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2.
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
3.
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
4.
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
5.
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
6.
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
7.
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
8.
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
9.
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 , Americanos Asiáticos , Transfusão de Sangue/estatística & dados numéricos , Estudos de Coortes , Feminino , Humanos , Laparoscopia , Laparotomia , Modelos Logísticos , Pessoa de Meia-Idade , Análise Multivariada , 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
10.
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
11.
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
12.
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
13.
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
14.
J Minim Invasive Gynecol ; 28(10): 1759-1764, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33713835

RESUMO

STUDY OBJECTIVE: To compare clinical and anatomic outcomes as well as patient satisfaction in women undergoing vaginal colposuspension using the Uphold Lite system (Boston Scientific Corporation, Marlborough, MA) and transvaginal hysterectomy with uterosacral ligament suspension (VUSLS) for the treatment of apical prolapse. DESIGN: Retrospective cohort study. SETTING: Female pelvic medicine and reconstructive surgery unit at a university-affiliated tertiary medical center. PATIENTS: Women with apical prolapse who underwent either vaginal colposuspension using the Uphold Lite system (uterine-preserving as well as after previous hysterectomy) or VUSLS from 2010 to 2019. Excluded were women with 1 month or less of follow-up. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 164 women were included in the study: 112 women underwent VUSLS, and 52 underwent colposuspension using the Uphold Lite mesh system. Age, body mass index, maximal birth weight, comorbidity rates, and pelvic organ prolapse severity were similar between the groups. The clinical cure rate was similarly high in both groups, with 91.1% in the women who underwent VUSLS and 88.5% in those in the Uphold Lite group (p = .60). No differences were noted between the groups with regard to anatomic cure rate or composite outcome success rate (73.9% vs 76.0%, p = .77 and 70.3% vs 74.0%, p = .63, in the VUSLS and Uphold Lite groups, respectively). An advantage was noted in the VUSLS group with regard to patient satisfaction with 98.1% of the women stating that their condition was very much better (Patient Global Impression of Improvement questionnaire: A) or much better (Patient Global Impression of Improvement questionnaire: B) compared with 83.9% of the women in the Uphold Lite group (p = .023). In an attempt to assess the association between different variables and the composite outcome, a multivariate analysis was performed in which increased body mass index, menopausal status, and increased preoperative genital hiatus were found to decrease composite outcome success. CONCLUSION: Vaginal colposuspension using the Uphold Lite system and VUSLS for the treatment of apical prolapse have comparable results with high clinical success rates.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Histerectomia , Histerectomia Vaginal , Ligamentos/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Estudos Retrospectivos , Telas Cirúrgicas , Resultado do Tratamento , Prolapso Uterino/cirurgia
15.
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
16.
Am J Obstet Gynecol ; 225(2): 153.e1-153.e31, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33716071

RESUMO

BACKGROUND: Vaginal hysterectomy with suture apical suspension is commonly performed for uterovaginal prolapse. Sacrospinous hysteropexy with graft (vaginal mesh hysteropexy) is an alternative, although in 2019 the Food and Drug Administration removed this mesh product from the United States market. OBJECTIVE: Our objective was to compare the efficacy and adverse events of these 2 procedures. STUDY DESIGN: At 9 clinical sites in the United States National Institutes of Health and National Institute of Child Health and Human Development Pelvic Floor Disorders Network, 183 postmenopausal women requesting vaginal surgery for symptomatic uterovaginal prolapse were enrolled in a multisite randomized superiority clinical trial, comparing a sacrospinous hysteropexy with graft (hysteropexy) with a vaginal hysterectomy with uterosacral ligament suspension (hysterectomy). Participants consented to remain masked to treatment assignment for the study duration. Study visits were conducted at 6-month intervals through 60 months. The primary treatment failure composite outcome (retreatment of prolapse, prolapse beyond the hymen, or prolapse symptoms) was evaluated with survival modeling. Secondary outcomes included complications or adverse events, individual anatomic measures of the pelvic organ prolapse quantification examination, and presence, severity, and impact and bother of prolapse, urinary, bowel, and pain symptoms as measured by validated questionnaires. The 3-year published results suggested better primary outcomes with sacrospinous hysteropexy with graft, but the differences were not statistically significant (P=.06). This study reports the 5-year outcomes. RESULTS: A total of 183 women with a mean age of 66 years were randomized between April 2013 and February 2015; 93 were randomized to hysteropexy and 90 were randomized to hysterectomy. Notably, 175 were included in the trial, and 156 (89%) completed the 5-year follow-up. The primary outcome showed fewer failures for hysteropexy than hysterectomy through 5 years (adjusted hazard ratio, 0.58; 95% confidence interval, 0.36-0.94; P=.03), with failure rates of 37% vs 54%, respectively, resulting in a difference of -18% (95% confidence interval, -33% to -3%) at 5 years. With the exception of the Urogenital Distress Inventory, no group differences were demonstrated in patient-reported pelvic floor symptoms, prolapse symptoms, bowel function symptoms, general quality of life, body image, or pelvic pain. At their last visit through 5 years, 70% of participants (129 of 183) reported they remained masked to their treatment with no difference in masking between groups. Adverse events for hysteropexy vs hysterectomy included mesh exposure (8% vs 0%), granulation tissue after 12 weeks (1% vs 12%), and suture exposure after 12 weeks (3% vs 21%), respectively. CONCLUSION: Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery, sacrospinous hysteropexy with graft resulted in a lower composite failure rate than vaginal hysterectomy through 5 years. There were no meaningful differences in patient-reported outcomes between groups. Our results suggest that this vaginal mesh hysteropexy procedure should be made available to patients.


