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1.
BMJ Open ; 11(10): e053679, 2021 10 04.
Artigo em Inglês | MEDLINE | ID: mdl-34607873

RESUMO

INTRODUCTION: Pelvic organ prolapse (POP) is the descent of pelvic organs into the vagina resulting in bulge symptoms and occurs in approximately 50% of women. Almost 20% of women will elect surgical correction of this condition by age 85. Removal of the uterus (hysterectomy) with concomitant vaginal vault suspension is a long-standing practice in POP surgery to address apical (uterine) prolapse. Yet, contemporary evidence on the merits of this approach relative to preservation of the uterus through suspension is needed to better inform surgical decision making by patients and their healthcare providers. The objective of this study is to evaluate POP-specific health outcomes and service utilisation of women electing uterine suspension compared with those electing hysterectomy and vaginal vault suspension for POP surgery up to 1-year postsurgery. METHODS AND ANALYSIS: This is a prospective cohort study planning to enrol 321 adult women with stage ≥2 POP from multiple sites in Alberta, Canada. Following standardised counselling from study surgeons, participants self-select either a hysterectomy based or uterine preservation surgical group. Data are being collected through participant questionnaires, medical records and administrative data linkage at four time points spanning from the presurgical consultation to 1-year postsurgery. The primary outcome is anatomic failure to correct POP, and secondary outcomes include changes in positioning of pelvic structures, retreatment, subjective report of bulge symptoms, pelvic floor distress and impact, sexual function and health service use. Data will be analysed using inverse probability weighting of propensity scores and generalised linear models. ETHICS AND DISSEMINATION: This study is approved by the Conjoint Health Research Ethics Board at the University of Calgary (REB19-2134). Results will be disseminated via peer-reviewed publications, presentations at national and international conferences, and educational handouts for patients. TRIAL REGISTRATION NUMBER: NCT04890951.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Idoso de 80 Anos ou mais , Alberta , Estudos de Coortes , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Histerectomia , Prolapso de Órgão Pélvico/cirurgia , Estudos Prospectivos , Resultado do Tratamento , Prolapso Uterino/cirurgia , Vagina/cirurgia
2.
Medicine (Baltimore) ; 100(42): e27236, 2021 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-34678860

RESUMO

INTRODUCTION: In the present investigation, a systematic evaluation of the clinical treatment performance of diagnosed with pelvic floor dysfunction is explored. By comparing the 4Dtransperineal pelvic floor ultrasound images with the acupuncture treatment performance of the patients, an evaluation system with various parameters is established to provide critical information to guide the clinical treatment fpostpartum female pelvic floor dysfunction (FPFD). METHODS: Eighty patients diagnosed with FPFD are divided into 2 groups. After the designated treatment to the patients, they are carefully examined using transperineal pelvic floor ultrasound. The shape and activity of bladder neck, cervix and rectum anal canal under resting, anal sphincter and Valsalva movements are observed and recorded. The morphology and continuous shape of levator ani muscle in different states after 4D image reconstruction are obtained. RESULTS: After the acupuncture treatment, the bladder neck descent is decreased by 3.8 cm and the anal levator muscle area is decreased by 3.4 cm2 comparing with the control group. The anal levator muscle hole diameter is decreased by 0.3 cm, while the anterior and posterior diameter is reduced by 0.5 cm. Reduced possibility of cystocele and uterine prolapse is demonstrated by X2 test. These changes upon acupuncture therapy are in line with the improved conditions of the patients, indicating these parameters can help evaluate the therapy performance. CONCLUSION: 4D pelvic floor ultrasound imaging provides objective and quantified information for the clinical diagnosis and treatment of FPFD and the assessment of therapy efficacy, making it a promising novel method in practical applications.


Assuntos
Terapia por Acupuntura/métodos , Distúrbios do Assoalho Pélvico/patologia , Distúrbios do Assoalho Pélvico/terapia , Período Pós-Parto/fisiologia , Terapia por Ultrassom/métodos , Adulto , Cistocele/prevenção & controle , Feminino , Humanos , Músculo Esquelético/patologia , Diafragma da Pelve/patologia , Modalidades de Fisioterapia , Método Simples-Cego , Prolapso Uterino/prevenção & controle , Adulto Jovem
3.
Res Vet Sci ; 140: 251-258, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34537551

RESUMO

Ovine pre-partum vaginal prolapse (known as bearings in sheep) occurs within a few weeks prior to lambing and unless treated both ewes and unborn lambs will die. It is a worldwide problem with no clear aetiology. Rates of prolapse in New Zealand typically vary from 0.1 to 2% per annum, varying between seasons and farms. In order to determine preclinical changes leading to prolapse, blood samples were collected prior to prolapse occurring and analysed for changes in both protein and specific hormone and vitamin levels. 650 ewes were ear tagged and blood samples were taken one month prior to the beginning of lambing; 28 of these ewes subsequently prolapsed. Using an improved proteomic method plasma samples were subjected to 2D DIGE (two dimensional differential in gel electrophoresis) to determine if there were differences between the pre-prolapse and non-prolapsing ewes. Acidic isoforms of haptoglobin, a major acute phase protein in ruminants, increased approximately 3-fold in ewes prior to prolapse occurring. Total haptoglobin quantitation was confirmed with an independent assay. Although another plasma protein, α-1B-glycoprotein, was down regulated close to prolapse, the biological significance of this is unknown. While vitamin D levels were not associated with subsequent prolapse there was, however, a negative correlation between cortisol and days to prolapse from sampling (r2 = 0.36); i.e. ewes sampled closest to prolapse had higher plasma cortisol concentrations than controls. This raises the possibility that the ewes which prolapsed may have been suffering from chronic stress. Further research is needed.


