Laparoscopic removal of a synthetic retropubic mid-urethral sling (tension-free vaginal tape): step-by-step technique.

INTRODUCTION AND HYPOTHESIS: The synthetic mid-urethral sling (MUS) has been the pre-eminent surgical treatment option for stress urinary incontinence (SUI) in women in recent times. However, increasing numbers of patients are now requesting mesh removal, secondary to persisting symptoms attributed to their sling. We present a video demonstrating a combined vaginal and laparoscopic approach to this procedure; along with supporting information outlining essential pre-operative assessment, counselling, and governance considerations. METHODS: A 60-year-old woman presented with a 4-year history of pelvic pain. She ascribed this to her retropubic MUS (a tension-free vaginal tape). Following extensive work-up, the mesh was removed using the technique described. RESULTS: On review, 3 months post-operatively, the patient reported improvement in the vaginal discomfort she had experienced prior to the procedure-albeit with concomitant deterioration in her SUI. CONCLUSIONS: An open or laparoscopic approach can be employed to dissect out the retropubic arms of an MUS. The latter provides a superior view of the retropubic space and confers potential advantages regarding recovery and cosmesis. The surgical technique detailed is safe and effective, especially when augmented by thorough preparation and patient counselling.

Laparoscopic sacrohysteropexy versus vaginal hysterectomy and apical suspension: 7-year follow-up of a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Laparoscopic mesh sacrohysteropexy offers a uterine-sparing alternative to vaginal hysterectomy with apical suspension, although randomised comparative data are lacking. This study was aimed at comparing the long-term efficacy of laparoscopic mesh sacrohysteropexy and vaginal hysterectomy with apical suspension for the treatment of uterine prolapse. METHODS: A randomised controlled trial comparing laparoscopic mesh sacrohysteropexy and vaginal hysterectomy with apical suspension for the treatment of uterine prolapse was performed, with a minimum follow-up of 7 years. The primary outcome was reoperation for apical prolapse. Secondary outcomes included patient-reported mesh complications, Pelvic Organ Prolapse Quantification, Patient Global Impression of Improvement in prolapse symptoms and the International Consultation on Incontinence Questionnaire Vaginal Symptoms, Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) and PISQ-12 questionnaires. RESULTS: A total of 101 women were randomised and 62 women attended for follow-up at a mean of 100 months postoperatively (range 84-119 months). None reported a mesh-associated complication. The risk of reoperation for apical prolapse was 17.2% following vaginal hysterectomy (VH) and 6.1% following laparoscopic mesh sacrohysteropexy (LSH; relative risk 0.34, 95% CI 0.07-1.68, p = 0.17). Laparoscopic sacrohysteropexy was associated with a statistically significantly higher apical suspension (POP-Q point C -5 vs -4.25, p = 0.02) and longer total vaginal length (9 cm vs 6 cm, p < 0.001). There was no difference in the change in ICIQ-VS scores between the two groups (ICIQ-VS change -22 vs -25, p = 0.59). CONCLUSION: Laparoscopic sacrohysteropexy and vaginal hysterectomy with apical suspension have comparable reoperation rates and subjective outcomes. Potential advantages of laparoscopic sacrohysteropexy include a lower risk of apical reoperation, greater apical support and increased total vaginal length.

Mesh-related complications of laparoscopic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Apical vaginal support for post-hysterectomy vault prolapse can be provided by vaginal, abdominal, or laparoscopic routes. Sacrocolpopexy is associated with higher satisfaction rates and a lower re-operation rate than vaginal sacrospinous fixation. The laparoscopic approach can reduce hospital stay and blood loss. There are concerns about the use of mesh in urogynaecological procedures, but limited data indicate a low mesh complication rate with sacrocolpopexy (0-5%). This study was aimed at establishing the incidence of complications following laparoscopic sacrocolpopexy. METHODS: We carried out a retrospective cohort study of patients who underwent laparoscopic sacrocolpopexy at a large tertiary hospital. Cases were identified from coding data, theatre logs and the national urogynaecology procedure database. Data were gathered from theatre records, patient notes and the national database. Demographic data, concomitant procedures performed, duration of surgery, intra-operative complications, change in pelvic organ prolapse quantification point C, duration of stay, late complications and further urogynaecological surgery were assessed. RESULTS: A total of 660 patients underwent laparoscopic sacrocolpopexy between 2005 and 2017 (median time from surgery 4 years 3 months). Five cases (0.7%) developed vaginal mesh exposure. Two were successfully managed conservatively with topical oestrogen. Three required surgical excision of the mesh. Four patients (0.6%) presented with erosion of non-absorbable vaginal sutures. Two were successfully managed conservatively with topical oestrogen and oral antibiotics. Two were managed with vaginal suture excision. CONCLUSIONS: This large series suggests that laparoscopic sacrocolpopexy might confer a low risk of mesh exposure. Together with good anatomical and patient-reported outcomes, laparoscopic sacrocolpopexy is a safe option for patients presenting with post-hysterectomy vault prolapse.

