Perioperative Vaginal Estrogen as Adjunct to Native Tissue Vaginal Apical Prolapse Repair: A Randomized Clinical Trial.

Importance: Surgical repairs of apical/uterovaginal prolapse are commonly performed using native tissue pelvic ligaments as the point of attachment for the vaginal cuff after a hysterectomy. Clinicians may recommend vaginal estrogen in an effort to reduce prolapse recurrence, but the effects of intravaginal estrogen on surgical prolapse management are uncertain. Objective: To compare the efficacy of perioperative vaginal estrogen vs placebo cream on prolapse recurrence following native tissue surgical prolapse repair. Design, Setting, and Participants: This randomized superiority clinical trial was conducted at 3 tertiary US clinical sites (Texas, Alabama, Rhode Island). Postmenopausal women (N = 206) with bothersome anterior and apical vaginal prolapse interested in surgical repair were enrolled in urogynecology clinics between December 2016 and February 2020. Interventions: The intervention was 1 g of conjugated estrogen cream (0.625 mg/g) or placebo, inserted vaginally nightly for 2 weeks and then twice weekly to complete at least 5 weeks of application preoperatively; this continued twice weekly for 12 months postoperatively. Participants underwent a vaginal hysterectomy (if uterus present) and standardized apical fixation (either uterosacral or sacrospinous ligament fixation). Main Outcomes and Measures: The primary outcome was time to failure of prolapse repair by 12 months after surgery defined by at least 1 of the following 3 outcomes: anatomical/objective prolapse of the anterior or posterior walls beyond the hymen or the apex descending more than one-third of the vaginal length, subjective vaginal bulge symptoms, or repeated prolapse treatment. Secondary outcomes included measures of urinary and sexual function, symptoms and signs of urogenital atrophy, and adverse events. Results: Of 206 postmenopausal women, 199 were randomized and 186 underwent surgery. The mean (SD) age of participants was 65 (6.7) years. The primary outcome was not significantly different for women receiving vaginal estrogen vs placebo through 12 months: 12-month failure incidence of 19% (n = 20) for vaginal estrogen vs 9% (n = 10) for placebo (adjusted hazard ratio, 1.97 [95% CI, 0.92-4.22]), with the anatomic recurrence component being most common, rather than vaginal bulge symptoms or prolapse repeated treatment. Masked surgeon assessment of vaginal tissue quality and estrogenization was significantly better in the vaginal estrogen group at the time of the operation. In the subset of participants with at least moderately bothersome vaginal atrophy symptoms at baseline (n = 109), the vaginal atrophy score for most bothersome symptom was significantly better at 12 months with vaginal estrogen. Conclusions and Relevance: Adjunctive perioperative vaginal estrogen application did not improve surgical success rates after native tissue transvaginal prolapse repair. Trial Registration: ClinicalTrials.gov Identifier: NCT02431897.

Evaluation of acupuncture treatments of postpartum female pelvic floor dysfunction by four-dimensional transperineal pelvic floor ultrasound.

INTRODUCTION: In the present investigation, a systematic evaluation of the clinical treatment performance of diagnosed with pelvic floor dysfunction is explored. By comparing the 4Dtransperineal pelvic floor ultrasound images with the acupuncture treatment performance of the patients, an evaluation system with various parameters is established to provide critical information to guide the clinical treatment fpostpartum female pelvic floor dysfunction (FPFD). METHODS: Eighty patients diagnosed with FPFD are divided into 2 groups. After the designated treatment to the patients, they are carefully examined using transperineal pelvic floor ultrasound. The shape and activity of bladder neck, cervix and rectum anal canal under resting, anal sphincter and Valsalva movements are observed and recorded. The morphology and continuous shape of levator ani muscle in different states after 4D image reconstruction are obtained. RESULTS: After the acupuncture treatment, the bladder neck descent is decreased by 3.8 cm and the anal levator muscle area is decreased by 3.4 cm2 comparing with the control group. The anal levator muscle hole diameter is decreased by 0.3 cm, while the anterior and posterior diameter is reduced by 0.5 cm. Reduced possibility of cystocele and uterine prolapse is demonstrated by X2 test. These changes upon acupuncture therapy are in line with the improved conditions of the patients, indicating these parameters can help evaluate the therapy performance. CONCLUSION: 4D pelvic floor ultrasound imaging provides objective and quantified information for the clinical diagnosis and treatment of FPFD and the assessment of therapy efficacy, making it a promising novel method in practical applications.

Protease Inhibition Improves Healing of The Vaginal Wall after Obstetrical Injury: Results from a Preclinical Animal Model.