Assuntos
Doenças dos Ovinos , Prolapso Uterino , Animais , Biomarcadores , Feminino , Proteômica , Ovinos , Doenças dos Ovinos/diagnóstico , Prolapso Uterino/veterinária , Vitaminas
4.
Am J Obstet Gynecol ; 225(5): 564.e1-564.e9, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34480873

RESUMO

BACKGROUND: Pelvic pain is a debilitating condition that is common among women with pelvic floor disorders. Limited information is known about the impact of preoperative pelvic pain on outcomes after vaginal reconstructive surgery. OBJECTIVE: This study aimed to compare the outcomes after vaginal reconstructive surgery between women with and without preoperative pelvic pain. STUDY DESIGN: Baseline and postoperative data were analyzed from the "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial." The multicenter trial involved women with anterior prolapse without symptoms of stress incontinence randomized to receive either a midurethral sling or sham incisions during a vaginal reconstructive surgery. Participants completed the visual analog scale adapted for suprapubic pain and Pelvic Floor Distress Inventory at baseline, 3 months, and 12 months. Preoperative pelvic pain was defined as a response of "5" or greater on pain on the visual analog scale or answering "moderately" or "quite a bit" on the Pelvic Floor Distress Inventory question, "Do you usually experience pain in the lower abdomen or genital area?" Outcomes and complication rates were compared between women with and without pelvic pain. RESULTS: The "Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial" participants included 112 women with pelvic pain (58 had a midurethral sling and 54 had sham incisions) and 212 women without pelvic pain (105 had a midurethral sling and 107 had sham incisions). Women who had a midurethral sling and pelvic pain were younger than women without pelvic pain (60.3±12.1 vs 65.1±8.6; P=.004). Women who had sham incisions and pelvic pain were more likely of Hispanic ethnicity than women without pelvic pain (27.8% vs 9.4%; P=.002). Patient improvement based on the Patient Global Impression of Improvement scale did not differ between arms. Women with pelvic pain had greater improvement on the visual analog scale pain scores after a surgical procedure at 3 months (-3.1±2.9 vs -0.4±1.6; P<.001) and at 12 months (-3.4±3.0 vs -0.6±1.6; P<.001) than women without pain, although their pain scores remained higher than those without preoperative pelvic pain at all time points (P<.001 for all). Similar improvements were found on the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire. The differences observed were not affected by whether women were in the midurethral sling or sham arm of the trial. Postoperative urinary tract infection and incomplete bladder emptying did not differ between the groups. CONCLUSION: Women with preoperative pelvic pain experienced significant improvements in pain and pelvic floor symptoms with vaginal reconstructive surgery and had similar subjective improvement postoperatively compared with women without preoperative pelvic pain. Reassuringly, the performance of a midurethral sling did not have an impact on the results.


Assuntos
Avaliação de Resultados da Assistência ao Paciente , Dor Pélvica/epidemiologia , Período Pré-Operatório , Slings Suburetrais , Prolapso Uterino/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Escala Visual Analógica
5.
Obstet Gynecol Clin North Am ; 48(3): 515-533, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34416935

RESUMO

Transvaginal mesh/grafts have been popularized over the past 20 years in an attempt to improve the longevity of traditional vaginal pelvic organ prolapse (POP) surgery. Several national bodies have concluded that the proposed benefits of mesh/graft implantation are outweighed by the significant increase in surgery complications related to these products. As a consequence mesh products for vaginal POP surgery have been withdrawn from use in many countries. This article is a narrative review of newer mesh and graft products including lightweight polypropylene mesh products, biological grafts, hybrid grafts, and tissue engineered grafts.


Assuntos
Produtos Biológicos , Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Humanos , Prolapso de Órgão Pélvico/cirurgia , Polipropilenos , Telas Cirúrgicas , Vagina/cirurgia
6.
J Biomech ; 127: 110649, 2021 10 11.
Artigo em Inglês | MEDLINE | ID: mdl-34375905

