Combined Robotic Ventral Mesh Rectopexy and Sacrocolpopexy for Multicompartmental Pelvic Organ Prolapse.

BACKGROUND: Multispecialty management should be the preferred approach for the treatment of pelvic floor dysfunction because there is often multicompartmental prolapse. OBJECTIVE: To assess the safety of combined robotic ventral mesh rectopexy and either uterine or vaginal fixation for the treatment of multicompartmental pelvic organ prolapse at our institution. DESIGN: Retrospective analysis. SETTINGS: Tertiary referral academic center. PATIENTS: All patients who underwent a robotic approach and combined procedure and whose cases were discussed at a biweekly pelvic floor multidisciplinary team meeting. MAIN OUTCOME MEASURES: Operative time, intraoperative blood loss and complications, postoperative pelvic organ prolapse quantification score, length of stay, 30-day morbidity, and readmission. RESULTS: From 2018 to 2021, there were 321 operations for patients with multicompartmental prolapse. The mean age was 63.4 years. The predominant pelvic floor dysfunction was rectal prolapse in 170 cases (60%). Pelvic organ prolapse quantification scores were II in 146 patients (53%), III in 121 patients (44%), and IV in 9 patients (3%); 315 of 323 cases included robotic ventral mesh rectopexy (98%). Sacrocolpopexy or sacrohysteropexy was performed in 281 patients (89%). Other procedures included 175 hysterectomies (54%), 104 oophorectomies (32%), 151 sling procedures (47%), 149 posterior repairs (46%), and 138 cystocele repairs (43%). The operative time for ventral mesh rectopexy was 211 minutes and for combined pelvic floor reconstruction was 266 minutes. Average length of stay was 1.6 days. Eight patients were readmitted within 30 days: 1 with a severe headache and 7 with postoperative complications (2.5%), such as pelvic collection and perirectal collection, both requiring radiologic drainage. Four complications required reoperation: epidural abscess, small-bowel obstruction, missed enterotomy requiring resection, and urinary retention requiring sling revision. There were no mortalities. LIMITATIONS: Retrospective single-center study. CONCLUSIONS: A combined robotic approach for multicompartmental pelvic organ prolapse is a safe and viable procedure with a relatively low rate of morbidity and no mortality. This is the highest volume series of combined robotic pelvic floor reconstruction in the literature and demonstrates a low complication rate and short length of stay. See Video Abstract . RECTOPEXIA Y SACROCOLPOPEXIA ROBTICA VENTRAL COMBINADAS CON MALLA PARA EL PROLAPSO DE RGANOS PLVICOS MULTICOMPARTIMENTALES: ANTECEDENTES:El tratamiento multiespecializado debe ser el enfoque preferido para el tratamiento de la disfunción del suelo pélvico, ya que a menudo hay prolapso multicompartimental.OBJETIVO:Evaluar la seguridad de la rectopexia robótica combinada con malla ventral y fijación uterina o vaginal para el tratamiento del prolapso multicompartimental de órganos pélvicos en nuestra institución.DISEÑO:Análisis retrospectivo.AJUSTES:Centro académico de referencia terciarioPACIENTES:Todos los pacientes que se sometieron a un enfoque robótico y un procedimiento combinado y se discutieron en una reunión quincenal del equipo multidisciplinario sobre el piso pélvico.MEDIDAS DE RESULTADO:Tiempo operatorio, pérdida de sangre intraoperatoria y complicaciones. Puntuación de cuantificación del prolapso de órganos pélvicos posoperatorio, duración de la estancia hospitalaria, morbilidad a 30 días y reingreso.RESULTADOS:De 2018 a 2021, se realizaron 321 operaciones de pacientes con prolapso multicompartimental. La edad media fue 63.4 años. La disfunción del suelo pélvico predominante fue el prolapso rectal en 170 casos (60%). Las puntuaciones de cuantificación del prolapso de órganos pélvicos fueron II en 146 pacientes (53%), III en 121 (44%) y IV en 9 (3%); 315 de los 323 casos incluyeron rectopexia robótica de malla ventral (98%). Se realizó sacrocolpopexia o sacrohisteropexia en 281 pacientes (89%). Otros procedimientos incluyeron 175 histerectomías (54%), 104 ooforectomías (32%), 151 procedimientos de cabestrillo (47%), 149 reparaciones posteriores (46%) y 138 reparaciones de cistocele (43%). El tiempo operatorio para la rectopexia con malla ventral fue de 211 minutos y la reconstrucción combinada del piso pélvico de 266 minutos. La estancia media fue de 1.6 días. Ocho pacientes reingresaron dentro de los 30 días, 1 con dolor de cabeza intenso y 7 pacientes con complicaciones posoperatorias (2.5%): colección pélvica y colección perirrectal, ambas requirieron drenaje radiológico. Cuatro complicaciones requirieron reoperación: absceso epidural, obstrucción del intestino delgado, enterotomía omitida que requirió resección y retención urinaria que requirió revisión del cabestrillo. No hubo mortalidades.LIMITACIONES:Estudio retrospectivo unicéntrico.CONCLUSIONES:Un enfoque robótico combinado para el prolapso multicompartimental de órganos pélvicos es un procedimiento seguro y viable con una tasa relativamente baja de morbilidad y ninguna mortalidad. Esta es la serie de mayor volumen de reconstrucción robótica combinada del suelo pélvico en la literatura y demuestra una baja tasa de complicaciones y una estancia hospitalaria corta. (Traducción-Dr. Aurian Garcia Gonzalez )See Editorial on page 195.

