Permanent or absorbable suture material for sacrospinous ligament fixation: Does it matter?

OBJECTIVE: To evaluate success and safety of sacrospinous ligament fixation (SSLF) using permanent versus absorbable suture materials 12 months following surgery. STUDY DESIGN: Following IRB approval, the electronic medical records of women who underwent SSLF in the gynecology department of a university-affiliated medical center from November 2012 to September 2021 were retrospectively reviewed. SSLF was carried out using Capio®and Digitex™, with either absorbable (polyglactin-910 or polydioxanone) sutures (group 1), or permanent (polypropylene) sutures (group 2), Pre-operative and post-operative assessment included prolapse staging using the pelvic organ prolapse quantification system and validated quality of life questionnaires (Pelvic Floor Distress Inventory and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12). Patients with postoperative information on objective and subjective outcome at 12 months were included in final analysis. Anatomical success was defined as POP stage < 2 at 12-months following surgery. For statistical analysis, the Mann-Whitney test was used for continuous variables, Fisher's exact test for dichotomous variables, and Chi-squared test of independence for variables with>2 categories. RESULTS: During the study period, 234 women underwent SSLF. One-hundred and forty-two patients (60.7 %) returned at the 12-month follow-up and were included in final analysis. Seventy-two (50.7 %) patients had absorbable suture and 70 patients (49.3 %) had permanent suture. Estimated blood loss was significantly higher in group 1 [100 (50-150) cc vs 50 (50-100) cc respectively, p =.016]. Moderate to severe pain on POD-1 was significantly higher in group 2 [VAS: 2.00 (0.00-4.00) vs 4.00 (3.00-5.75) respectively, p =.001]. Anatomical success, defined as POP ≤ stage 2 at 12 months, was similar between groups: 69 % in group 1 vs 67 % in group 2 (p =.77). Subjective cure was similar between groups, 97.2 % in group 1 vs 94.3 % in group 2 (p =.44). At the 12-month follow-up, none of the patients had gluteal pain. The rate of de-novo dyspareunia was similar between groups: 4 women (5.9 %) in the absorbable suture group versus 2 women (3.3 %) in the permanent suture group (p =.49). CONCLUSIONS: Our findings suggest that absorbable or permanent suture material does not affect outcome of SSLF. Permanent sutures may be related to increased immediate postoperative pain.

Predictors of persistent overactive bladder following surgery for advanced pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Reliable risk factors for persistent urgency following pelvic organ prolapse (POP) surgery are still unclear. We aimed to identify preoperative parameters related to persistent postoperative urgency in a cohort of women following surgery for POP stage 3-4 with concomitant overactive bladder (OAB). METHODS: In this retrospective analysis, women with POP stage 3-4 and OAB who underwent POP repair during November 2012-December 2020 were included. Preoperative evaluation included history, Pelvic Organ Prolapse Quantification (POP-Q), multi-channel urodynamic studies and Pelvic Floor Distress Inventory (PFDI-20). Surgical procedures included: anterior and posterior colporrhaphy, sacrospinous ligament suspension, anterior vaginal wall mesh repair and robotic-assisted laparoscopic sacrocolpopexy. At the 12-month follow-up, urogynecological history, POP-Q evaluation, cough stress test and the PFDI-20 questionnaire were repeated. RESULTS: One hundred seventy-three patients were included in the analysis. Resolution of urgency was observed in 56% of women. Variables associated with persistent postoperative urgency included body mass index (BMI) (27 kg/m2 vs 25.7 kg/m2, p = 0.04), preoperative increased daytime frequency (46.39% vs 61.84%, p = 0.05), urgency urinary incontinence (UUI) (51.46% vs 80.26%, p = 0.0001), detrusor overactivity (DO) (40.2% vs 61.84%, p = 0.009) and lower maximum flow rate on UDS (13.9 ml/s vs 15 ml/s, p = 0.04). Multivariate analysis confirmed preoperative DO (OR: 12.2 [95% CI: 1.4-16.6]; p = 0.01), preoperative UUI (OR 3.8 [95% CI: 1.3-11.0]; p = 0.008) and BMI > 25 kg/m2 (OR 1.8 [95% CI: 1.1-7.2]; p = 0.04) as predictive factor for persistent urgency. CONCLUSIONS: In women with advanced POP and OAB, being overweight, preoperative UUI and DO are related to persistent postoperative urgency. These findings will guide our future preoperative counseling and reinforce the role of UDS in POP management.

