Intermediate-term outcomes of laparoscopic pectopexy and vaginal sacrospinous fixation: a comparative study

ABSTRACT Objective To compare the intermediate-term follow-up results of laparoscopic pectopexy and vaginal sacrospinous fixation procedures. Materials and Methods Forty-three women who had vaginal sacrospinous fixations(SSF) using Dr. Aksakal's Desta suture carrier and 36 women who had laparoscopic pectopexies were re-examined 7 to 43 months after surgery. The PISQ-12 and P-QOL questionnaires were answered by all of the women. Results The apical descensus relapse rates did not differ between the groups (14% in the SSF vs. 11.1% in the pectopexy group). The de novo cystocele rates were higher in the SSF group (25.6% in the SSF vs. 8.3% in the pectopexy group). There were no significant differences in the de novo rectocele numbers between the groups. The treatment satisfaction rates were high in both groups (93% in the SSF vs. 91.7% in the pectopexy group), which was not statistically significant. Moreover, the postoperative de novo urge and stress urinary incontinence rates did not differ; however, the postoperative sexual function scores (PISQ-12) (36.86±3.15 in the SSF group vs. 38.21±5.69 in the pectopexy group) were better in the pectopexy group. The general P-QOL scores were not significantly different between the surgery groups. Conclusion The vaginal sacrospinous fixation maintains its value in prolapse surgery with the increasing importance of native tissue repair. The new laparoscopic pectopexy technique has comparable positive follow-up results with the conventional sacrospinous fixation procedure.

Colpocleisis sitio-específica: 3 años de experiencia / Site-specific colpocleisis: 3 years of experience

RESUMEN El prolapso de órganos pélvicos es definido como el descenso de la pared anterior y /o posterior de la vagina y/ o la cúpula o útero a través de la vagina. Esta patología se ha visto asociada a disfunción urinaria, alteración de la defecación y disfunción sexual. El prolapso sintomático de órganos pélvicos es una condición que afecta negativamente la calidad de vida de las mujeres, encontrando una prevalencia de 3-6%. La cirugía obliterativa de vagina, tiene un menor tiempo quirúrgico, las tasas de morbilidad y pérdida de sangre son más bajas, la recuperación es más rápida, y el éxito anatómico mayor. Las pacientes que son ideales candidatas a la colpocleisis suelen presentar múltiples comorbilidades médicas que las descartan para llevar a una cirugía reconstructiva con una eficiencia de 90% en la literatura, refiriendo que mejora de la calidad de vida y la imagen corporal para la mayoría de pacientes. OBJETIVO: Realizar una revisión sobre el procedimiento de colpocleisis referente a los resultados anatómicos, resolución de los síntomas, satisfacción con los resultados quirúrgicos y la morbimortalidad asociada de pacientes que consultaron a una institución prestadora de salud privada de tercer nivel, ubicada en Medellín, (Colombia). METODOLOGÍA: Se realizó un estudio de cohorte retrospectivo en el cual se incluyen todas las pacientes con prolapso grado 3-4 a quienes se les haya realizado colpocleisis en el periodo de tiempo comprendido entre 2013 al 2016, en una institución prestadora de salud privada de III nivel en Medellín, Antioquia, que atiende régimen contributivo del sistema seguridad social en Colombia y pacientes particulares. Se usó la escala de cuantificación del Prolapso del Órgano Pélvico (POP-Q) para determinar los niveles de prolapso y que tipo de prolapso se identificaba antes y después de la cirugía. Se les solicitó a todas evaluación urodinámica multicanal preoperatoria con reducción del prolapso para evaluar incontinencia oculta o dificultades de micción. Y se realizó una evaluación subjetiva de la respuesta a la cirugía con la escala de Impresión Global de Mejora del paciente (PGI-I). RESULTADOS: Se realizó una recolección de datos entre enero de 2013 a diciembre de 2016. Fueron sometidas a colpocleisis 143 pacientes, 27 de ellas (18.8 %) tenían más de 80 años. 52 pacientes (36.3%) entre 60-70 años, 62 pacientes (43.3%) entre 70-80 años y 1 pacientes <60 años. La edad media del grupo de edad fue de 75 años, rango 58-94 años; el índice de masa corporal promedio fue de 27, la duración del seguimiento promedio fue 9 meses, y el número de partos vaginales 4. El 97.9% de las pacientes presentaban comorbilidades médicas. Hubo una tasa de curación de 97.9%. CONCLUSIÓN: El estudio de cohorte describe nuestra experiencia y agrega a los datos existentes que apoyan la viabilidad y seguridad de la colpocleisis. Encontramos alta eficacia de las cleisis en cuanto a la satisfacción de las pacientes, en mejoría de calidad de vida, independiente de la edad, con una baja tasa de complicaciones y fallas quirúrgicas. La colpocleisis es una buena opción de tratamiento para prolapso de órganos pélvicos estadio 3-4, en quienes no deseen conservar la función sexual, sin embargo este concepto debe ser individualizado para cada paciente.