Vaginal delivery with obstetrical trauma is a risk factor for pelvic organ prolapse later in life. Loss of fibulin-5 (FBLN5), an elastogenesis-promoting cellular matrix protein, results in prolapse in mice. Here, we evaluated effects of pregnancy, parturition, and obstetrical injury on FBLN5 content, elastic fibers, biomechanics, and histomorphology of the vaginal wall in rats. Further, we analyzed the effects of actinonin, a protease inhibitor, on obstetrical injury of the vaginal wall. Vaginal FBLN5 decreased significantly in pregnancy, and injury resulted in further downregulation. Stiffness of the vaginal wall decreased 82% in pregnant rats and 74% (p = 0.019) with injury relative to uninjured vaginal delivery controls at 3d. Actinonin ameliorated loss of FBLN5, rescued injury-induced loss of elastic fibers and biomechanical properties after parturition, and reduced the area of injury 10-fold. We conclude that pregnancy and parturition have a profound impact on vaginal FBLN5 and biomechanics of the vaginal wall. Further, obstetrical injury has significant deleterious impact on recovery of the vaginal wall from pregnancy. Actinonin, a non-specific matrix metalloprotease inhibitor, improved recovery of the parturient vaginal wall after obstetrical injury.

Modified Extraperitoneal Uterosacral Ligament Suspension in Preventing Cuff Prolapse Risk after Vaginal Hysterectomy; 4 Clamp Method.

Objectives: The extraperitoneal uterosacral ligament suspension (ULS) can be performed during the removal of the uterus in vaginal hysterectomy to prevent cuff prolapse. In this study, we evaluated the modified extraperitoneal ULS technique in terms of preventing cuff prolapse. Methods/Technique: Forty patients with second and third-stage uterine prolapse who were operated were included in the study. During routine vaginal hysterectomy procedure performed on patients, after sacrouterine ligaments which are the first-bites and uteroovarian and round ligaments which are the last-bites have been sutured and knotted, these ligaments were marked with 4-distinct clamps to make the right and left, upper and lower separation. After vaginal cuff was closed the sutures hanged by the clamps were ligated together, and the cuff tissue was stretched to the apical line. Results: According to the POP-Q classification, 22 patients with stage-2 and 18 patients with stage-3 prolapse were operated. During the 2-year follow-up; 4 patients could not be reached and were excluded from follow-up. Five of the remaining 36 patients (13.8%) found to have stage-1 cuff prolapse and 31 (86.1%) of patients had no prolapse. There was no significant decrease in postoperative vaginal length (p [Formula: see text] 0.05). The PISQ-12 sexual function scores was found similar before and after surgery (p [Formula: see text] 0.05). Conclusions: The extraperitoneal ULS is a successful method to prevent cuff prolapse after hysterectomy. Although there are various modified forms of this method, the modified ULS, which we have described as the 4-clamp method, seems to be successful in terms of initial results.

Modified extraperitoneal uterosacral ligament suspension for prevention of vault prolapse after vaginal hysterectomy.

INTRODUCTION AND HYPOTHESIS: During vaginal hysterectomy, extraperitoneal uterosacral ligament suspension (ULS) bites can be taken before removing the uterus. We evaluated this modified extraperitoneal ULS for vault prolapse prevention. METHODS: Study period was 3.5 years. Fifty-one women with third- and fourth-degree prolapse were enrolled. An inverted V incision was made on the anterior vaginal wall and continued as a semicircular incision on the posterior vaginal wall. Lateral vaginal mucosa was pushed up to expose the cardinal-uterosacral ligament complex. The first ULS suture, using polypropylene no. 1, was taken in the upper-most exposed area of the uterosacral ligament. The second suture, using polyglactin no. 1 or 0, was taken 0.5-1 cm below the first suture. During placement of both sutures, traction on the cervix was maintained. The cardinal-uterosacral ligament complex was clamped, dissected, and ligated 1 cm below the second suture. Vaginal hysterectomy was completed. Ends of the ULS suture were fastened to the vault via vesicovaginal and rectovaginal septum using polypropylene within and polyglactin outside vaginal mucosa. RESULTS: Prolapse stage was 3 in 42 cases and 4 in nine. Duration of operation ranged from 60 to 120 min. Blood loss was 100-300 ml. During follow-up (average 2.3 years) four (8.3%), cases had stage 1 pelvic organ prolapse (POP), three were lost to follow-up, and 44 (91.6%) had no POP. CONCLUSIONS: Using the cervix as a traction device is a good option when performing extraperitoneal ULS during vaginal hysterectomy to prevent vault prolapse.

Does Home Birth Reduce the Risk of Pelvic Organ Prolapse?