RESUMO

The female pelvic cavity involves muscles, ligaments, endopelvic fasciae and multiple organs where different pathologies may occur, namely the pelvic organ prolapse (POP). The synthetic implants are used for the reconstructive surgery of POP, but severe complications associated with their use have been reported, mainly related to their mechanical properties (e.g., implant stiffness) and microstructure. In this study, we mimicked a transvaginal reconstructive surgery to repair the apical ligaments (uterosacral ligaments (USLs) and cardinal ligaments (CLs)), by modeling, their impairment (90% and 50%) and/or total rupture. The implants to reinforce/replace these ligaments were built based on literature specifications and their mechanical properties were obtained through uniaxial tensile tests. The main aim of this study was to simulate the effect of mesh anchoring technique (simple stich and continuous stitch), and compare the displacement magnitude of the pelvic tissues, during Valsalva maneuver. The absence/presence of the synthetic implant was simulated when total rupture of the CLs and USLs occurs, causing a variation of the vaginal displacement (9% for the CLs and 27% for the USLs). Additionally, the simulations showed that there was a variation of the supero-inferior displacement of the vaginal wall between different anchoring techniques (simple stich and continuous stitch) being approximately of 10% for the simulation USLs and CLs implant. The computational simulation was able to mimic the biomechanical behavior of the USLs and CLs, in response to different anchoring techniques, which can be help improving the outcomes of the prolapse surgery.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Análise de Elementos Finitos , Humanos , Ligamentos/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas , Resultado do Tratamento
7.
Obstet Gynecol ; 138(3): 435-442, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34352830

RESUMO

OBJECTIVE: To compare prolapse recurrence after total vaginal hysterectomy with uterosacral ligament suspension to recurrence after supracervical hysterectomy with mesh sacrocervicopexy for the primary management of uterovaginal prolapse. METHODS: We conducted a retrospective cohort study of women undergoing uterovaginal prolapse repair at an academic center from 2009 to 2019. Women who underwent vaginal hysterectomy with uterosacral ligament suspension or laparoscopic supracervical hysterectomy with mesh sacrocervicopexy were included. The primary outcome was composite prolapse recurrence (prolapse beyond the hymen or retreatment with pessary or surgery). Secondary outcomes included mesh complications, time to recurrence, and overall reoperation for either prolapse recurrence or mesh complication. We used propensity scoring with a 2:1 ratio of sacrocervicopexy to uterosacral suspension. RESULTS: The cohort consisted of 654 patients, of whom 228 (34.9%) underwent uterosacral suspension and 426 (65.1%) underwent sacrocervicopexy. The median follow-up was longer for the sacrocervicopexy group (230 vs 126 days, P<.001) and less than 1 year for both groups. The uterosacral group had a greater proportion of composite prolapse recurrence (14.9% [34/228] vs 8.7% [37/426], P=.02) and retreatment for recurrent prolapse (7.5% [17/228] vs 2.8% [12/426], P=.02). The uterosacral group demonstrated a shorter time to prolapse recurrence on multivariable Cox regression (hazard ratio 3.14, 95% CI 1.90-5.16). There were 14 (3.3%) mesh complications in the sacrocervicopexy group. Overall reoperation was similar between groups (4.8% [11/228] vs 3.8% [16/426], P=.51). CONCLUSION: Total vaginal hysterectomy with uterosacral ligament suspension was associated with higher rate of, and shorter time-to-prolapse recurrence compared with supracervical hysterectomy with mesh sacrocervicopexy.


Assuntos
Prolapso Uterino/cirurgia , Estudos de Coortes , Intervalo Livre de Doença , Feminino , Humanos , Histerectomia , Histerectomia Vaginal , Ligamentos/cirurgia , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Telas Cirúrgicas , Resultado do Tratamento
8.
Vet Clin North Am Equine Pract ; 37(2): 367-405, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34243878

RESUMO

Selected conditions affecting broodmares are discussed, including arterial rupture, dystocia, foal support with ex utero intrapartum treatment, uterine prolapse, postpartum colic, the metritis/sepsis/systemic inflammatory response syndrome complex, and retained fetal membranes. Postpartum colic beyond third-stage labor contractions should prompt comprehensive evaluation for direct injuries to the reproductive tract or indirect injury of the intestinal tract. Mares with perforation or rupture of the uterus are typically recognized 1 to 3 days after foaling, with depression, fever, and leukopenia; laminitis and progression to founder can be fulminant. The same concerns are relevant in mares with retention of fetal membranes.


Assuntos
Distocia/veterinária , Doenças dos Cavalos/diagnóstico por imagem , Paresia Puerperal/diagnóstico por imagem , Placenta Retida/veterinária , Reprodução , Prolapso Uterino/veterinária , Animais , Distocia/diagnóstico por imagem , Distocia/terapia , Técnicas de Imagem por Elasticidade/veterinária , Emergências/veterinária , Membranas Extraembrionárias/diagnóstico por imagem , Feminino , Hemorragia/veterinária , Doenças dos Cavalos/terapia , Cavalos , Paresia Puerperal/terapia , Parto , Placenta Retida/diagnóstico por imagem , Placenta Retida/terapia , Período Pós-Parto , Gravidez , Prolapso Uterino/diagnóstico por imagem , Prolapso Uterino/terapia , Útero/diagnóstico por imagem
9.
Int Urogynecol J ; 32(8): 2143-2148, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34181067