Transcriptional Regulation of Connective Tissue Metabolism Genes in Women With Pelvic Organ Prolapse.

OBJECTIVE: The aim of this study was to compare differences in expressions and relationships between key genes involved in extracellular matrix metabolism and tissue cellularity in women with and without pelvic organ prolapse (POP). METHODS: A total of 80 biopsies (anterior cuff, posterior cuff, and/or leading edge) were obtained from 30 women: n = 10 premenopausal without POP (controls), n = 10 premenopausal with POP, and n = 10 postmenopausal with POP. Quantitative reverse-transcriptase polymerase chain reaction was used to assess gene expression of bone morphogenetic protein 1 (BMP1), collagen types I (COL1) and III (COL3), relaxin family peptide receptor 1 (RXFP1), matrix metallopeptidase 2, and TIMP metallopeptidase inhibitors 2 and 3. Hematoxylin and eosin staining was used to assess cellularity of the connective tissue layer. Kruskal-Wallis test, Mann-Whitney U test, Pearson correlation, or linear regression analyses were used, as appropriate. RESULTS: Bone morphogenetic protein 1 expression was significantly up-regulated in patients with POP compared with controls. Bone morphogenetic protein 1 expression was correlated with COL1 expression in all groups but only correlated with TIMP metallopeptidase inhibitor 3 expression in controls. Similarly, COL3 expression was correlated with RXFP1 expression in women with POP but not in controls. The degree of dependence (slope of the regression line) between COL1 and COL3 expressions was significantly elevated in premenopausal women with POP compared with the other 2 groups. The slopes between COL1-COL3, COL3-matrix metallopeptidase 2, COL1-RXFP1, and COL3-RXFP1 expressions were significantly lower in postmenopausal women compared with premenopausal women with POP. No differences were found in overall tissue cellularity. CONCLUSIONS: Bone morphogenetic protein 1 expression may play a significant role in the pathophysiology of POP. The finding that BMP1 expression was correlated with COL1 expression in all groups suggests a conserved association between BMP1 and collagen synthesis in the vaginal wall. The elevated slope between COL1 and COL3 expressions may be associated with early (premenopausal) development of POP. The expression of RXFP1 in postmenopausal women and its altered intergene regulation suggests a role for RXFP1 in connective tissue metabolism outside pregnancy.

Vaginal Expression of LOXL1 in Premenopausal and Postmenopausal Women With Pelvic Organ Prolapse.

OBJECTIVES: This study aimed to compare cellular expression of lysyl oxidase-like 1 (LOXL1), a key enzyme in elastin metabolism, of premenopausal women with pelvic organ prolapse (POP) compared with premenopausal controls without POP and postmenopausal women with POP. In addition, we examined whether variation of LOXL1 expression was dependent on biopsy site. METHODS: A standardized protocol was utilized to obtain vaginal biopsies from 30 women (10 premenopausal POP, 10 postmenopausal POP, and 10 premenopausal non-POP). Expression levels of messenger RNA (mRNA) and protein of LOXL1 were determined using real-time quantitative polymerase chain reactions and enzyme-linked immunosorbant assays. Analysis was performed to determine if there were differences between group or biopsy site. RESULTS: Significant differences in LOXL1 mRNA expression were found between patient groups (P = 0.0033). LOXL1 mRNA expression (relative to 18S) was upregulated in the postmenopausal POP group (54.5 ± 14.7) compared with the premenopausal POP group (5.2 ± 14.7, P = 0.0034) and the premenopausal non-POP group (23 ± 18, P = 0.0359). No significant differences in LOXL1 protein expression (nanogram/milliliter per microgram total protein) were seen between groups (premenopausal POP, 3.2 × 10 ± 6.3 × 10; postmenopausal POP, 4.3 × 10 ± 6.3 × 10; premenopausal non-POP, 5.0 × 10 ± 7.7 × 10; P = 0.15). No differences in mRNA expression were seen between sites (P = 0.74), but significant variation was noted in protein expression (P = 0.001). CONCLUSIONS: Premenopausal and postmenopausal women with POP exhibit differential expression of LOXL1 suggesting different pathways in the pathogenesis of POP. The role of biopsy location on LOXL1 expression requires further investigation.

