Uterine Scar Evaluation during the Postpartum: Pleading for Extradecidual Suturing during Cesarean Section.

OBJECTIVE: Our objective is to evaluate ultrasound differences in uterine scar between techniques using extramucosal suturing and full thickness suturing of the uterine incision. STUDY DESIGN: A retrospective observational study included cases of primary cesarean section. At 6-week postpartum, we evaluated by endovaginal ultrasound two elements in the sagittal view: the thickness of the uterine scar and the surface of defect (niche). Hysterotomy sites closed using a running full-thickness technique including the uterine mucosa (group 1) were compared to hysterotomies operated by the same surgeon but with extramucosal suturing (group 2). The operator switched from the running suture technique to extramucosal in 2013. RESULTS: The study included 241 patients (115 cases in group 1 that were compared to 126 cases in group 2). There were no significant differences in age or body mass index between the two groups. Cesarean scar and niche were detectable in the entire studied population. There was a significant difference in both uterine scar thickness (5.8 vs. 6.2 mm, p = 0.02) and the presence and size of the niche (49 vs. 40 mm2, p = 0.001) in transvaginal ultrasound performed at 6-week postpartum. CONCLUSION: Extramucosal suturing of the uterine scar seems to be associated with a better outcome on the postpartum ultrasound evaluation. KEY POINTS: · The technique for suturing the hysterotomy can be the source of healing changes.. · An extramucosal suturing of the uterus seems to give a better aspect at the postpartum ultrasound.. · Decreasing the niche at cesarean scar may be beneficial for future pregnancies..

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.

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.

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.

Cesarean section rates in a tertiary referral hospital in Beirut from 2018 to 2020: Our experience using the Robson Classification.

OBJECTIVE: To evaluate the cesarean section rate using the Robson Classification for the first time in Lebanon, at Hôtel-Dieu de France University Hospital, a tertiary referral center in Beirut. METHODS: Routine medical record data that included all live births from January 1, 2018 to September 30, 2020 was investigated. The overall cesarean section rate was recorded, and the size, cesarean section rate, and absolute and relative contributions were calculated within each group. RESULTS: The overall cesarean section rate was 56.8%. The highest relative contribution to this rate came from Robson groups 5, 2 and 10, respectively. A decrease in cesarean section rate was noted in 2020 among women admitted for induction of labor (groups 2 and 4) following the implementation of new department policies and the restrictions caused by the coronavirus disease 2019 pandemic. CONCLUSION: More than 50% of the deliveries in our department were by cesarean sections (CS). Strategies to reduce this rate should include stricter departmental policies for avoidance of unindicated primary CS and raising practitioners' and patients' awareness about trial of labor after cesarean section.

Long term outcomes of laparoscopic sacro/colpo-hysteropexy with and without rectopexy for the treatment of prolapse.

INTRODUCTION AND HYPOTHESIS: Laparoscopic sacrohysteropexy (LSH), sacrocolpopexy (LSC) and ventral rectopexy (LVR) with mesh are advocated for surgical treatment of pelvic and rectal prolapse. Our study aims at showing the feasibility of concomitant laparoscopic prolapse repair by comparing perioperative and long-term outcomes of LSH or LSC with and without LVR. METHODS: This is a retrospective study carried out on 348 women operated on between July 2009 and July 2019. Patients were divided into four groups: (1) LSH only, (2) LSC only, (3) LSH + LVR and (4) LSC + LVR. POP-Q scores and satisfaction questionnaires were recorded at baseline and then annually. Outcomes were defined as subjective failure (vaginal/rectal prolapse symptoms), objective failure (prolapse to/beyond the hymen, full thickness rectal prolapse) or retreatment for prolapse. Complications were collected and graded according to the Clavien-Dindo classification. RESULTS: Three hundred forty-eight women underwent laparoscopic repair for pelvic and rectal prolapse (219, 44, 66 and 19 in group 1, 2, 3 and 4, respectively). Median follow-up was 24 (4-174) months. Success rate for both rectal and pelvic prolapse was 90.2%. Recurrence rates were not significantly different between the groups (12.3%, 6.8%, 9.1% and 10.5% for groups 1, 2, 3 and 4, respectively). Significant improvement was noticed in satisfaction questionnaires in all groups. There was no difference in perioperative and late complications. CONCLUSION: The combined laparoscopic procedure appears to be safe and efficient in treating pelvic and rectal prolapse. Appropriate patient selection and available surgical expertise should determine whether to perform these procedures combined or separately.

A case of pelvic actinomycosis affecting genital, urinary and digestive tracts: a rare misleading diagnosis.

Pelvic actinomycosis is an uncommon chronic invasive disease caused by a bacteria of the Actinomyces spp. Its diagnosis constitutes a clinical challenge and is usually reached in the postoperative period after resecting a pelvic mass that usually mimics advanced ovarian cancer. Although pelvic actinomyocosis involving the digestive and genital tract has been commonly described, very few reports have described cases involving both ovaries and requiring partial cystectomy for bladder involvement. Herein, we illustrate a case of pelvic actinomycosis with extensive involvement of multiple pelvic organs, misleading the surgeon into undergoing a complete clearance of the wrongfully thought adnexal malignancy.