Society of gynecologic surgeons' survey: mesh use in vaginal prolapse surgery.

OBJECTIVE: : To evaluate the practice patterns of the Society of Gynecologic Surgeons (SGS) members and guests regarding the use of synthetic mesh in vaginal prolapse repair. METHODS: : A 26-item questionnaire regarding synthetic mesh use in vaginal prolapse repair was placed on the desks of those SGS attendees present at the fourth scientific session of the 2008 annual scientific meeting. Voluntary participation was requested and the survey questionnaires were retrieved at the session's conclusion. Descriptive statistics and cross-tabulation using χ tests were performed with SPSS. RESULTS: : One hundred twenty-eight of the 180 scientific session attendees completed the surveys. Sixty-nine percent (88/128) of the respondents identified themselves as urogynecologists and 45% (83/128) were male. Forty-five percent (58/128) were SGS members. Sixty-six percent (84/128) described their practice setting as academic, 28% (36/128) as community-based, and 6% (8/128) as other. The majority of the urogynecologists, 65% (64/88), used mesh at the time of survey completion versus 40% (8/18) of the obstetrician/gynecologists (P < 0.001). Fifty-nine percent (74/125) respondents were currently using mesh and 11% (14/125) reported using mesh at one time. Fifty-six percent (48/86) used mesh in both primary and recurrent repairs. For anterior repair, 97% (82/86) used mesh; of these, 31% (26/86) used only mesh kits, 33% (28/86) used only free mesh and 33% (28/86) reported using both. For posterior repair, 70% (62/88) used mesh; of these 18% (16/88) used only mesh kits, 26% (23/88) used only free mesh and 26% (23/88) used both. For anterior repair, 84% (71/85) dissected full-thickness and 43% (35/85) plicated connective tissue prior to inserting the mesh. The respondents had excised mesh for indications including: persistent drainage (59%), persistent pain (21%), hispareunia (21%), dyspareunia (16%), and asymptomatic exposure (11%). Fifty percent (44/88) initially managed mesh erosion with estrogen cream whereas 29% (26/88) started with mesh excision. CONCLUSIONS: : This survey suggests that the majority of urogynecologists attending the 34th SGS annual scientific meeting have used vaginal mesh for prolapse repair, and they more commonly used it in the anterior as compared to the posterior compartment. This has occurred in the absence of prospective, controlled, high-quality studies supporting its efficacy and safety. Research is clearly needed in this area.

Vaginal surgery for pelvic organ prolapse.

The vaginal approach to pelvic organ prolapse repair has been a mainstay of surgical therapy since the beginning of modern gynecologic surgery. In this article, the major vaginal procedures are reviewed with emphasis on techniques of pelvic reconstruction. Vaginal hysterectomy, apical suspension, repair of the anterior and posterior compartments, and perineal repair are covered in detail.

Anatomic outcomes of vaginal mesh procedure (Prolift) compared with uterosacral ligament suspension and abdominal sacrocolpopexy for pelvic organ prolapse: a Fellows' Pelvic Research Network study.

OBJECTIVE: The objective of the study was to compare apical support anatomic outcomes following vaginal mesh procedure (VMP) (Prolift) to uterosacral ligament suspension (USLS) and abdominal sacrocolpopexy (ASC). STUDY DESIGN: This multicenter, retrospective chart review compared apical anatomic success (stage 0 or 1 based on point C or D of the Pelvic Organ Prolapse Quantification), level of vaginal apex (point C or D) 3-6 months after prolapse repair at 10 US centers between 2004 and 2007. RESULTS: VMP, USLS, and ASC were performed for 206, 231, and 305 subjects respectively. There was no difference in apical success after VMP (98.8%) compared with USLS (99.1%) or ASC (99.3%) (both P = 1.00) 3-6 months after surgery. The average elevation of the vaginal apex was lower after VMP (-6.9 cm) than USLS (-8.05 cm) and ASC (-8.5 cm) (both P < .001) CONCLUSION: Patients undergoing VMP have similar apical success compared with USLS and ASC despite lower vaginal apex 3-6 month after surgery.