Bacterial uropathogens and antibiotic susceptibility of positive urine cultures in women with pelvic organ prolapse and urinary incontinence.

AIMS: The aims of the study are to describe the speciation and resistance patterns of positive urinary cultures in women with pelvic floor disorders (PFDs) and those undergoing pelvic reconstructive surgery. METHODS: Urine cultures with a colony count of >10(5) CFU and <3 isolated uropathogens at a tertiary care Urogynecology practice over a 5-year period for patients with anterior wall dominant pelvic organ prolapse (POP) or urinary incontinence (UI) were identified. Speciation and culture sensitivity data were described for each group and compared to a control group who did not currently have a PFD and who had not undergone pelvic surgery within a year of their positive culture. Additionally, early post-operative UTIs (≤6 weeks) and late post-operative UTIs (>6 weeks but ≤1 year) were compared. RESULTS: 1,306 positive urine cultures over the 5-year period with 51 different species of uropathogens were identified. The percentage of Escherichia coli identified was not significantly different between groups: POP 57.1%, Stress UI 58.4%, Urge UI 54.3%, non-operative controls 54.3%. Cultures obtained from patients on prophylactic antibiotics were significantly less likely to have E. coli (adjusted OR 0.45, 95% CI 0.22, 0.89, P < 0.0216). Non-E. coli cultures were more common in the early post-operative period compared to the late post-operative cultures (69% vs. 41%, adjusted OR 0.33, 95% CI 0.22, 0.48, P < 0.0001). CONCLUSIONS: Patients with PFDs who develop UTIs have rates of non-E. coli over 40% of the time. Treatment based on culture and antibiotic sensitivity data should be considered.

Uterine Conservation During Prolapse Repair: 9-Year Experience at a Single Institution.

OBJECTIVES: The primary aim is to compare safety and long-term outcomes between uterine-sparing prolapse procedures performed using 4 different surgical routes over a 9-year period. METHODS: This is a retrospective cohort study of women who underwent uterine-sparing prolapse procedures performed by 10 female pelvic medicine and reconstructive surgeons between January 2003 and December 2011. Demographic information, operative characteristics, complications (intraoperative and postoperative), and prolapse recurrence were obtained by chart review. Additional information collected included subsequent uterine or cervical pathology, procedures, and pregnancies. RESULTS: Two hundred forty uterine-sparing prolapse procedures were performed in the 9-year period. One hundred two patients (42.5%) underwent a vaginal procedure, 95 patients (39.6%) underwent a conventional laparoscopic procedure, 28 patients (11.7%) underwent a robotic-assisted laparoscopic procedure, and 15 patients (6.3%) underwent an abdominal procedure. Median follow-up time and interquartile range for abdominal, vaginal, laparoscopic, and robotic surgical routes were 16.4 (3.9-23.9), 14 (3.3-36.4), 22.6 (2.9-64.5), and 6.1 (3-24.4) months, respectively. Prolapse recurrence rates were similar for all groups (abdominal 13.3%, vaginal 14.7%, laparoscopic 11.6%, robotic 3.6%; P = 0.39). Intraoperative, postoperative, and long-term complications rates were similar between all groups (P = 0.63, P = 0.43, P = 0.10). The rate of benign gynecologic conditions encountered after surgery was similar among all groups, with an overall rate of abnormal uterine bleeding/postmenopausal bleeding of 5.4% and overall rate of cervical dysplasia of 0.8%. Two pregnancies were reported, both undergoing cesarean delivery at term. CONCLUSIONS: Uterine-sparing prolapse procedures appear to have good long-term safety and a low risk of future gynecologic pathology.

The effect of an air knot on surgical knot integrity.