ABSTRACT Pelvic organ prolapse is defined as the descent of the anterior and / or posterior wall of the vagina and / or the dome or uterus through the vagina. This pathology has been associated with urinary dysfunction, altered defecation and sexual dysfunction. Symptomatic prolapse of pelvic organs is a condition that negatively affects the quality of life of women, finding a prevalence of lifetime prevalence is 3-6%. Obliterative vaginal surgery, has a shorter surgical time, morbidity and blood loss rates are lower, recovery is faster, and anatomic success greater. Patients who are ideal candidates for colpocleisis usually present multiple medical comorbidities that discard them to lead to reconstructive surgery. With an efficiency of 90% in the literature, indicating that improvement of the quality of life and body image for the majority of patients. OBJECTIVE: To perform a review of the colpocleisis procedure regarding anatomical results, resolution of symptoms, satisfaction with surgical results and associated morbidity and mortality of patients who consulted a third-level private health care institution located in Medellín, (Colombia). METHODOLOGY: A retrospective cohort study was carried out in which all patients with grade III-IV prolapse who underwent colpocleisis were included in the period from 2013 to 2016, in a private health institution of III level in Medellín, Antioquia, that attends contributory regime of the social security system in Colombia and private patients. The Pelvic Organ Prolapse (POP-Q) scale was used to determine prolapse levels and what type of prolapse was identified before and after surgery. All preoperative multichannel urodynamic evaluations with prolapse reduction were requested to evaluate occult incontinence or micturition difficulties. And a subjective evaluation of the response to surgery was performed with the Global Impression of Patient Improvement (PGI-I) scale. RESULTS: Data were collected between January 2013 and December 2016. Thirty-three patients were submitted to colpocleisis, 27 of which 18.8 (%) were older than 80 years. 52 (36.3%) patients between 60-70 years, 62 (43.3%) between 70-80 years and <60 years 1 patient. The mean age of the age group was 75 years, range 58-94 years; the mean body mass index was 27, the average follow-up duration was 9 months, and the number of vaginal deliveries was 4. (97.9%) of the patients had medical comorbidities. With a cure rate of 97.9%. CONCLUSION: The cohort study describes our experience and adds to existing data that support the viability and safety of colpocleisis. We found high efficacy of cleisis in terms of patient satisfaction, improvement in quality of life, independent of age, with a low rate of complications and surgical failures. Colpocleisis is a good treatment option for prolapse of pelvic organs stage III-IV, in those who do not wish to preserve sexual functionality, however this concept must be individualized for each patient.

Técnicas obliterativas en el tratamiento quirúrgico del prolapso genital femenino: experiencia en el Servicio de Salud Metropolitano Oriente, Santiago-Chile / Obliterative techniques in the surgical treatment of female genital prolapse: experience in the Metropolitan Health Service Oriente, Santiago-Chile