Long-term efficacy of the pubovaginal Mersilene mesh sling.

OBJECTIVE: The objective of the study was to determine the efficacy of the pubovaginal Mersilene mesh sling (PVMMS) for complicated urodynamic stress incontinence (USI). STUDY DESIGN: Between 1990 and 2008, patients with USI plus an at-risk diagnosis underwent a PVMMS by a single surgeon. They were followed up with urodynamics (UDE) and Pelvic Floor Distress Inventory-short form 20 (PFDI-20). Stratification was in an at-risk hierarchy: intrinsic sphincter deficiency (ISD) greater than recurrent USI (RUSI) greater than USI with chronically increased intraabdominal pressure (CI-IAP). A cough stress test determined objective cure. PFDI question 17 assessed subjective cure. RESULTS: Three hundred six patients with ISD (43.5%), RUSI (26.8%), and CI-IAP (29.7%) had objective cure rates of 89.2% in the short term, 86.7% in the intermediate term, and 91.2% in the long term. A group of 48 patients with both short- and long-term UDEs showed cures of 100% and 91.7%. Long-term objective cure rates were: ISD, 90.5% (n = 21); RUSI, 84.2%, (n = 19); CI-IAP, 100% (n = 17). The mean score of postoperative PFDI question 17 was 0.57 (n = 119). Mean symptom improvement was -2.98 (n = 52; P < .0001). CONCLUSION: We demonstrated PVMMS to be subjectively and objectively effective in long-term treatment of complicated forms of USI.

Graft use in transvaginal pelvic organ prolapse repair: a systematic review.

OBJECTIVE: To estimate the anatomic and symptomatic efficacy of graft use in transvaginal prolapse repair and to estimate the rates and describe the spectrum of adverse events associated with graft use. DATA SOURCES: Eligible studies, published between 1950 and November 27, 2007, were retrieved through Medline and bibliography searches. METHODS OF STUDY SELECTION: To assess anatomic and symptomatic efficacy of graft use, we used transvaginal prolapse repair studies that compared graft use with either native tissue repair or repair with a different graft. To estimate rates of adverse events from graft use, all comparative studies and case series with at least 30 participants were included. For spectrum of adverse events, all study designs were included. TABULATION, INTEGRATION AND RESULTS: Eligible studies were extracted onto standardized forms by one reviewer and confirmed by a second reviewer. Comparative studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic-absorbable, synthetic nonabsorbable) and outcome (anatomic, symptomatic). We found 16 comparative studies, including six randomized trials, 37 noncomparative studies with at least 30 women, 11 case series with fewer than 30 women, and 10 case reports of adverse events. One randomized trial and one prospective comparative study evaluating synthetic, nonabsorbable graft use in the anterior compartment reported favorable anatomic and symptomatic outcomes with graft use. Data regarding graft use for posterior and apical compartments or for biologic or synthetic absorbable graft use in the anterior compartment were insufficient to determine efficacy. Rates and spectrum of adverse events associated with graft use included bleeding (0-3%), visceral injury (1-4%), urinary infection (0-19%), graft erosion (0-30%), and fistula (1%). There were insufficient data regarding dyspareunia, sexual, voiding, or defecatory dysfunction. CONCLUSION: Overall, the existing evidence is limited to guide decisions regarding whether to use graft materials in transvaginal prolapse surgery. Adequately powered randomized trials evaluating anatomic and symptomatic efficacy as well as adverse events are needed.

Paper versus web-based administration of the Pelvic Floor Distress Inventory 20 and Pelvic Floor Impact Questionnaire 7.

Web-based questionnaires are increasingly employed for clinical research. To investigate whether web-based and paper versions of the Pelvic Floor Distress Inventory 20 (PFDI-20) and Pelvic Floor Impact Questionnaire 7 (PFIQ-7) yield similar results, we compared results obtained with these two modes of administration. Women with pelvic floor disorders completed both versions of these questionnaires. Scores between modes of administration were compared using the paired t test and the intraclass correlation coefficient (ICC). Among the 52 participants, there were no significant differences in scores or scale scores between the web-based and paper questionnaires. The ICC was 0.91 for the PFDI-20 score and 0.81 for the PFIQ-7 score (p < 0.001 for each). The web-based format was preferred by 22 participants (53%), ten (24%) preferred the paper format, and nine (21%) had no preference. The acceptability and score equivalence recommend these web-based questionnaires as an alternative to paper questionnaires for clinical research.