OBJECTIVES: To determine the relationship between vaginal birth and the development of POP among women who deliv-ered in non-hospital settings (home birth). MATERIAL AND METHODS: Data were collected retrospectively from the files of patients who presented to a hospital outpatient clinic between April 1, 2011 and April 1, 2012 with complaints of urinary incontinence, uterine sagging, vaginal mass, or vaginal pain. The patients' age, height, weight, body mass index, menopause age, number of deliveries, and presence of hypertension and diabetes mellitus were noted. Patients whose urogynecologic evaluation included POP Quantification (POP-Q) scoring were included in the study. The patients were separated into a group of women who had never given birth and another group of women with one or more deliveries. RESULTS: Of the 179 patients in the study, 28 had never given birth and 151 had given birth at least once. The nulliparous patients had no cystocele, rectocele, or uterine prolapse. The prevalence rates of cystocele, rectocele, and uterine prolapse were significantly higher in the multiparous group. Cystocele, rectocele, and uterine prolapse development were significantly correlated with number of deliveries, but there was no statistical association with age, body mass index, menopausal age, diabetes mellitus, or hypertension. univariate analysis reveals that the only factor effective in the development of cytocele, rectocele and prolapse is the number of births. CONCLUSIONS: Our study suggests that only number of deliveries is associated with development of cystocele, rectocele, and uterine prolapse in women who gave birth by vaginal route in residential settings.

Laparoscopic management of severe ureteral obstruction after vaginal hysterectomy and colposuspension.

INTRODUCTION AND HYPOTHESIS: After vaginal hysterectomy, uterosacral ligaments are commonly used to suspend the vaginal vault in order to prevent and to treat recurrence of central prolapse. Shull et al. proposed a technique to fix endopelvic fascia and vagina to the higher portion of the uterosacral ligaments using a vaginal approach [1]. This technique is associated with a risk of ureteral obstruction (0-11%) [2, 3]. Although intraoperative cystoscopy is recommended to check ureteral patency at the end of colposuspension, this secondary prevention technique could be false negative due to partial stenosis [4]. METHODS: A 60-year-old woman with stage 3 uterine and anterior compartment descensus assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system underwent vaginal hysterectomy, bilateral adnexectomy, and vaginal vault suspension to the uterosacral ligaments using the Shull technique. Intraoperative cystoscopy with indigo carmine was negative. On postoperative day 0, the patient complained left flank pain. Transabdominal ultrasound showed a left hydroureteronephrosis without ureteral stones, which was confirmed by uro-computed tomography scan. The attempts of ureteral stent positioning and opening the vaginal vault failed to resolve the ureteral obstruction, which was corrected, and a new vault suspension performed using the laparoscopic approach. Prophylactic ureteral stent positioning was performed. Informed consent was obtained from the patient for publication of this case report. RESULTS: The patient was discharged on postoperative day 5 with normal renal function. The ureteral stent was removed after 1 month, and renal ultrasound at 3 and 6 months' follow-up showed normal renal pelvis caliber. No recurrence of genital prolapse was observed at gynecological examination. CONCLUSIONS: Laparoscopy can be a wise alternative option to manage ureteral obstruction secondary to vaginal colposuspension for genital organ prolapse.

Clinical outcomes in women undergoing laparoscopic hysteropexy: A systematic review.

OBJECTIVES: To systematically review the current evidence on the anatomic and functional outcomes in women undergoing laparoscopic hysteropexy. STUDY DESIGN: An electronic database search was undertaken (2000-2016). Keywords were: "laparoscopy", "hysteropexy", "cervicopexy", "uterine suspension", "uterosacral plication". References of identified studies as well as abstracts from conferences were considered. We restricted the search to humans, female patients and currently used surgical procedures. Studies with ≥5 cases in English language and published in 2000 or later, were included. After the initial yield, studies were selected following title screening, abstract and full text scrutiny. RESULTS: A total of 17 studies were deemed suitable for inclusion in the review. A total of 770 patients in 17 studies received the intervention being studied (laparoscopic hysteropexy) and were assessed post-operatively with pooled success rates of 85.32% (95%CI: ±2.5). Laparoscopic suture hysteropexy has pooled success of 70.5% (95%CI:±5.33) whereas the pooled success of the suspension to the sacral promontory using mesh or tape is 92% (95%CI: ±2.53). One small study on suspension to the anterior abdominal wall (28 cases) and one to the pectineal ligament (18 cases) have shown 96.4% (95%CI:±6.9) and 94.5% (95%CI:±10.53) objective success rates respectively. CONCLUSION: Laparoscopic hysteropexy was associated with good anatomic cure rates of greater than 90% in majority of the studies. There was an improvement in symptoms, and good subjective cure rates in 73%-100% of the patients. Reoperation rates were low in most studies ranging from around 0%-28%. Complications rates were generally low. Laparoscopic hysteropexy is a feasible alternative for women needing surgical correction of uterovaginal prolapse and who desire conservation of the uterus.

Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse.

BACKGROUND: A wide variety of grafts have been introduced with the aim of improving the outcomes of traditional native tissue repair (colporrhaphy) for vaginal prolapse. OBJECTIVES: To determine the safety and effectiveness of transvaginal mesh or biological grafts compared to native tissue repair for vaginal prolapse. SEARCH METHODS: We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ongoing trials registers, and handsearching of journals and conference proceedings (6 July 2015). We also contacted researchers in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing different types of vaginal repair (mesh, biological graft, or native tissue). DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed risk of bias, and extracted data. The primary outcomes were awareness of prolapse, repeat surgery, and recurrent prolapse on examination. MAIN RESULTS: We included 37 RCTs (4023 women). The quality of the evidence ranged from very low to moderate. The main limitations were poor reporting of study methods, inconsistency, and imprecision. Permanent mesh versus native tissue repairAwareness of prolapse at one to three years was less likely after mesh repair (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.54 to 0.81, 12 RCTs, n = 1614, I(2) = 3%, moderate-quality evidence). This suggests that if 19% of women are aware of prolapse after native tissue repair, between 10% and 15% will be aware of prolapse after permanent mesh repair.Rates of repeat surgery for prolapse were lower in the mesh group (RR 0.53, 95% CI 0.31 to 0.88, 12 RCTs, n = 1675, I(2) = 0%, moderate-quality evidence). There was no evidence of a difference between the groups in rates of repeat surgery for continence (RR 1.07, 95% CI 0.62 to 1.83, 9 RCTs, n = 1284, I(2) = 21%, low-quality evidence). More women in the mesh group required repeat surgery for the combined outcome of prolapse, stress incontinence, or mesh exposure (RR 2.40, 95% CI 1.51 to 3.81, 7 RCTs, n = 867, I(2) = 0%, moderate-quality evidence). This suggests that if 5% of women require repeat surgery after native tissue repair, between 7% and 18% in the permanent mesh group will do so. Eight per cent of women in the mesh group required repeat surgery for mesh exposure.Recurrent prolapse on examination was less likely after mesh repair (RR 0.40, 95% CI 0.30 to 0.53, 21 RCTs, n = 2494, I(2) = 73%, low-quality evidence). This suggests that if 38% of women have recurrent prolapse after native tissue repair, between 11% and 20% will do so after mesh repair.Permanent mesh was associated with higher rates of de novo stress incontinence (RR 1.39, 95% CI 1.06 to 1.82, 12 RCTs, 1512 women, I(2) = 0%, low-quality evidence) and bladder injury (RR 3.92, 95% CI 1.62 to 9.50, 11 RCTs, n = 1514, I(2) = 0%, moderate-quality evidence). There was no evidence of a difference between the groups in rates of de novo dyspareunia (RR 0.92, 95% CI 0.58 to 1.47, 11 RCTs, n = 764, I(2) = 21%, low-quality evidence). Effects on quality of life were uncertain due to the very low-quality evidence. Absorbable mesh versus native tissue repairThere was very low-quality evidence for the effectiveness of either form of repair at two years on the rate of awareness of prolapse (RR 1.05, 95% CI 0.77 to 1.44, 1 RCT, n = 54).There was very low-quality evidence for the effectiveness of either form of repair on the rate of repeat surgery for prolapse (RR 0.47, 95% CI 0.09 to 2.40, 1 RCT, n = 66).Recurrent prolapse on examination was less likely in the mesh group (RR 0.71, 95% CI 0.52 to 0.96, 3 RCTs, n = 292, I(2) = 21%, low-quality evidence)The effect of either form of repair was uncertain for urinary outcomes, dyspareunia, and quality of life. Biological graft versus native tissue repairThere was no evidence of a difference between the groups at one to three years for the outcome awareness of prolapse (RR 0.97, 95% CI 0.65 to 1.43, 7 RCTs, n = 777, low-quality evidence).There was no evidence of a difference between the groups for the outcome repeat surgery for prolapse (RR 1.22, 95% CI 0.61 to 2.44, 5 RCTs, n = 306, I(2) = 8%, low-quality evidence).The effect of either approach was very uncertain for recurrent prolapse (RR 0.94, 95% CI 0.60 to 1.47, 7 RCTs, n = 587, I(2) = 59%, very low-quality evidence).There was no evidence of a difference between the groups for dyspareunia or quality of life outcomes (very low-quality evidence). AUTHORS' CONCLUSIONS: While transvaginal permanent mesh is associated with lower rates of awareness of prolapse, reoperation for prolapse, and prolapse on examination than native tissue repair, it is also associated with higher rates of reoperation for prolapse, stress urinary incontinence, or mesh exposure and higher rates of bladder injury at surgery and de novo stress urinary incontinence. The risk-benefit profile means that transvaginal mesh has limited utility in primary surgery. While it is possible that in women with higher risk of recurrence the benefits may outweigh the risks, there is currently no evidence to support this position.Limited evidence suggests that absorbable mesh may reduce rates of recurrent prolapse on examination compared to native tissue repair, but there was insufficient evidence on absorbable mesh for us to draw any conclusions for other outcomes. There was also insufficient evidence for us to draw any conclusions regarding biological grafts compared to native tissue repair.In 2011, many transvaginal permanent meshes were voluntarily withdrawn from the market, and the newer, lightweight transvaginal permanent meshes still available have not been evaluated within a RCT. In the meantime, these newer transvaginal meshes should be utilised under the discretion of the ethics committee.