Outcomes after laparoscopic removal of retropubic midurethral slings for chronic pain.

INTRODUCTION AND HYPOTHESIS: Midurethral slings (MUS) are an established treatment for stress urinary incontinence (SUI), with good objective outcomes and low rates of complications. However, large population-based registry studies highlighted long-term complications from polypropylene slings including erosion, dyspareunia and chronic pain. With recent highly negative media coverage, many women are presenting with chronic pain attributed to the mesh to request complete removal. The available literature provides limited evidence on safety, symptom resolution and incontinence following MUS removal. METHODS: We identified all patients who underwent laparoscopic removal of MUS mesh at our hospital between 2011 and 2016. We extracted data from medical records to assess operative safety and contacted all patients by questionnaire that incorporated pain scales, symptom severity and satisfaction. RESULTS: A total of 56 women were assessed. Removal occurred at a median of 44 months following sling insertion (range 3-192). Mean operative time was 74 min (range 44-132). Two patients were returned to theatre (one at 24 hours and one at 14 days) to evacuate a retropubic haematoma, but no visceral injuries occurred. The median inpatient stay was 2 days (range 1-7). Of the 46% of patients who returned the questionnaire (n = 26), 88% said they would recommend the procedure. There was a median 6-point decrease in pain scores (10-point numerical scale, p < 0.0001); 44.6% reported worsening SUI, more common with removal of the suburethral mesh [odds ratio (OR) 10.72 95% confidence interval (CI) 1.10-104]. CONCLUSIONS: Laparoscopic removal of MUS is feasible and effective but carries a risk of worsening SUI.

Obturator nerve injury: a rare complication of retropubic tension-free vaginal sling.

The tension-free vaginal tape (TVT) retropubic sling is a very effective treatment for stress urinary incontinence. High cure rates are typically achieved, and the reported complication rate is relatively low. Obturator neuralgia secondary to insertion of a midurethral sling is a rare and specific type of chronic pain that is more commonly associated with transobturator tape slings. The purpose of this video case report was to demonstrate that obturator nerve injury is a possible complication of TVT retropubic slings placement. A discussion of symptoms and signs of obturator nerve injury and how these should be managed is also presented.

Laparoscopic hysteropexy versus vaginal hysterectomy for the treatment of uterovaginal prolapse: a prospective randomized pilot study.

INTRODUCTION AND HYPOTHESIS: We have previously reported on laparoscopic hysteropexy for uterine prolapse. We now report a pilot randomized study comparing laparoscopic hysteropexy (LH) with vaginal hysterectomy (VH) for the surgical management of uterine prolapse. METHODS: Women with symptomatic uterine prolapse requiring surgery for uterine prolapse were recruited. The data were analyzed for those who had completed a 1-year follow-up. As this is a pilot randomized study, no power calculation was available. The main primary outcome measure was repeat apical prolapse. Secondary outcomes included operation data, complications, recovery time, functional and QoL outcomes, and anatomical outcomes. Wilcoxon signed rank and Mann-Whitney tests compared pre-operative with post-operative data and the difference between the two groups respectively. RESULTS: One hundred and thirty-two women were recruited. Of these, 101 were randomized. Eighty percent of the 31 women who dropped out preferred LH. One-year follow-up data were analyzed for 37 women in the LH and 35 women in the VH group. Time before return to normal activity was significantly shorter, estimated blood loss was significantly less, pain score 24 h post-operatively was significantly lower, and hospital stay was significantly shorter in the hysteropexy group compared with the vaginal hysterectomy group. Operation time was significantly longer in the hysteropexy group. Both procedures showed significant improvement in prolapse symptoms. Hysteropexy was associated with better apical support; point C and total vaginal length were significantly improved. More vaginal repairs were subsequently required post-hysteropexy. CONCLUSIONS: Laparoscopic hysteropexy is a safe surgical alternative to vaginal hysterectomy with a similar risk of repeat apical surgery at 1 year. Longer follow-up data from larger studies are required.

Laparoscopic sacrocolpopexy: an observational study of functional and anatomical outcomes.

