1.1%) anterior compartment failures and two (0.7%) posterior compartment failures with no significant differences between the groups. Similarly, there were no differences in functional outcomes or mesh position as assessed by ultrasound. CONCLUSIONS: There were no differences in surgical, short- and long-term outcomes of laparoscopic sacrocolpopexy for pelvic organ prolapse in obese compared with non-obese women.

Are the same tapes really the same? Ultrasound study of laser-cut and mechanically cut TVT-O post-operative behavior.

INTRODUCTION AND HYPOTHESIS: TVT-O production has been modified to laser cutting from mechanical cutting. We compared the behavior of laser and mechanically cut tension-free vaginal tape-obturator (TVT-O) using ultrasound at various time points after surgery. METHODS: This is a retrospective analysis of clinical and ultrasound data from two previously reported randomized controlled trials with TVT-O. Behavior of mechanically cut TVT-O implanted in January 2007 to November 2009 and laser-cut TVT-O implanted in May 2010 to May 2012 was assessed by ultrasound at day 1, the 2nd week, the 3rd month, and the 1st and 2nd years post-operatively. Bladder neck and tape margins positions were described by coordinates in the orthogonal system calculated from polar coordinates. Tape mobility was measured as a change in the upper and lower tape margin position from rest to maximal Valsalva. Comparison of 2-year subjective and objective surgery outcomes was also performed. RESULTS: In total, 68 mechanically cut and 50 laser-cut TVT-Os were implanted. Follow-up data were available from 49 and 45 women respectively. No differences in any baseline characteristics or bladder neck mobility were observed. Significantly lower tape mobility was observed on day 1 and week 2 after mechanically cut TVT-O, although subsequent mobility was comparable to laser-cut TVT-O. The subjective and objective surgery outcomes were comparable. CONCLUSIONS: Although without clinical significance, early postoperative behavior of the mechanically cut and laser-cut TVT-O tapes differs. The less stiff, mechanically-cut TVT-O loosens within 2 weeks of implantation, whereas the stiffer, laser-cut TVT-O keeps its tension.