Vaginal revision of intravesical tension-free vaginal tape 44 h after initial placement: a case report.

Unintentional cystotomy is a known complication of the tension-free vaginal tape procedure and is commonly diagnosed intraoperatively. Delayed diagnosis does occur and various reparative techniques have been described, some requiring laparotomy with intentional cystotomy and repair. We report a case where a 46-year-old woman underwent vaginal reconstructive surgery including placement of a tension-free vaginal tape, which was complicated by unilateral cystotomy. A delayed diagnosis of intravesical tape placement was made requiring reoperation. The patient underwent a minimally invasive transvaginal procedure for removal and immediate replacement of the malpositioned arm of the tape. We conclude that a transvaginal approach may be an acceptable technique for revision and replacement of the tension-free vaginal tape where cystotomy is identified within 44 h after the initial procedure. With this technique, a more invasive surgery including laparotomy with cystotomy might successfully be avoided.

Midline anterior repair alone vs anterior repair plus vaginal paravaginal repair: a comparison of anatomic and quality of life outcomes.

Our aim was to study the anatomic recurrence rates and quality of life outcomes of patients who had undergone either anterior colporrhaphy (AC) or anterior colporrhaphy and vaginal paravaginal repair (AC + VPVR) as part of surgery for pelvic organ prolapse. Chart reviews were used to identify anatomic prolapse recurrence. Phone interviews assessed quality of life outcomes [Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ)] outcomes. There was a trend towards longer time to anatomic recurrence (any compartment > or =grade 2) in the AC group compared with the AC + VPVR group (median 24 vs 13 months, p=0.069). If only patients who had undergone previous surgery were compared, time to anatomic recurrence appeared significantly longer in the AC group (median 41 vs 12 months, p=0.022). There were 55% of women in the AC group and 46% of women in the AC + VPVR group who reported significant bladder or bulge symptoms based on responses to the phone-administered UDI and IIQ (p=0.89). Our retrospective study did not suggest that adding VPVR was superior in terms of anatomic or quality of life outcomes. Prospective assessment of the role of VPVR in the treatment of pelvic organ prolapse is needed.

Prediction of successful voiding immediately after outpatient mid-urethral sling.

We set out to identify predictors of successful voiding immediately after outpatient mid-urethral sling. The charts of 126 patients who underwent an outpatient mid-urethral sling procedure were identified. Using discharge without a urinary catheter as the dependent variable, logistic regression analysis modeled the relationship of independent variables including demographic, preoperative urodynamic, and perioperative variables. Sixty-one percent of the patients passed their immediate postoperative voiding trial. Logistic regression analysis revealed that parity > or = 3, Valsalva leak point pressure > 60 cm H(2)O, and high preoperative anxiety remained independently associated with successful voiding. Identifying preoperative variables that are associated with successful voiding after mid-urethral sling may be useful in helping to accurately shape patient expectations and identify those most likely to benefit from preoperative teaching of self-catheterization.

Low risk of ureteral obstruction with "deep" (dorsal/posterior) uterosacral ligament suture placement for transvaginal apical suspension.

OBJECTIVE: Transvaginal uterosacral ligament fixation (USLF), often called "high" USLF, is associated with a 1.0% to 10.9% ureteral obstruction rate. Anatomic relations and pelvic rotation with positioning imply "high" (cephalad) suture placement may bring sutures closer to the ureter. We examined the ureteral obstruction rate with a "deep" (dorsal/posterior) uterosacral ligament suture placement modification of a standard USLF procedure. STUDY DESIGN: At the University of Massachusetts and Tufts, 411 consecutive patients underwent Mayo culdoplasty utilizing > or = 3 uterosacral sutures placed "deep" bilaterally. Intraoperative cystoscopy was performed. RESULTS: One patient (0.24% [.01%-1.35%]) had ureteral obstruction attributable to USLF. Two had obstruction secondary to concomitant procedures. Compared with previous published series, the odds of ureteral injury secondary to USLF was 4.6 times lower (95% CI 2.31-9.24; P < .0001). CONCLUSION: Placement of USLF sutures "deep" (dorsal/posterior) increases the margin of safety for the ureter and, in this study, decreased the ureteral injury rate nearly 5-fold.