RESUMO

INTRODUCTION AND HYPOTHESIS: Following vaginal hysterectomy (VH), fixation of the vaginal vault is needed to prevent post-operative recurrence/exacerbation of vault prolapse. The effectiveness of McCall culdoplasty in cases of advanced prolapse is unclear. We aimed to compare the effectiveness of McCall culdoplasty following VH in patients with mild versus advanced stages of uterine prolapse. METHODS: In this retrospective study, the Pelvic Floor Distress Inventory (PFDI-20) was utilized to compare the subjective results of vaginal hysterectomy plus McCall culdoplasty between women with mild uterine prolapse stage 2 (mild prolapse group) and advanced uterine prolapse stages 3-4 (advanced prolapse group). The primary outcome, the subjective awareness of prolapse, was analyzed as well as all other aspects of PFDI-20. A sample size of 130 was calculated. RESULTS: The mild prolapse group consisted of 26 (19.3%) patients and the advanced prolapse group consisted of 109 (80.7%) patients. There were no differences between the groups in demographic and clinical characteristics. The rates of concomitant prolapse and incontinence surgeries, performed at the time of VH and post-operative complications. were the same between groups. The mean follow-up was more than 5 years in both groups. Awareness of prolapse was similar between the groups (11.5% in the mild prolapse group and 5.5% in the advanced prolapse group, p = 0.374). There was no significant correlation between the stage of apical prolapse before surgery and awareness of prolapse after the surgery (r = 0.0132, p = 0.879). All aspects of the PFDI-20 questionnaire were similar in the two groups. CONCLUSION: McCall culdoplasty was found to have an equal subjective effectiveness following VH in both mild and advanced stages of uterine prolapse.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Humanos , Histerectomia , Histerectomia Vaginal , Diafragma da Pelve , Prolapso de Órgão Pélvico/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Prolapso Uterino/cirurgia , Vagina
10.
Medicine (Baltimore) ; 100(24): e26386, 2021 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-34128901

RESUMO

RATIONALE: Vesicovaginal fistula (VVF) most commonly occurs due to iatrogenic injury during surgery or obstructed labor. We report a rare case of a patient with severe pelvic organ prolapse who developed VVF even though pessary had not been used. PATIENT CONCERNS: A 63-year-old postmenopausal woman, para 3 (all spontaneous vaginal deliveries), complained of vaginal bulging sensation and involuntary urinary leakage for 3 years. DIAGNOSIS: Stage IV uterine prolapse with VVF. INTERVENTIONS: She underwent transvaginal VVF repair combined with total vaginal hysterectomy and sacrospinous ligament fixation. The postoperative course was uncomplicated. OUTCOMES: The patient remained free of complications during the 1-year follow-up. LESSONS: This case illustrates the point that patients with pelvic organ prolapse (POP) should be treated promptly and careful follow-up should be conducted. Clinicians should be aware of the symptoms of VVF to ensure its early diagnosis and treatment.


Assuntos
Prolapso Uterino/complicações , Fístula Vesicovaginal/complicações , Feminino , Humanos , Histerectomia Vaginal , Ligamentos/cirurgia , Pessoa de Meia-Idade , Transtornos Urinários/etiologia , Prolapso Uterino/cirurgia , Fístula Vesicovaginal/cirurgia
11.
Am J Obstet Gynecol ; 225(5): 506.e1-506.e28, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34087229

RESUMO

BACKGROUND: Prolapse recurrence after transvaginal surgical repair is common; however, its mechanisms are ill-defined. A thorough understanding of how and why prolapse repairs fail is needed to address their high rate of anatomic recurrence and to develop novel therapies to overcome defined deficiencies. OBJECTIVE: This study aimed to identify mechanisms and contributors of anatomic recurrence after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair) vs transvaginal mesh (VM) hysteropexy surgery for uterovaginal prolapse. STUDY DESIGN: This multicenter study was conducted in a subset of participants in a randomized clinical trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Overall, 94 women with uterovaginal prolapse treated via native tissue repair (n=48) or VM hysteropexy (n=46) underwent pelvic magnetic resonance imaging at rest, maximal strain, and poststrain rest (recovery) 30 to 42 months after surgery. Participants who desired reoperation before 30 to 42 months were imaged earlier to assess the impact of the index surgery. Using a novel 3-dimensional pelvic coordinate system, coregistered midsagittal images were obtained to assess study outcomes. Magnetic resonance imaging-based anatomic recurrence (failure) was defined as prolapse beyond the hymen. The primary outcome was the mechanism of failure (apical descent vs anterior vaginal wall elongation), including the frequency and site of failure. Secondary outcomes included displacement of the vaginal apex and perineal body and change in the length of the anterior wall, posterior wall, vaginal perimeter, and introitus of the vagina from rest to strain and rest to recovery. Group differences in the mechanism, frequency, and site of failure were assessed using the Fisher exact tests, and secondary outcomes were compared using Wilcoxon rank-sum tests. RESULTS: Of the 88 participants analyzed, 37 (42%) had recurrent prolapse (VM hysteropexy, 13 of 45 [29%]; native tissue repair, 24 of 43 [56%]). The most common site of failure was the anterior compartment (VM hysteropexy, 38%; native tissue repair, 92%). The primary mechanism of recurrence was apical descent (VM hysteropexy, 85%; native tissue repair, 67%). From rest to strain, failures (vs successes) had greater inferior displacement of the vaginal apex (difference, -12 mm; 95% confidence interval, -19 to -6) and perineal body (difference, -7 mm; 95% confidence interval, -11 to -4) and elongation of the anterior vaginal wall (difference, 12 mm; 95% confidence interval, 8-16) and vaginal introitus (difference, 11 mm; 95% confidence interval, 7-15). CONCLUSION: The primary mechanism of prolapse recurrence following vaginal hysterectomy with uterosacral ligament suspension or VM hysteropexy was apical descent. In addition, greater inferior descent of the vaginal apex and perineal body, lengthening of the anterior vaginal wall, and increased size of the vaginal introitus with strain were associated with anatomic failure. Further studies are needed to provide additional insight into the mechanism by which these factors contribute to anatomic failure.