INTRODUCCIÓN Y OBJETIVOS: El prolapso genital afecta hasta al 50% de las mujeres a nivel mundial, su calidad de vida, percepción corporal y vida sexual. A las pacientes de edad avanzada frecuentemente les ofrecemos técnicas quirúrgicas obliterativas para su manejo. El objetivo fue evaluar los resultados de las técnicas obliterativas basados en nuestra experiencia local. MÉTODOS: análisis retrospectivo de pacientes tratadas con técnicas obliterativas en nuestro hospital entre los años 2008 y 2016. RESULTADOS: se incluyeron 78 pacientes, la edad promedio fue de 74.5 años, 11.5% de las pacientes presentaba comorbilidad de mayor riesgo quirúrgico, 24% eran pacientes histerectomizadas por prolapso y 30.8% presentaba incontinencia de orina al momento de la cirugía. El tiempo quirúrgico promedio fue 52 minutos, 73.1% de las cirugías fueron con técnica de LeFort y 5.1% presentó complicaciones postquirúrgicas precoces. Se contactaron telefónicamente 59 pacientes, 90% refirió mejor calidad de vida, 92% satisfacción con la cirugía, 3.4% recidiva del prolapso y 44% incontinencia urinaria, en su mayoría moderada o severa. La recidiva reportada estuvo acorde a lo reportado en la literatura, pero la incontinencia de orina reportada fue muy alta respecto a lo reportado y de predominio de urgencias. CONCLUSIÓN: las técnicas obliterativas son efectivas en el tratamiento quirúrgico del prolapso y el principal problema postquirúrgico a largo plazo asociado fue la incontinencia de orina de urgencias.

INTRODUCTION AND OBJECTIVES: Genital prolapse affects up to 50% of women worldwide, their quality of life, body perception and sex life. For older patients, we often offer obliterative surgical techniques to manage it. The objective was to evaluate the results of the obliterative techniques based on our local experience. METHODS: retrospective analysis of patients treated with obliterative techniques in our hospital between 2008 y 2016. RESULTS: 78 patients were included, with an average age of 74.5 years, 11.5% of the patients had comorbidities of high surgical risk, 24% were previously hysterectomized because of genital prolapse and 30.8% had urinary incontinence at the time of the surgery. Average surgical time was 52 minutes, 73.1% of the surgeries were performed with the LeFort technique and 5.1% presented early postoperative complications. 59 patients were contacted by telephone, 90% reported better quality of life, 92% were satisfied with the surgery, 3.4% had recurrence of the prolapse and 44% reported urinary incontinence, mostly moderate or severe. The reported relapse was in line with what was reported in the literature, but the reported urinary incontinence was very high compared to what was reported, and was predominantly urge incontinence. CONCLUSION: obliterative techniques are effective in the surgical treatment of genital prolapse and the main long term problem after surgery was urge incontinence.

Survey on Aesthetic Vulvovaginal Procedures: What do Portuguese Doctors and Medical Students Think? / Inquérito sobre procedimentos estéticos vulvovaginais: qual a opinião dos médicos e estudantes de medicina portugueses?

Abstract Objective To assess themedical doctors andmedical students' opinion regarding the evidence and ethical background of the performance of vulvovaginal aesthetic procedures (VVAPs). Methods Cross-sectional online survey among 664 Portuguese medical doctors and students. Results Most participants considered that there is never or there rarely is amedical reason to perform: vulvar whitening (85.9% [502/584]); hymenoplasty (72.0% [437/607]); mons pubis liposuction (71.6% [426/595]); "G-spot" augmentation (71.0% [409/576]); labia majora augmentation (66.3% [390/588]); labia minora augmentation (58.3% [326/559]); or laser vaginal tightening (52.3%[313/599]).Gynecologists and specialistsweremore likely to consider that there are no medical reasons to performVVAPs; the opposite was true for plastic surgeons and students/residents. Hymenoplasty raised ethical doubts in 51.1% (283/554) of the participants. Plastic surgeons and students/residents were less likely to raise ethical objections, while the opposite was true for gynecologists and specialists. Most considered that VVAPs could contribute to an improvement in self-esteem(92.3% [613/664]); sexual function (78.5% [521/664]); vaginal atrophy (69.9% [464/664]); quality of life (66.3% [440/664]); and sexual pain (61.4% [408/664]). Conclusions While medical doctors and students acknowledge the lack of evidence and scientific support for the performance of VVAPs, most do not raise ethical objections about them, especially if they are students or plastic surgeons, or if they have had or have considered having plastic surgery.