Advanced Cystocele is a Risk Factor for Surgical Failure after Robotic-assisted Laparoscopic Sacrocolpopexy.

STUDY OBJECTIVE: To assess the outcome of robotic-assisted laparoscopic sacrocolpopexy (RALSCP) and to identify risk factors for surgical failure and long-term complications in patients at high risk for surgical failure. DESIGN: Retrospective cohort study. SETTING: A university hospital. PATIENTS: Sixty-seven women with pelvic organ prolapse (POP) at high risk for surgical failure. INTERVENTIONS: RALSCP from November 2012 to July 2020. MEASUREMENTS AND MAIN RESULTS: Information was collected from the electronic medical records. Preoperative and postoperative assessment included urogynecologic history, prolapse staging, cough stress test, and validated quality of life questionnaires. Anatomic success was defined as POP stage < 2 at the last follow-up. Mean follow-up was 24.6 ± 17.9 months. Sixteen women (23.9%) reported bulge symptoms at the latest follow-up; upon POP Quantification staging, surgical failure or recurrence was observed in 35 patients (52.2%). On multiple logistic regression analysis, a preoperative POP Quantification point Ba measurement ≥3 cm beyond the hymen was independently related to surgical failure. Late postoperative complications included 3 cases (4.5%) of postoperative ventral hernia and 5 cases (7.5%) of mesh erosion, all in patients operated using Ethibond sutures. CONCLUSIONS: Anatomic success of RALSCP in POP patients at high risk for surgical failure is worse than previously reported. Advanced preoperative anterior vaginal wall prolapse is a risk factor for surgical failure. Delayed absorbable sutures for vaginal mesh fixation seem to be safer than multifilament, permanent sutures, in terms of the risk of mesh erosion.

The clinical significance of inflammatory cytokines in primary cell culture in endometrial carcinoma.

Endometrial cancer is the most common malignancy of the female genital tract, and the incidence and mortality rates from this disease are increasing. Although endometrial carcinoma has been regarded as a tissue-specific disease mediated by female sex steroid pathways, considerable evidence implicates a role for an inflammatory response in the development and propagation of endometrial cancer. We hypothesized that if specific patterns of cytokine expression were found to be predictive of adverse outcome, then selective receptor targeting may be a therapeutic option. This study was therefore undertaken to determine the relationship between cytokine production in primary cell culture and clinical outcome in endometrial adenocarcinoma. Fresh endometrial tissues were fractionated into epithelial and stromal fractions and cultured. After 6-7 days, supernatants were collected and cells enumerated. Batched aliquots were assayed using ELISA kits specific for CSF-1, GMCSF, G-CSF, TNF-α, IL-6, IL-8, and VEGF. Data were compared using ANOVA, Fisher's exact, and log rank tests. Increased epithelial VEGF production was observed more often in tumors with Type 2 variants (p = 0.039) and when GPR30 receptor expression was high (p = 0.038). Although increased stromal VEGF production was detected more often in grade 3 endometrioid tumors (p = 0.050), when EGFR expression was high (p = 0.003), and/or when ER/PR expression was low (p = 0.048), VEGF production did not correlated with overall survival (OS). Increased epithelial CSF-1 and TNF-α production, respectively, were observed more often in tumors with deep myometrial invasion (p = 0.014) and advanced stage (p = 0.018). Increased CSF-1 (89.5% vs. 42.9%, p = 0.032), TNF-α (88.9% vs. 42.9%, p = 0.032, and IL-6 (92.3% vs. 61.5%, p = 0.052) also correlated with low OS. In Cox multivariate models, CSF-1 was an independent predictor of low survival when stratified by grade (p = 0.046) and histology (p = 0.050), and TNF-α, when stratified by histology (p = 0.037). In this study, high CSF-1, TNF-α, and IL-6 production rates identified patients at greatest risk for death, and may signify patients likely to benefit from receptor-specific therapy.