Assuntos
Imageamento por Ressonância Magnética , Pelve/diagnóstico por imagem , Falha de Tratamento , Prolapso Uterino/diagnóstico por imagem , Prolapso Uterino/cirurgia , Idoso , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Humanos , Histerectomia Vaginal/efeitos adversos , Imageamento Tridimensional , Pessoa de Meia-Idade , Recidiva
12.
J Minim Invasive Gynecol ; 28(11): 1818-1819, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34171475

RESUMO

STUDY OBJECTIVE: Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) was previously described as a feasible approach to perform several procedures including hysterectomy followed by uterosacral ligament suspension [1,2]. Approaching the cul-de-sac with vNOTES while the uterus is intact allowing access to the uterosacral ligaments. This enables attainment of apical support by placing sutures on the ligaments, shortening them, and reinforcing their attachment to the cervix. The objective of this video is to demonstrate a surgical technique for vNOTES uterosacral ligament hysteropexy (ULH). DESIGN: Stepwise demonstration of the technique with narrated video footage. This video report is part of an institutional, investigational review board-approved study. SETTING: Academic tertiary referral center. INTERVENTIONS: This video presents our team's vNOTES technique for ULH in a woman aged 37 years (gravida 3 para 3) who presented with pelvic organ prolapse quantification stage 3 symptomatic uterine prolapse. The patient requested uterine prolapse repair surgery while retaining the uterus. After performing a posterior colpotomy and entering the posterior cul-de-sac, the alexis and then the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA) were placed into the vagina. Three trocars were inserted into the port. We used a 10-mm scope with a 30°-angle view. The instruments included a needle driver and a clinch grasper. The next step was to identify the uterosacral ligamentous structures. Once identified, 2 absorbable vicryl sutures and 1 nonabsorbable Ti-cron suture were placed on each ligament and then secured with large bites into the junctional portion of the uterosacral ligament with the posterior aspect of the cervix. The GelPOINT was then extracted, and the sutures locked in place to shorten the uterosacral ligaments and reinforce their attachment to the cervix. After all the suspensory sutures were tied, cystoscopy was performed to assess ureteral patency. The vaginal incision was then reapproximated in a horizontal manner, using continuous absorbable suture. CONCLUSION: vNOTES ULH appears to be feasible in women with uterine prolapse when uterus conservative treatment is desired. Advantages of this technique include good exposure of the ureter, lowering the risk of ureteric injury. In addition, the absence of incisions on the abdomen eliminates the risk of abdominal wound infection and incisional pain and yields a better cosmetic outcome. Further studies are needed to appraise the long-term outcomes and demonstrate the ultimate use of this modality.


Assuntos
Cirurgia Endoscópica por Orifício Natural , Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Humanos , Histerectomia Vaginal , Ligamentos/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Resultado do Tratamento , Prolapso Uterino/cirurgia , Vagina/cirurgia
13.
Int Urogynecol J ; 32(8): 2021-2031, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34050771