Effect of uterine preservation on outcome of laparoscopic uterosacral suspension.

STUDY OBJECTIVE: To compare the objective outcome of laparoscopic uterosacral hysteropexy with that of hysterectomy combined with laparoscopic uterosacral colpopexy. DESIGN: Retrospective cohort study, 1999-2010 (Canadian Task Force classification II-2). SETTING: University hospital in South Australia. PATIENTS: Women with uterovaginal prolapse who had undergone laparoscopic uterosacral hysteropexy (n = 104) or laparovaginal hysterectomy with uterosacral colpopexy (n = 160). Apical suspension procedures were subdivided into prophylactic (Pelvic Organ Prolapse Quantification System [POP-Q] stage 1 apical descent, with stage ≥2 prolapse in an adjacent compartment) and therapeutic (POP-Q stage ≥2 apical descent, with or without adjacent compartment prolapse). INTERVENTIONS: All patients were assessed via POP-Q scoring preoperatively and postoperatively at 6 weeks, 6 months, annually, and then biannually. Recurrence of bulge symptoms and need for repeat treatment were recorded. MEASUREMENTS AND MAIN RESULTS: Demographic data, preoperative degree of prolapse, and percentages of prophylactic and therapeutic procedures were similar in both groups. With a median follow-up of 2.5 years, objective success rates (POP-Q stage <2 in all compartments) for uterosacral hysteropexy were 53% for prophylactic procedures and 41% for therapeutic procedures, and for hysterectomy with uterosacral colpopexy were 66% for prophylactic procedures and 59% for therapeutic procedures. Repeat operation rates overall were 28% for hysteropexy and 21% for hysterectomy with colpopexy. Failures at the apex specifically were 27% for hysteropexy and 11% for hysterectomy with colpopexy (p < .02). CONCLUSION: Hysterectomy with laparoscopic uterosacral colpopexy produced better objective success rates than did laparoscopic uterosacral hysteropexy; however, repeat operation rates were not significantly different.

A review of the technique and complications from 2,012 cases of laparoscopically assisted vaginal hysterectomy at a single institution.

AIMS: To present our experience of modified laparoscopically assisted vaginal hysterectomy (LAVH) and to evaluate the surgical outcomes and complications. METHODS: Women with benign gynaecologic tumours that underwent a modified LAVH at the Samsung Medical Centre were analysed retrospectively. The technique is primarily a vaginal hysterectomy with a minor component of the laparoscopic procedures (stage 2 laparoscopic hysterectomy (LH)) and had two modifications (vaginal anterior colpotomy and McCall culdoplasty) from the standard technique. RESULTS: A total of 2012 LAVH procedures were performed from January 2000 to May 2008. The mean duration of the operations and the uterine weight were 102±32 min and 305±168 g, respectively. In 196 (9.7%) cases, the uterine weight was more than 500 g. Conversion to laparotomy was needed in 97 cases. Major intraoperative complications occurred in 45 cases (2.2%): bladder injury, 26 (1.29%); bowel injury, nine (0.45%); haemorrhage of major vessels, nine (0.45%); and ureteral injury, one (0.05%). Major long-term complications occurred in three cases: one fistula and two trocar site herniations. CONCLUSIONS: Stage 2 LH combined with modified vaginal anterior colpotomy and modified McCall culdoplasty is safe and effective for benign gynaecologic tumours and the prevention of post-LAVH vaginal prolapse.