OBJECTIVE: Surgical trainees may tie air knots, which have a questionable tensile strength and rate of untying. The purpose of this study was to determine the effect of an air knot on knot integrity. METHODS: The 5 suture materials tested were 0-0 gauge coated polyethylene, polyglyconate, glycolide/lactide, polypropylene, and silk. The suture was tied between 2 hex screws 50 mm on center. The strands were tied using 5 square throws, and the knot tails were cut at 3-mm length. To create a standardized air knot, a round common nail measuring 3 mm in diameter was inserted between throws before tying square throw #3. The suture loop was positioned around the upper and lower hooks of the tensiometer so the location of the knot was roughly equidistant from the hooks. Ultimately, either the loop broke or the knot slipped. At that time, the peak tensile force as well as the outcome of the knot were recorded. RESULTS: A total of 480 knots were tied. The presence of an air knot significantly lowered the tension at knot failure in the glycolide/lactide (P = 0.0003), polypropylene (P = 0.0005), and silk (P = 0.0001) knot configurations. Air knots had the same integrity as surgical knots when coated polyethylene and polyglyconate suture were used. Linear regression was performed and identified both suture material (P < 0.0001) and presence of an air knot (P < 0.0001) to be independently associated with a lower tension at failure. CONCLUSIONS: Under laboratory conditions, an air knot may contribute to a lower tensile strength at failure for certain suture materials.

Assessing intraoperative judgment using script concordance testing through the gynecology continuum of practice.

OBJECTIVE: To measure surgical judgment across the Obstetrics and Gynecology (OBGYN) continuum of practice and identify factors that correlate with improved surgical judgment. METHODS: A 45-item written examination was developed using script concordance theory, which compares an examinee's responses to a series of "ill-defined" surgical scenarios to a reference panel of experts. The examination was administered to OBGYN residents, Female Pelvic Medicine and Reconstructive Surgery (FPMRS) fellows, practicing OBGYN physicians and FPMRS experts. Surgical judgment was evaluated by comparing scores against the experts. Factors related to surgical experience were measured for association with scores. RESULTS: In total, 147 participants including 11 residents, 37 fellows, 88 practicing physicians and 11 experts completed the 45-item examination. Mean scores for practicing physicians (65.2 ± 7.4) were similar to residents (67.2 ± 7.1), and worse than fellows (72.6 ± 4.2, p < 0.001) and experts (80 ± 5, p < 0.001). Positive correlations between scores and surgical experience included: annual number of vaginal hysterectomies (r = 0.32, p = <0.001), robotic hysterectomies (r = 0.17, p = 0.048), stress incontinence (r = 0.29, p < 0.001) and prolapse procedures (r = 0.37, p < 0.001). Inverse correlation was seen between test scores and years in practice. (r = -0.19, p = 0.02). CONCLUSION: Intraoperative judgment in practicing OBGYN physicians appears similar to resident physicians. Practicing physicians who perform FPMRS procedures perform poorly on this examination of surgical judgment; lower performance correlates with less surgical experience and the greater amount of time in practice.

Tools for the direct observation and assessment of psychomotor skills in medical trainees: a systematic review.

CONTEXT: The Accreditation Council for Graduate Medical Education (ACGME) Milestone Project mandates programmes to assess the attainment of training outcomes, including the psychomotor (surgical or procedural) skills of medical trainees. The objectives of this study were to determine which tools exist to directly assess psychomotor skills in medical trainees on live patients and to identify the data indicating their psychometric and edumetric properties. METHODS: An electronic search was conducted for papers published from January 1948 to May 2011 using the PubMed, Education Resource Information Center (ERIC), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Web of Science electronic databases and the review of references in article bibliographies. A study was included if it described a tool or instrument designed for the direct observation of psychomotor skills in patient care settings by supervisors. Studies were excluded if they referred to tools that assessed only clinical or non-technical skills, involved non-medical health professionals, or assessed skills performed on a simulator. Overall, 4114 citations were screened, 168 (4.1%) articles were reviewed for eligibility and 51 (1.2%) manuscripts were identified as meeting the study inclusion criteria. Three authors abstracted and reviewed studies using a standardised form for the presence of key psychometric and edumetric elements as per ACGME and American Psychological Association (APA) recommendations, and also assigned an overall grade based on the ACGME Committee on Educational Outcome Assessment grading system. RESULTS: A total of 30 tools were identified. Construct validity based on associations between scores and training level was identified in 24 tools, internal consistency in 14, test-retest reliability in five and inter-rater reliability in 20. The modification of attitudes, knowledge or skills was reported using five tools. The seven-item Global Rating Scale and the Procedure-Based Assessment received an overall Class 1 ACGME grade and are recommended based on Level A ACGME evidence. CONCLUSIONS: Numerous tools are available for the assessment of psychomotor skills in medical trainees, but evidence supporting their psychometric and edumetric properties is limited.