RESUMO

INTRODUCTION AND HYPOTHESIS: While approximately 225,000 pelvic organ prolapse (POP) surgeries are performed annually in the US, there is no consensus on the optimal route for pelvic support for the initial treatment of uterovaginal prolapse (UVP). Our objective is to compare the outcomes of abdominal sacrocolpopexy (ASC) to vaginal pelvic support (VPS) with either uterosacral ligament suspension (USLS) or sacrospinous ligament fixation (SSF) in combination with hysterectomy for treating apical prolapse. METHODS: A systematic search was performed through March 2021. Studies comparing ASC with VPS for treatment of UVP were included in the review. The primary outcome was the rate of overall anatomic prolapse failure per studies' definition. Secondary outcomes included evaluating isolated recurrent vaginal wall prolapse, postoperative POP-Q points, total vaginal length (TVL), and Pelvic Floor Distress Inventory (PFDI-20) scores. Random effect analyses were generated utilizing R 4.0.2. RESULTS: Out of 4225 total studies, 4 met our inclusion criteria, including 226 patients in the ASC group and 199 patients in the VPS group. ASC was not found to be associated with a higher rate of vaginal wall prolapse recurrence (OR = 0.6; 95% CI = 0.2-2.4; P = 0.33). There was no significant difference between groups for anterior or apical vaginal wall prolapse recurrence (P = 0.58 and P = 0.97, respectively). ASC was associated with significantly longer TVL (mean difference [MD]: 1.01; 95% CI = 0.33-1.70; P = 0.02) and better POP-Q Ba scores [MD = -0.23; 95% CI = -0.37; -0.10; P = 0.01]. CONCLUSIONS: ASC and vaginal pelvic support (either USLS or SSF) have comparable anatomical outcomes. However, weak evidence of a difference in TVL and Ba was found. The strength of the evidence in this study is based on the small number of observational studies. A large, randomized trial is highly warranted.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Histerectomia , Histerectomia Vaginal , Ligamentos/cirurgia , Estudos Observacionais como Assunto , Prolapso de Órgão Pélvico/cirurgia , Peritônio , Resultado do Tratamento , Prolapso Uterino/cirurgia
14.
J Minim Invasive Gynecol ; 28(7): 1425-1428, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33962025

RESUMO

Surgical approach to pelvic organ prolapse has traditionally included hysterectomy; however, in the past decade, uterine sparing prolapse surgery (hysteropexy) has become increasingly popular within female pelvic medicine and reconstructive surgery. The current literature demonstrates comparable outcomes for hysteropexy and traditional approach. As these procedures become more common, it is important to consider how to approach patients with unique anatomy such as uterine anomalies who desire uterine sparing surgery. In our case, we describe a woman aged 77 years with uterine didelphys who underwent a successful vaginal uterosacral ligament hysteropexy for stage 2 pelvic organ prolapse and was followed for 12 months postoperatively. Our case demonstrates that vaginal uterosacral ligament hysteropexy is feasible in a patient with uterine didelphys.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Ligamentos/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Resultado do Tratamento , Prolapso Uterino/cirurgia
15.
Am J Obstet Gynecol ; 225(4): 405.e1-405.e7, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33984303

RESUMO

BACKGROUND: There is limited literature identifying racial and ethnic health disparities among surgical modalities and outcomes in the field of urogynecology and specifically pelvic organ prolapse surgery. OBJECTIVE: This study aimed to evaluate the differences in surgical approach for apical vaginal prolapse and postoperative complications by race and ethnicity. STUDY DESIGN: This is a retrospective cohort study of women undergoing surgical repair for apical vaginal prolapse between 2014 and 2017 using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients were eligible for inclusion if they underwent either vaginal colpopexy or abdominal sacrocolpopexy. Abdominal sacrocolpopexy cases were further divided into those performed by laparotomy and those performed by laparoscopy. Multivariable logistic regression models that controlled for age, comorbidities, American Society of Anesthesiologists physical status classification, and concurrent surgery were used to determine whether race and ethnicity are associated with the type of colpopexy (vaginal vs abdominal) or the surgical route of abdominal sacrocolpopexy. Similar models that also controlled for surgical approach were used to assess 30-day complications by race and ethnicity. RESULTS: A total of 22,861 eligible surgical cases were identified, of which 12,337 (54%) were vaginal colpopexy and 10,524 (46%) were abdominal sacrocolpopexy. Among patients who had an abdominal sacrocolpopexy, 2262 (21%) were performed via laparotomy and 8262 (79%) via laparoscopy. The study population was 70% White, 9% Latina, 6% African American, 3% Asian, 0.6% Native Hawaiian or Pacific Islander, 0.4% American Indian or Alaska Native, and 11% unknown. In multivariable analysis, Asian and Native Hawaiian or Pacific Islander women were less likely to undergo abdominal sacrocolpopexy compared with White women (odds ratio, 0.82; 95% confidence interval, 0.68-0.99, and odds ratio, 0.56; 95% confidence interval, 0.39-0.82, respectively). Among women who underwent an abdominal sacrocolpopexy, Latina women and Native Hawaiian or Pacific Islander women were less likely to undergo a laparoscopic approach compared with White women (odds ratio, 0.68; 95% confidence interval, 0.58-0.79, and odds ratio, 0.31; 95% confidence interval, 0.1-0.56, respectively). Complication rates also differed by race and ethnicity. After a colpopexy, African American women were more likely to need a blood transfusion (odds ratio, 3.04; 95% confidence interval, 1.95-4.73; P≤.001) and have a deep vein thrombosis or pulmonary embolus (odds ratio, 2.46; 95% confidence interval, 1.10-5.48; P=.028), but less likely to present with postoperative urinary tract infections (odds ratio, 0.68; 95% confidence interval, 0.49-0.96; P=.028) than White women in multivariable regression models. Using the Clavien-Dindo classification system, Latina women had higher odds of developing grade II complications than White women in multivariable models (odds ratio, 1.25; 95% confidence interval, 1.04-1.51; P=.02). CONCLUSION: There are racial and ethnic differences in the type and route of surgical repair for apical vaginal prolapse. In particular, Latina and Pacific Islander women were less likely to undergo a laparoscopic approach to abdominal sacrocolpopexy compared with White women. Although complications were uncommon, there were several complications including blood transfusions that were higher among African American and Latina women. Additional studies are needed to better understand and describe associated factors for these differences in care and surgical outcomes.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Disparidades em Assistência à Saúde/etnologia , Complicações Pós-Operatórias/etnologia , Embolia Pulmonar/etnologia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Prolapso Uterino/cirurgia , Trombose Venosa/etnologia , Adolescente , Adulto , Afro-Americanos , Idoso , Nativos Estadunidenses , Americanos Asiáticos , Transfusão de Sangue/estatística & dados numéricos , Estudos de Coortes , Grupo com Ancestrais do Continente Europeu , Feminino , Hispano-Americanos , Humanos , Laparoscopia , Laparotomia , Modelos Logísticos , Pessoa de Meia-Idade , Análise Multivariada , Grupo com Ancestrais Oceânicos , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Embolia Pulmonar/epidemiologia , Estudos Retrospectivos , Sacro , Estados Unidos/epidemiologia , Infecções Urinárias/epidemiologia , Infecções Urinárias/etnologia , Trombose Venosa/epidemiologia , Adulto Jovem
16.
J Obstet Gynaecol Can ; 43(10): 1129-1135, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33984523