INTRODUCTION AND HYPOTHESIS: the aim of the study was to evaluate the clinical and functional outcomes of laparoscopic sacrocolpopexy, in particular its effect on female sexual function. METHODS: a retrospective observational study of women undergoing laparoscopic sacrocolpopexy between February 2005 and March 2009 was undertaken. Pelvic organ support was assessed objectively using the pelvic organ prolapse quantification scale (POP-Q). Functional outcomes were assessed using the International Consultation on Incontinence questionnaire for vaginal symptoms (ICIQ-VS), both preoperatively and at 6-36 months postoperatively. RESULTS: eighty-four women with a mean age of 65 years (range, 49-78 years) were studied. At follow-up in clinic, all women had good vault support (mean point C, -8.9; range, 10 to -8). Subjective improvements in prolapse symptoms and sexual well-being were observed with significant reductions in the respective questionnaire scores. CONCLUSIONS: our results confirm previous findings that laparoscopic sacrocolpopexy is a safe and efficacious surgical treatment for post-hysterectomy vaginal vault prolapse. It provides excellent apical support and good functional outcome with overall improvement in sexual function.

Pelvic floor exercise for urinary incontinence: a systematic literature review.

Urinary incontinence is a common problem among adults and conservative management is recommended as the first-line treatment. Physical therapies, particularly pelvic floor muscle exercise, are the mainstay of such conservative management. The purpose of this review is to summarise current literature and describe trends in the use of pelvic floor muscle exercise in the management of urinary incontinence in women. Our review confirms that pelvic floor muscle exercise is particularly beneficial in the treatment of urinary stress incontinence in females. Studies have shown up to 70% improvement in symptoms of stress incontinence following appropriately performed pelvic floor exercise. This improvement is evident across all age groups. There is evidence that women perform better with exercise regimes supervised by specialist physiotherapists or continence nurses, as opposed to unsupervised or leaflet-based care. There is evidence for the widespread recommendation that pelvic floor muscle exercise helps women with all types of urinary incontinence. However, the treatment is most beneficial in women with stress urinary incontinence alone, and who participate in a supervised pelvic floor muscle training programme for at least three months.

Urinary incontinence: can weight loss treat urinary incontinence in obese women?

New research confirms that weight loss is an effective first-line intervention for overweight or obese women with urinary incontinence. Such patients should be encouraged to lose weight, but must also be given access to a full range of treatment options.

Advances in laparoscopic techniques in pelvic reconstructive surgery for prolapse and incontinence.

Advances in minimally invasive surgery have led to an increasing adoption of laparoscopic techniques in pelvic reconstructive surgery and treatment of urinary incontinence. Our review of recent developments aims to identify and evaluate the evidence for use of these procedures. Recent literature continues to support the use of laparoscopy for colposuspension and sacrocolpopexy, as an effective alternative to open surgery. However, with the advent of retropubic mid-urethral slings for stress urinary incontinence, laparoscopic Burch colposuspension has now become obsolete. There are relatively few reports on other laparoscopic prolapse procedures, such as uterosacral ligament vault suspension, uterine suspension, paravaginal defect repair and rectocele repair. In conclusion, several short-term studies support the use of laparoscopy in pelvic reconstructive surgery and urogynaecology but longer-term investigations are needed to confirm their findings.

A novel midstream urine-collection device reduces contamination rates in urine cultures amongst women.

OBJECTIVE: To evaluate a novel urine-collection device (UCD) that automatically collects a midstream urine (MSU) sample, and compare contamination rates to those of the conventional MSU sampling method, as the contamination of urine samples for microbiological analysis in women leads to diagnostic ambiguity and unnecessary costs, and may result in part from an incorrect collection procedure. PATIENTS AND METHODS: In all, 2823 women from four centres, most from antenatal clinics, were randomized to two urine-collection methods: conventional MSU collection and collection with a novel MSU UCD (the Whiz, JBOL Ltd, Oxford, UK). Semi-quantitative growth and user acceptability were compared between the collection methods. RESULTS: MSU samples collected with the UCD had significantly fewer mixed growth samples (9% vs 14%, P = 0.001; 36% relative reduction), significantly fewer heavy mixed growth samples (1.2% vs 3.0%, P = 0.004; 60% relative reduction) and required significantly fewer re-tests (11% vs 16%, P = 0.002; 31% relative reduction). There were more samples with clinically insignificant growth than the conventional MSU group (86% vs 82%, P = 0.005). Those using the UCD preferred it to the conventional method (67.5%) and experienced significantly less spillage during sample collection (27% vs 46%, P = 0.001; relative reduction 41%). CONCLUSION: The UCD reduced contamination rates in urine samples and improved the predictive value of the urine culture in a manner acceptable to patients and staff.