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.

The association between maternal age at first delivery and risk of obstetric trauma.

BACKGROUND: There are a number of poor birth outcomes with advancing maternal age. Although there is some evidence of a higher risk of trauma to obstetric anal sphincter and the levator ani muscle with advancing age, findings to date are inconclusive. OBJECTIVE: The aim of this study was to assess the risk of pelvic floor injury using translabial 3- and 4-dimensional ultrasound relative to advancing maternal age in primiparous women after a singleton vaginal delivery at term and to determine any association between maternal age and obstetric trauma, including obstetric anal sphincter injuries, levator avulsion, and irreversible overdistension of the levator hiatus. STUDY DESIGN: This is a subanalysis of a perinatal intervention trial conducted in a specialist urogynecology referral unit at 2 tertiary units. All primiparous women with singleton birth at term underwent 3- and 4-dimensional translabial pelvic floor ultrasound both ante- and postnatally for the assessment of the obstetric trauma including levator ani muscle avulsion, hiatal overdistension to 25 cm(2) or more, and obstetric anal sphincter injuries. A multivariate logistic regression analysis was performed to examine the association between maternal age and obstetric trauma diagnosed on 3- and 4-dimensional translabial ultrasound. Multiple confounders were included, and the most significant (forceps and vacuum delivery) were used for probability modeling. RESULTS: Of 660 women recruited for the original study, a total of 375 women who had a vaginal delivery with complete data sets were analyzed. A total of 174 women (46.4%) showed evidence of at least 1 form of major pelvic floor trauma. Advancing maternal age at first delivery carries with it a significant incremental risk of major pelvic floor trauma with an odds ratio of 1.064 for overall risk of injury for each increasing year of age past age 18 years (P = .003). The probability of any type of trauma appears to be substantially higher for forceps delivery. Vacuum delivery appears to increase the risk of obstetric anal sphincter injuries but not of levator avulsion. CONCLUSION: There is a significant association between the risk of major pelvic floor injury and increasing maternal age at first delivery.

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 hysteropexy: 1- to 4-year follow-up of women postoperatively.

INTRODUCTION AND HYPOTHESIS: Uterine conserving re-suspension surgery has become more popular in recent years. Such surgery may allow preservation of fertility in younger women, but may also have the added benefit of augmenting weak connective tissue and possibly providing stronger apical support than the conventional hysterectomy. Our goal was to evaluate the 1- to 4-year outcome of laparoscopic hysteropexy for the surgical management of uterine prolapse. METHODS: This study was a prospective observational study of 182 consecutive women who underwent laparoscopic hysteropexy, with or without additional vaginal repair, from the beginning of 2007 until the end of 2010. Women were invited to attend a dedicated clinic for interview and their prolapse was assessed using the Patient Global Impression of Improvement (PGI-I), the International Consultation on Incontinence Questionnaire for Vaginal Symptoms (ICIQ-VS) and the pelvic organ prolapse quantification (POP-Q) scale. Wilcoxon signed-rank test was used to compare pre-operative with postoperative data. Complications and women's satisfaction were also noted. RESULTS: One hundred and forty women agreed to participate; the mean interval from operation was 2.1 years (range 1-4.4). Eighty-nine percent of women felt that their prolapse is "very much" or "much" better using PGI-I subjective outcome measure. There was significant improvement for all parameters of ICIQ-VS and POP-Q scoring post-surgery (p < 0.001). Six women (4 %) had further apical prolapse; of these, 3 underwent further prolapse surgery. None of the participants had any mesh exposure. Ninety two percent of participants would recommend the operation. CONCLUSIONS: Laparoscopic hysteropexy is a safe and effective treatment. The 1- to 4-year outcome suggests high patient satisfaction and low rates of apical prolapse recurrence. Longer term follow-up and randomized controlled studies are required.

Short-term test-retest reproducibility of urethral pressure profilometry in women with urodynamic stress incontinence with and without detrusor overactivity.

AIMS: To determine and compare reproducibility of urethral pressure profilometry (UPP) in women with urodynamic stress incontinence (USI) alone or together with detrusor overactivity (DO). METHODS: Women were recruited from a urodynamic clinic diagnosed with USI using dual channel cystometry. UPP was performed with the technique described by Hilton and Stanton [Hilton P, Stanton SL. Br J Obstet Gynaecol 90:919-33,1983]. Different urethral function parameters were obtained. Two weeks later the tests were repeated. The precision and bias of the tests were measured using the Bland and Altman method [Bland JM, Altman DG. Lancet 1:307-10,1986]. The coefficient of variation (CV) value allowed direct comparison of repeatability of each test, with a lower value indicating less variation. RESULTS: Thirty-one women completed both visits. Fourteen women had USI, the other 17 diagnosed with USI with DO at the end of two visits. There was no significant difference between visits for all the parameters for all women recruited. The most reproducible parameter was functional urethral length and maximum urethral pressure as demonstrated by lowest CV. The women with USI group had more reproducible UPP parameters than those with mixed USI and DO in all parameters apart from pressure transmission ratio in Quartiles 2, 3, and 4. However, there was no significant difference between the two diagnostic groups. CONCLUSIONS: Tests of urethral function in urethral pressure profilometry are shown to have poor reproducibility in women with USI, but limit of agreement may be acceptable in some of the tests. The with-in subject CV appears to be higher in women with mixed USI and DO compared to USI only.

Reliability testing of urodynamics, pressure flow studies and cough leak point pressure in women with urodynamic stress incontinence with and without detrusor overactivity.

Urodynamic studies which included cough leak point pressure (CLPP) and pressure flow studies were performed at two visits 2 weeks apart. Reproducibility between the two visits and also between the two diagnostic groups, urodynamic stress incontinence (USI) and urodynamic mixed incontinence (UMI) were analysed. Thirty-one women completed both visits, of those 14 had USI in both sets of urodynamic studies, 11 had UMI on both visits, six had USI on one visit and UMI in the other. The urodynamic variables of maximum cystometric capacity and CLPP have the most repeatability. Analysis in women with USI alone compared to USI with detrusor overactivity (DOA) showed that the repeatability for pressure flow parameters and CLPP was better in women without DOA, of which the CLPP was significantly different (p = 0.036). Urodynamic variables are inconsistent. This may reflect variations in urinary tract behaviour.