RESUMO

OBJECTIVE: The incidence of post-hysterectomy vault prolapse following native tissue repair has been reported to be as high as 43%. The optimal way to maintain vault support is unknown. Our aim was to evaluate the long-term efficacy of modified McCall culdoplasty during vaginal hysterectomy for symptomatic uterine prolapse in preventing the recurrence of vaginal vault prolapse. METHODS: We conducted a retrospective chart review involving 490 patients who underwent vaginal hysterectomy with modified McCall culdoplasty, with or without a concomitant stress incontinence procedure, between January 2008 and December 2018 at Mount Sinai Hospital in Toronto. Data analyzed included patient demographics, preoperative prolapse staging, intraoperative and postoperative complications, and postoperative subjective and objective success rates. RESULTS: A total of 490 patients underwent vaginal hysterectomy with modified McCall culdoplasty. The mean follow-up period was 2.8 years. The objective success rate of vault support was 97.1%, and the subjective success rate was 94.1%. The total rate of reoperation for recurrence of vault prolapse was 1.0%. The objective cystocele recurrence rate was 8.6%, and 2.4% of these cases required reoperation. The objective rectocele recurrence rate was 4.7%, with 1.2% requiring reoperation. Unilateral ureteric kinking requiring intraoperative release of the McCall suture was recorded for 2.9% of patients. Overall, there was significant improvement in urinary, bowel, and prolapse symptoms post procedure. CONCLUSION: This cohort of patients who underwent modified McCall culdoplasty had low rates of vault prolapse recurrence and prolapse symptoms. The modified McCall culdoplasty technique practised at our institution is safe and effective in preventing post-hysterectomy vault prolapse.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Humanos , Histerectomia , Histerectomia Vaginal , Prolapso de Órgão Pélvico/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Prolapso Uterino/cirurgia
17.
Int Urogynecol J ; 32(6): 1409-1417, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33847771

RESUMO

INTRODUCTION AND HYPOTHESIS: The objective was to assess if puborectalis muscle (PRM) function changes in women with pelvic organ prolapse (POP) undergoing pessary treatment. METHODS: This was a prospective cohort study of women with symptomatic POP choosing pessary treatment. An interview, clinical examination and 3D/4D transperineal ultrasound were performed at baseline and at 3-month follow-up. POP was assessed using the Pelvic Organ Prolapse Quantification system (POPQ). Parameters compared between baseline and follow-up were: hiatal area at rest (HArest), maximal contraction (HActx), and maximal Valsalva maneuver (HAVal), displacement in contraction (DISPL-ctx, i.e., relative difference between HArest and HActx), and displacement in Valsalva (DISPL-Val, i.e., relative difference between and HAVal and HArest). Parameters were compared in women with and those without complete avulsion. RESULTS: A total of 162 women were assessed and 34 were included. Mean age was 64 years (SD 11.4), and mean BMI 24 kg/m2 (SD 3.1). Thirty-one women had a cystocele, 8 a uterine prolapse, and 12 had a posterior compartment prolapse. Twenty-one women (61.8%) had a POP stage II, and 13 (38.2%) a POP stage III. Ring pessaries were most frequently used (97%). In the entire group a statistically significant increase in DISPL-ctx was observed (mean difference 2.1%, p = 0.017). In the no avulsion group HArest and DISPL-ctx increased significantly (mean difference 4.1%, p = 0.016 and 2.7%, p = 0.016 respectively) and the increase in DISPL-ctx was higher than in the avulsion group (mean difference 2.7% vs 0.2%, p = 0.056). CONCLUSION: Our results show that PRM function changes in women with POP undergoing pessary treatment and suggest that such change occurs mainly in the absence of complete avulsion.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Humanos , Pessoa de Meia-Idade , Diafragma da Pelve , Pessários , Estudos Prospectivos
18.
BMC Womens Health ; 21(1): 154, 2021 04 16.
Artigo em Inglês | MEDLINE | ID: mdl-33863314