Management options for women with uterine prolapse interested in uterine preservation.

A variety of nonsurgical and surgical treatment options exist for the treatment of pelvic organ prolapse. While nonsurgical management is often selected as first-line treatment, many women eventually elect to undergo surgical management. Traditionally, prolapse repair often includes concomitant hysterectomy; however, women increasingly desire uterine preservation for a myriad of reasons. Multiple surgical procedures have been described to correct apical prolapse while preserving the uterus. Many studies suggest similar anatomic and functional outcomes compared to prolapse procedures with concomitant hysterectomy. Potential benefits include decreased operative time and avoidance of hysterectomy-specific complications, although there are several unique issues to consider if the uterus is retained. Surgeons must provide adequate counseling and preoperative evaluation before proceeding with uterine preservation.

Groin granuloma formation after midurethral sling.

BACKGROUND: Complications of midurethral transoburator slings include injuries directly associated with trocar placement or subsequent erosion of the mesh that is placed. While tissue reaction to implanted mesh material occurs, rarely does it produce clinical symptoms. We report a case of granuloma formation after a transobturator tape midurethral sling presenting as a groin mass. CASE: A 59-year-old para 2 postmenopausal woman underwent uncomplicated placement of a transobturator tape midurethral sling concomitantly with prolapse repair. Two years later, she presented to her primary care physician complaining of a 1-cm groin mass. After failure of empiric treatment with antibiotics for a presumed infectious etiology, surgical resection of the mass was performed, which revealed granuloma formation surrounding the polypropylene mesh. CONCLUSION: Granuloma formation can occur years after placement of a midurethral transobturator sling. Whereas a rare complication, it is important for surgeons to consider this diagnosis during the workup of a groin mass.

Enterococcus osteomyelitis secondary to pyelonephritis.

We report a case of enterococcus lumbar osteomyelitis that developed after post-operative pyelonephritis. A 78-year-old G2P2 with Stage III uterovaginal prolapse and genuine stress urinary incontinence who underwent laparoscopic-assisted vaginal hysterectomy, high uterosacral ligament suspension, tension-free vaginal tape-obturator approach, and cystoscopy presented with post-operative back pain. Work-up of her back pain revealed enterococcus pyelonephritis. She continued to have back pain despite outpatient antibiotic treatment and further work-up revealed enterococcus lumbar osteomyelitis at the level of L1-L2. Enterococcus vertebral osteomyelitis is a rare infection that can occur by hematogenous spread from an infection of the urinary tract.

Effect of petroleum gauze packing on the mechanical properties of suture materials.

OBJECTIVE: To test the tensile properties of knotted suture made of 4 different suture materials and exposed to petroleum gauze. STUDY DESIGN: We tested the tensile strength of United States Pharmacopeia size 0-0 gauge polydioxanone, polyglyconate, glycolide/lactide copolymer, and silk when exposed to petroleum packing or saline. Suture materials were randomized, and knots were tied and then evaluated via tensiometer to the point of knot failure. RESULTS: A total of 285 knots were tied in 8 groups based on material and exposure to saline or petroleum gauze. We found that petroleum exposure knots failed at a mean of 116.7 N (SD = 31.5) and that saline soaked knots failed at 123.8 N (SD = 32.0). We conducted a 4 × 2 factorial analysis of variance, finding knots exposed to petroleum failed at a statistically significantly lower tensile strengths than saline soaked knots (p = 0.002). CONCLUSION: Petroleum-exposed sutures fail at lower tensions than saline-exposed sutures.

Minimum number of throws needed for knot security.

OBJECTIVE: The purpose of the study was to determine the optimal number of throws to ensure knot security. STUDY DESIGN: Knots were tied with 3, 4, 5, or 6 square throws with 0-gauge coated polyester, polydioxanone, polypropylene, and polyglactin 910. The suture was soaked in 0.9% sodium chloride and subsequently transferred to a tensiometer and broken. RESULTS: A total of 225 knots were tied. Regardless of the suture type, tension at failure for knots with 4 throws, 5 throws, and 6 throws was higher than tension at failure of knots with only 3 throws (p < 0.05 for each). We found no difference in the tensile strength between knots with 4, 5, or 6 throws (p > 0.05 for each). Knots with 4 throws were significantly more likely to come untied than knots with 5 or 6 throws (p < 0.01). CONCLUSIONS: Under laboratory conditions, the ideal knot has 5 throws to maximize tensile strength and rate of untying. This finding does not seem to vary by type of suture material.