Prevención del prolapso genital en histerectomía abdominal utilizando los ligamentos redondos: experiencia personal / Prevention of genital prolapse in abdominal hysterectomy using the round ligaments: personal experience

Prevenir el prolapso de la cúpula vaginal, empleando una técnica peroperatoria que consiste en fijar la cúpula vaginal a los ligamentos redondos, en el momento de realizar la intervención. Realizada la histerectomía, se procedió al cierre de la cúpula vaginal con puntos separados en número de 6 a 8 con material no absorbible, dependiendo de la amplitud de la vagina. Los cabos distales son utilizados para anudar horizontalmente los ligamentos redondos. La fijación de las dos paredes del extremo superior de la vagina, garantiza mayor estabilidad de la vagina y menor posibilidad de producir el prolapso de la cúpula y/o de las paredes anterior y posterior de la vagina. Servicio de Ginecología, Hospital Universitario de Caracas. Las 124 pacientes histerectomizadas y controladas anualmente en un lapso entre 2 y 27 años, con un promedio de 7 años, ninguna de ellas presentó prolapso de cúpula vaginal. Las histerectomías se realizaron en el ejercicio privado. En centros asistenciales públicos, es muy difícil hacer seguimiento y evaluar las pacientes, por razones múltiples. La histerectomía ocupa el primer lugar de las intervenciones ginecológicas, esto obliga a realizar la suspensión y fijación de la cúpula vaginal y simultáneamente corregir la patología asociada del aparato genital. El procedimiento que hemos empleado tuvo resultados muy favorables. La calidad de vida de las mujeres intervenidas quirúrgicamente no se desmejoró, como suele suceder cuando se produce el prolapso de la cúpula vaginal

To prevent vaginal vault prolapse, using a preoperative technique to fix the vaginal vault to the round ligaments in total abdominal hysterectomy, and identify associated pathology in the genital area. After hysterectomy, we proceed to the closure of the vaginal vault with interrupted sutures with non-absorbable material, in number of 6-8, depending of the amplitude of the vagina, the distal ends are used to tie horizontally bilateral round ligaments. The setting of the two upper walls of the vagina, ensures greater stability of the vagina and lower possibility of occurrence of prolapse of the dome and/or the anterior and posterior vaginal walls. Servicio de Ginecologia, Hospital Universitario de Caracas The 124 patients undergoing hysterectomy, checked annually over a period of time between 2 and 27 years, with an average of 7 years, neither had vaginal prolapse. Histerectomy is the firstone gynecological operation. It requires making the suspension and fixation of the vaginal vault and simultaneously correct the genital tract associated pathology. The procedure we used had very favorable results. We can not compare our results with other techniques, do to scarse national an international references. The quality of life of women surgically intervened did not deteriorated, as usually happens when there is prolapse of the vaginal vault

Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up.

OBJECTIVE: The objective of the study was to compare anterior colporrhaphy with and without a mesh. STUDY DESIGN: Two hundred two women with anterior prolapse were assigned to undergo colporrhaphy alone or reinforced with a tailored polypropylene mesh. Before and 2, 12, 24, and 36 months after surgery, the outcome was assessed by examination and standard questions. The primary endpoint was anatomic recurrence of anterior vaginal prolapse. Secondary outcomes were symptom resolution, reoperation, and mesh exposure. RESULTS: Recurrences of anterior vaginal prolapse were noted in 40 of the 97 (41%) in the colporrhaphy group and 14 of 105 (13%) in the mesh group (P < .0001). The number needed to treat was thus 4. The proportion of symptomatic patients, including those with dyspareunia, did not differ between the groups. The mesh erosion rate was 19%. CONCLUSION: At 3 year follow-up, anterior colporrhaphy with mesh reinforcement significantly reduced anatomic recurrences of anterior vaginal prolapse, but no difference in symptomatic recurrence were noted and the mesh erosion rate was high. The use of mesh was not associated with an increase in dyspareunia.

Transvaginal mesh repair of anterior and posterior vaginal wall prolapse: a clinical and ultrasonographic study.