RESUMO

BACKGROUND: Sacrospinous ligament fixation (SSLF) is a widely used vaginal procedure for correction of apical vaginal prolapse. The objective of this study was to evaluate subjective and objective outcomes of SSLF performed in a fast-track setting. METHODS: This was a prospective cohort study of sacrospinous ligament fixation performed using local anesthesia and light sedation in a fast-track setting at Aarhus University Hospital between April 2016 and December 2017. Objective signs of prolapse were assessed by gynecological examination preoperatively and at 6 months after the operation. Subjective symptoms were evaluated by questionnaires (the Pelvic Floor Distress Inventory (PFDI 20), and the Patient Global Impression of Improvement (PGI-I) supplemented with individual questions from the ICIQ-vaginal Symptoms (ICIQ-VS) and Sexual Questionnaire-IR (PISQ-12) questionnaires). RESULTS: One hundred and three women with a median age of 65 (36-84) years were included. Previous hysterectomy had been performed in 40% of the women, and 43% had a history of previous prolapse operations. At follow-up, 75% of the women had apical descent less than stage 2. However, 18% had anterior vaginal wall prolapse beyond the hymen, and 25% had recurrence of the apical prolapse stage 2 or more and were offered reoperation. Bladder and anal symptoms improved in most women after the operation, and the number of women reporting dyspareunia was halved. In the overall assessment by Patient Global Impression of Improvement (PGI-I) questionnaire, 76% reported improvement. No serious operative complications were reported, and 81% of the patients were discharged on the day of the surgery. CONCLUSION: In this cohort with a high rate of previous prolapse surgery, sacrospinous ligament fixation performed in a fast-track setting showed subjective and objective results comparable to the results of apical native tissue repair reported in the literature. Furthermore, the complication rate was low. Trial registration This study was notified to The Central Denmark Region Committees on Health Research Ethics on July 7, 2015, and was approved by The Danish Data Protection Agency (1-16-02-442-15). All methods were performed in accordance with the relevant guidelines and regulations. An informed consent for participation in the study and acceptance of using data for scientific purposes and publication was signed by all patients.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Ligamentos/cirurgia , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/cirurgia , Estudos Prospectivos , Resultado do Tratamento , Prolapso Uterino/cirurgia
19.
Int Urogynecol J ; 32(8): 2291-2293, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33730231

RESUMO

INTRODUCTION AND HYPOTHESIS: There is a great interest in avoiding mesh usage in vaginal surgeries. We propose using the autologous rectus fascia to repair apical vaginal prolapse in a similar way it has been successfully used in urinary stress incontinence surgery. This study aims to demonstrate the technique of sacrospinous hysteropexy using autologous rectus fascia for apical pelvic organ prolapse (POP) treatment. METHODS: We present a video of a 63-year-old female with stage IV pelvic organ prolapse and urinary obstruction. A rectus fascia sling of approximately 90 × 10 mm was harvested through a Pfannenstiel incision. It was used in vaginal surgery to suspend the cervix and fix the apical POP. RESULTS: The patient resumed her usual activities after 1 week and waited 2 months to resume physical activities and sexual intercourse. She is satisfied at 6 months follow-up, without complications or prolapse recurrence. CONCLUSION: The sacrospinous hysteropexy using autologous rectus fascia is a feasible technique with excellent results and low risk of complication. Further studies are required to compare POP repair using autologous rectus fascia and polypropylene meshes.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Fáscia , Feminino , Humanos , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas , Resultado do Tratamento
20.
Int Urogynecol J ; 32(8): 2287-2289, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33704537

RESUMO

INTRODUCTION AND HYPOTHESIS: In this video we present the surgical management of a 58-year-old woman presenting with a large prolapsed myomatous uterus treated with vaginal hysterectomy (VH) and pelvic floor repair (PFR) (uterosacral ligament suspension and posterior colporraphy) under local anesthesia and conscious sedation. METHODS: The patient underwent VH and PFR by using an infiltration of a local anesthetic solution of lidocaine, ropivacaine and adrenaline in combination with intravenous (iv) conscious sedation. Debulking techniques, such as intramyometrial coring, uterine bisection, myomectomy and wedge resection, were used to facilitate VH. The final weight of the removed uterus was 870 g. RESULTS: This video demonstrates that performing a surgically challenging VH under local anesthesia is feasible. CONCLUSIONS: Vaginal uterine morcellation can be performed to debulk the enlarged uterus so that hysterectomy can be accomplished under local anesthesia. The use of local anesthesia may safely be offered as an alternative to patients undergoing a complex vaginal hysterectomy and reconstructive surgery.


Assuntos
Histerectomia Vaginal , Prolapso Uterino , Anestesia Local , Sedação Consciente , Feminino , Humanos , Histerectomia , Pessoa de Meia-Idade , Prolapso Uterino/cirurgia , Útero
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