Exclusion of elderly women from published randomized trials of stress incontinence surgery.

OBJECTIVE: More than 20,000 women, aged 70 years or older, undergo surgery for stress urinary incontinence each year. Our objective was to review the published randomized trials of the surgical treatment of stress urinary incontinence and estimate the proportion of women 70 years or older enrolled in those trials. DATA SOURCES: MEDLINE and Cochrane Databases of Clinical Trials were searched from January 1966 through December 2003 with the terms "urinary incontinence," "stress incontinence," "urethropexy," "needle suspension," "pubovaginal sling," "tension-free vaginal tape," "urethral injection," "collagen injection," "anterior colporrhaphy," and "clinical trial," "controlled trial," or "randomized trial" as both subject headings and words contained in article titles. We supplemented this search with manual searches of meta-analyses and review articles from 2000 to 2003. METHODS OF STUDY SELECTION: All studies that included at least one group undergoing an invasive treatment for stress incontinence (including urethral bulking injections) were reviewed. We excluded reports without sufficient data to estimate the number of women aged 70 and older who participated, those published only in abstract form, and those studies in languages other than English, French, German, Italian, or Spanish. Twenty studies met our inclusion criteria. TABULATION, INTEGRATION, AND RESULTS: The number of women aged 70 or older in each study was estimated using the demographic data provided. The median percentage of subjects aged 70 or older was 3.8% (interquartile range 0.37-15%). There was no significant difference in the proportion of subjects 70 years of age or older based on the year of publication. CONCLUSION: Our review of the published literature suggests that elderly women are underrepresented in clinical trials of stress incontinence surgery. Efforts should be made to include more elderly women in clinical trials of stress incontinence surgery.

A survey of the complications of vaginal prolapse surgery performed by members of the Society Of Gynecologic Surgeons.

This study aimed to examine the frequency and nature of complications of vaginal prolapse surgery performed by members of SGS over a year and to determine the feasibility and the problems associated with prospective, multicentered collaborative data acquisition. A survey form, which included demographics, surgical indications, colpopexy type, concomitant procedures, technique, estimated blood loss (EBL), OR time, and intra/postoperative complications, was distributed to society members. The nature, extent, and solution of the complications were examined. There were 147 members of SGS at the time of the study. Many were reproductive endocrinologists and gynecologic oncologists. Twenty-one (14%) members participated. Three hundred forty-nine (349) completed forms were received: 187 sacrospinous fixations (SSF), 92 colposacropexies (CSP), and 70 high utero sacral suspensions (HUS). There were seven (3.7%) intraoperative complications for SSF, seven (7.6%) for CSP and three (4.3%) for HUS. There were four (2.1%) postoperative complications for SSF, six (6.5%) for CSP and none for HUS (NS). OR time was significantly longer for CSP vs. HUS ( P<.003) and for SSF vs. HUS ( p=.042). The EBL was significantly higher for SSF compared with CSP for the colpopexy procedure ( p=.013) and for entire cases ( p<.003). Analysis showed that all three colpopexies had significant intraoperative and postoperative complications of less than 8%. Intraoperative visceral damage was a concern for all three procedures. With SSF and CSP there was risk of bleeding and with HUS there was a risk of ureteral obstruction. Postoperative CSP complications were bowel obstruction, bleeding or hernia; for SSF neuropathy, and for HUS none. No life-threatening intraoperative or postoperative complications were reported. OR time was significantly shorter for HUS than SSF. The highest EBL was with SSF. Only 14% of the SGS membership responded, despite multiple requests for participation, demonstrating the difficulty of multicenter data gathering.