OBJECTIVES: To investigate whether ultrasonography coupled with clinical examination can help in understanding the mechanism of recurrence after transvaginal mesh repair of anterior and posterior vaginal wall prolapse. METHODS: Ninety-one patients who had undergone surgery for anterior and/or posterior vaginal wall prolapse with the Prolift system had a clinical examination and introital/endovaginal two-dimensional ultrasonography a minimum of 1 year later. The retraction of anterior and posterior meshes was estimated relative to the original length of the mesh by transvaginal palpation. Patients with no, moderate (< 50%) or severe (> or = 50%) mesh retraction were compared. Anterior recurrence of prolapse was defined according to the International Continence Society by a Ba value > or = -1 and posterior recurrence by a Bp value > or = -1 (where Ba represents the most distal position of the anterior vaginal wall and Bp the most distal position of the posterior vaginal wall). On ultrasonography, two distances were measured in the midsagittal plane: Distance 1, from the distal margin of the anterior mesh to the bladder neck, and Distance 2, from the distal margin of the posterior mesh to the rectoanal junction. RESULTS: Seventy-five anterior and 62 posterior meshes were studied at a mean follow-up of 17.9 months. Patients with anterior recurrence presented significantly more often with severe anterior mesh retraction compared with patients without anterior recurrence (5/8 vs. 2/67, P < 0.001) and also had an increased Distance 1 (P < 0.001). Patients with posterior recurrence presented significantly more often with severe posterior mesh retraction compared with patients without posterior recurrence (3/4 vs. 3/58, P < 0.01) and also had an increased Distance 2 (P < 0.01). CONCLUSIONS: Recurrence of prolapse after transvaginal mesh repair appears to be associated with severe mesh retraction and loss of mesh support on the distal part of the vaginal walls.

Pelvic-floor imaging using three-dimensional ultrasonography and magnetic resonance imaging in the long term follow-up of the bladder-exstrophy-epispadias complex.

OBJECTIVE: To investigate whether established pelvic floor variables can be used to predict the risk of uterine prolapse after surgery and to compare two different operative strategies, pelvic adaptation with functional reconstruction and an open pelvis with urinary diversion, as a congenital bony pelvis and pelvic floor defect predisposes females with bladder-exstrophy-epispadias complex (BEEC) to uterine prolapse. PATIENTS, SUBJECTS AND METHODS: We conducted a cross-sectional study using perineal three-dimensional ultrasonography (3D-US) and magnetic resonance imaging (MRI) to describe pelvic floor anatomy in 19 women with BEEC (mean age 27.3 years) and five controls, with the outcome evaluated by a semi-structured interview. The analysis of 3D-US and MRI was conducted by two independent investigators. RESULTS: Of the 19 women with BEEC, 13 initially had a functional bladder reconstruction, six a urinary diversion with removal of the exstrophic bladder, and 12 women had closure of the pelvis either by traction bandage or osteotomy, and in the other seven the symphysis was not approximated. Four patients had a complete and one a mild uterine prolapse. After a mean follow-up of 24 years, the mean symphyseal diastasis was 4.5 cm after symphyseal approximation, 9.0 cm without symphyseal approximation in BEEC and 0.49 cm in controls. The mean levator hiatus was 4.9 cm on 3D-US and 4.1 cm on MRI after symphyseal approximation, 5.9 and 7.6 cm without symphyseal approximation and 4.2 and 3.2 cm in controls, respectively. The respective mean levator angle was 86.6 degrees and 87.3 degrees after symphyseal approximation, 104.1 degrees and 101.3 degrees without and 71.3 degrees and 45.5 in controls. Prolapse was statistically significantly more common in patients with no symphyseal approximation. CONCLUSION: This is the first study showing that perineal 3D-US is useful for pelvic floor imaging in BEEC. Established pelvic floor variables might be useful for predicting the risk of pelvic organ prolapse in BEEC.

Body image and sexuality in women with pelvic organ prolapse.

INTRODUCTION: The effect of physical changes associated with pelvic organ prolapse on a woman's body image and how that may influence sexuality has not been well studied. OBJECTIVE: The goal of this study was to assess the implementation and utility of a body image questionnaire in women with pelvic organ prolapse. Two research questions were asked: (1) What is the impact of pelvic organ prolapse on women's body image and how does this affect their sexual health?, and (2) Does the Vaginal Changes Sexual and Body Esteem (VSBE) Scale show utility for use in assessing body image and sexual health in women with pelvic organ prolapse? METHOD: A qualitative design was used for this study. Telephone interviews were conducted using a semi-structured questionnaire and an adapted body image and sexuality questionnaire specific to genital body image. RESULTS: Thirteen women with pelvic organ prolapse completed the study. Eight women were classified as sexually active, and 5 women were not sexually active. Data showed women with pelvic organ prolapse, classified as sexually active, scored significantly lower on the VSBE scale than women who were not sexually active. There was a positive correlation between severity of prolapse and VSBE scores. CONCLUSION: The VSBE scale questionnaire showed utility and potential for demonstrating change in body image in women with pelvic organ prolapse. This tool may assist clinicians in a more thorough assessment of body image and sexuality in this population of women.

[Recommendations of The Polish Society of Obsterics and Gynaecology regarding prevention and treatment of pelvic organ prolapse and urinary incotinence in patients qualified to hysterectomy]. / Rekomendacje Polskiego Towarzystwa Ginekologicznego dotyczace profilaktyki oraz leczenia zaburzen statyki narzadów plciowych i wysilkowego nietrzymania moczu u pacjentek zakwalifikowanych do histerektomii.