Assuntos
Histerectomia Vaginal/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Telas Cirúrgicas , Prolapso Uterino/cirurgia , Idoso , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Ligamentos/cirurgia , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Sacro , Técnicas de Sutura , Falha de Tratamento , Prolapso Uterino/fisiopatologia , Prolapso Uterino/psicologia
17.
Actas urol. esp ; 45(2): 160-166, mar. 2021. graf, ilus
Artigo em Espanhol | IBECS | ID: ibc-201622

RESUMO

INTRODUCCIÓN: La colposacropexia laparoscópica (CL) es el tratamiento gold standard del prolapso de órganos pélvicos (POP) apical. El esfínter urinario artificial (EUA) presenta elevada eficacia en el tratamiento de la incontinencia urinaria de esfuerzo recidivada (IUEr). OBJETIVO: Describir por primera vez la técnica de CL e implante laparoscópico de EUA mediante un abordaje vesicovaginal a la cara posterior del cuello vesical. MATERIAL Y MÉTODOS: La cirugía se realiza por un abordaje transperitoneal. Se crea el espacio rectovaginal y se fija la malla posterior. Se realiza la disección del espacio vesicovaginal con ayuda de una valva vaginal, se crean los espacios laterovesicales y se comunican ambos con el espacio vesicovaginal. Se fija la malla anterior. Se diseca la cara anterior del cuello y se coloca el manguito. Se fijan ambas mallas al promontorio. Se introduce el reservorio, se coloca el botón de activación en el labio mayor y se realizan las conexiones de forma habitual. Finalmente, se cierra el peritoneo. RESULTADOS: El tiempo quirúrgico fue de 180 minutos, la sonda vesical se retiró al quinto día y la estancia fue de cinco días. El EUA se activó a la sexta semana. No hubo complicaciones perioperatorias. Tras 12 meses, la paciente presenta continencia completa y curación objetiva y subjetiva del POP. CONCLUSIONES: La disección vesicovaginal es un paso común en esta técnica de CL y colocación de EUA. La visión directa del cuello vesical permitiría disminuir el riesgo de erosión. Recomendamos esta técnica en casos seleccionados de POP e IUEr


INTRODUCTION: Laparoscopic sacral colpopexy (LSC) is the gold standard treatment for apical pelvic organ prolapse (POP). Artificial urinary sphincter (AUS) has a high success rate in treating recurrent stress urinary incontinence (SUI). OBJECTIVE: To describe the first simultaneous LSC and AUS implantation through a vesicovaginal approach to the bladder neck. MATERIAL AND METHODS: Operation is performed through a transperitoneal approach. The rectovaginal space is created and the posterior mesh is fixed. The vesicovaginal and both laterovesical spaces are dissected. The vesicovaginal space is connected to both lateral spaces. This is main step of the procedure because it let us place the cuff around the bladder neck in a non-blind fashion. The anterior mesh is fixed to the vagina. The anterior side of the bladder neck is dissected and the cuff implanted. Both meshes are fixed to the promontory. Pressure-regulating balloon is inserted, the pump is placed in the labia majora and the components are connected. Peritoneum is closed. RESULTS: Surgical time was 180 minutes, bladder catheter was removed at 5th postoperative day, hospital stay was 5 days. The AUS was activated 6 weeks after surgery. No perioperative complications occurred. After 12 months the patient is pad-free and prolapse was objectively and subjectively cured. CONCLUSIONS: Vesicovaginal dissection is a shared step in this technique of LSC and AUS implantation. This approach could minimize the risk of bladder neck injury. We propose this technique in selected cases of prolapse and recurrent SUI


Assuntos
Humanos , Feminino , Idoso , Laparoscopia/métodos , Prolapso Uterino/cirurgia , Incontinência Urinária por Estresse/cirurgia , Esfíncter Urinário Artificial , Terapia Combinada , Resultado do Tratamento , Duração da Cirurgia , Tempo de Internação , Reprodutibilidade dos Testes , Telas Cirúrgicas
18.
Int Urogynecol J ; 32(8): 2203-2209, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33635351

RESUMO

INTRODUCTION AND HYPOTHESIS: The aim of this study was to evaluate the impact of an adjuvant posterior repair (PR) on treatment outcomes of native tissue apical suspension. MATERIALS AND METHODS: This retrospective cohort study included 194 women who underwent iliococcygeus or uterosacral ligament suspension with or without PR for Pelvic Organ Prolapse Quantification (POPQ) stage 2-4 posterior vaginal wall prolapse that resolved under simulated preoperative apical support and who completed a 1-year follow-up. The primary outcome was composite surgical failure defined as the presence of vaginal bulge symptoms, descent of the vaginal apex more than one-third of the way into the vaginal canal (apical recurrence), anterior or posterior vaginal wall descent beyond the hymen (anterior or posterior recurrence), or retreatment for prolapse. Secondary outcomes included anatomical outcomes, perioperative outcomes, obstructed defecation, dyspareunia, and adverse events. RESULTS: One hundred thirty women underwent concomitant PR, and 64 did not. Surgical failure rates were significantly higher in the group not receiving PR than in the group receiving PR (29.7% vs. 12.3%, p < 0.01). Anatomically, anterior and apical recurrence was more common in the group not receiving PR (p < 0.05). Concomitant PR was associated with a longer operating time and more blood loss (p < 0.01). However, there were few adverse events related to PR, and the rates of de novo obstructed defecation and dyspareunia were low in both groups, with no significant difference between the groups. CONCLUSION: Concomitant PR at the time of native tissue apical suspension may reduce the recurrence of symptomatic anterior and apical prolapse without significant morbidity.


Assuntos
Prolapso de Órgão Pélvico , Prolapso Uterino , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Recidiva Local de Neoplasia , Prolapso de Órgão Pélvico/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Prolapso Uterino/cirurgia
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