To develop guidelines regarding prevention and treatment of pelvic organ prolapse and stress urinary incontinence in patients qualified to hysterectomy. The Polish Gynecological Society formed a work group to develop guidelines. The work group formulated the following guidelines: 1. Since the hysterectomy per se is a risk factor for pelvic organ prolapse, more conservative procedures to hysterectomy should be considered and applied, whenever it is possible. 2. Pelvic organ prolapse is not the indication for hysterectomy. 3. Not all lesions of the uterine cervix without concomitant pathological changes of the uterine corpus are indications for hysterectomy. 4. During both abdominal and laparoscopic hysterectomy the fixation of vaginal vault to sacro-uterine and round ligaments, McCall procedure, Burch procedure and paravaginal defect repair should be done as a prevention or treatment of pelvic organ prolapse. 5. During vaginal hysterectomy, sacrospinal colpopexy or McCall procedure is recommended. 6. In cases of hysterectomy performed due to oncological indications, prophylactic fixation of the vaginal vault to sacro-uterine and round ligaments is recommended. In these cases, the repair of the defects of DeLancey second and third level are not recommended because of postradiotherapy vaginal vault shortening and stenosis. In most of oncological indications for hysterectomies, the surgical treatment of stress urinary incontinence should be postponed until the radiotherapy has been completed.

Use of synthetic mesh to prevent recurrent vaginal evisceration: a case report.

Vaginal evisceration of the bowel is a rare and life-threatening complication of gynecologic surgery; recurrence is even more rare. Most cases in the literature discuss primary closure of the dehisced vaginal cuff with delayed absorbable sutures via a vaginal, abdominal, or laparoscopic approach. The case presented here is of a patient who had a history of recurrent vaginal evisceration treated with an abdominal sacrocolpopexy utilizing synthetic mesh. Further recurrence, to date, has been prevented.

Does supracervical hysterectomy provide more support to the vaginal apex than total abdominal hysterectomy?

OBJECTIVE: The objective of the study was to assess whether cervical preservation at the time of hysterectomy may help prevent subsequent apical vaginal vault prolapse. STUDY DESIGN: Supracervical hysterectomies were performed in 12 unembalmed cadavers. Successive hanging weights of 1, 2, 3, and 4 kg were loaded against the cervical stump and distances moved were recorded. The same process was repeated after completion of a total hysterectomy. RESULTS: Average distances pulled with 1, 2, 3, and 4 kg of traction against the cervical stump were 17.8 +/- 1.9, 24.1 +/- 2.5, 29.0 +/- 2.8, and 34.3 +/- 3.5 mm, respectively. After total hysterectomy, these distances were 17.5 +/- 2.5, 23.5 +/- 2.6, 29.3 +/- 3.1, and 34.5 +/- 3.6 mm, respectively. CONCLUSION: In unembalmed cadavers, it appears that total abdominal hysterectomy and supracervical hysterectomy provide equal resistance to forces applied to the vaginal apex.

Sacrospinous ligament fixation for neovaginal prolapse prevention in male-to-female surgery.

OBJECTIVES: To report our experiences of vaginal sacrospinous ligament fixation after vaginoplasty in male transsexual patients with the aim of preventing its postoperative prolapse. METHODS: From August 1997 through November 2005, a total of 62 male transsexual patients (mean age 26 years, range 18 to 58) underwent sacrospinous ligament fixation for neovaginal prolapse during male-to-female sex reassignment surgery. The neovagina was created from a penile skin tube flap combined with a urethral flap. A deep and wide perineal cavity between the urethra, bladder, and rectum was created by dissection of the tendineous center and rectourethral muscle. The right pararectal space was opened by penetrating the right pararectal fascia (rectal pillar) and right ischial spine was palpated. Using the ischial spine as a prominent landmark, the sacrospinous ligament was palpated. Long-handled Deschamps ligature was used to pierce the ligament medially to the ischial spine. Vaginopexy to the sacrospinous ligament was performed, and the neovagina was placed deep in the perineal cavity. RESULTS: The median follow-up was 32 months (range 7 to 102). Sacrospinous ligament fixation was successfully performed in all patients. The mean vaginal length was 10.7 cm (range 9.5 to 16). Of the 62 patients, 42 (76%) were able to have normal sexual intercourse. The appearance of the neovagina was aesthetically acceptable in 52 patients. In 3 cases, a minor bulge of the anterior vaginal wall was easily resolved by simple excision. CONCLUSIONS: Vaginal sacrospinous fixation is feasible in male transsexuals for neovaginal prolapse prevention. However, extensive experience with male pelvic surgery is required to avoid possible complications.