Resumo Objetivos Avaliar a opinião de médicos e estudantes de medicina relativamente à evidência e contexto ético para a realização de procedimentos estéticos vulvovaginais (PEVVs). Métodos Estudo transversal, consistindo de inquérito online a 664 médicos e estudantes de medicina portugueses. Resultados A maioria dos participantes considerou que nunca ou raramente há uma razão médica para a realização de: branqueamento vulvar (85,9% [502/584]); himenoplastia (72,0% [437/607]); lipoaspiração do mons pubis (71,6% [426/595]); aumento do "ponto G" (71,0% [409/576]); aumento dos grandes lábios (66,3% [390/588]); aumento dos pequenos lábios (58,3% [326/559]) ou aperto vaginal com laser (52,3% [313/599]). Ser ginecologista e especialista associou-se a maior probabilidade de considerar não haver razões médicas para a realização de PEVV; o oposto foi verdade para os cirurgiões plásticos e estudantes/internos. A himenoplastia levantou dúvidas em termos éticos em 51,1% (283/554) dos participantes. Cirurgiões plásticos e estudantes/internos relatarammenos dúvidas emtermos éticos; o oposto foi verdade para os ginecologistas ou especialistas. Amaioria considerou que os PEVVs podemcontribuir para uma melhoria na autoestima (92,3% [613/664]); função sexual (78,5% [521/664]); atrofia vaginal (69,9% [464/664]); qualidade de vida (66,3% [440/664]); e dor sexual (61,4% [408/664]). Conclusões Ainda que os médicos e estudantes de medicina reconheçam a falta de evidência e bases científicas para a realização de PEVVs, a maioria não levanta objecções em termos éticos, especialmente se forem estudantes, cirurgiões plásticos, ou se eles próprios tiverem sido submetidos a cirurgia plástica ou considerem vir a sê-lo.

Factors associated with intraoperative conversion during robotic sacrocolpopexy

Objective To evaluate for potential predictors of intraoperative conversion from robotic sacrocolpopexy (RSC) to open abdominal sacrocolpopexy. Patients and Methods We identified 83 consecutive patients from 2002-2012 with symptomatic high-grade post-hysterectomy vaginal vault prolapse that underwent RSC. Multiple clinical variables including patient age, comorbidities (body-mass index [BMI], hypertension, diabetes mellitus, tobacco use), prior intra-abdominal surgery and year of surgery were evaluated for potential association with conversion. Results Overall, 14/83 cases (17%) required conversion to an open sacrocolpopexy. Patients requiring conversion were found to have a significantly higher BMI compared to those who did not (median 30.2kg/m2 versus 25.8kg/m2; p=0.003). Other medical and surgical factors evaluated were similar between the cohorts. When stratified by increasing BMI, conversion remained associated with an increased BMI. That is, conversion occurred in 3.8% (1/26) of patients with BMI ≤25 kg/m2, 14.7% (5/34) with BMI 25-29.9 kg/m2 and 34.7% (8/23) with BMI ≥30 kg/m2 (p=0.004). When evaluated as a continuous variable, BMI was also associated with a significantly increased risk of conversion to an open procedure (OR 1.18, p=0.004). Conclusions Higher BMI was the only clinical factor associated with a significantly increased risk of intra-operative conversion during robotic sacrocolpopexy. Recognition of this may aid in pre-operative counseling and surgical patient selection. .

Efficacy of Pelvisoft® Biomesh for cystocele repair: assessment of long-term results

Introduction and Hypothesis To our knowledge a study regarding the efficacy of Pelvisoft® Biomesh for cystocele repair has not previously been reported in the literature. The aim of our study was to assess the long-term efficacy, subjective outcomes and complications in the use of a non-synthetic porcine skin mesh graft (Pelvisoft® Biomesh) associated with transvaginal anterior colporrhaphy in the treatment of cystocele prolapse. Materials and Methods A retrospective study was performed at a single centre. Thirty-three women aged 35-77 years underwent cystocele repair using Pelvisoft® graft between December 2005 and June 2009. Twenty-nine women who underwent transvaginal cystocele repair with Pelvisoft® Biomesh for over a 2 years period were assessed. Four patients were lost to follow-up. Cystocele repair was performed via the vaginal route using Pelvisoft®Biomesh implant by inserting it in the anterior vaginal wall. The median follow-up time was 54.0 months. The rate of recurrence was 17.3%. A total of 6.9% of patients presented early mesh exposure treated by conservative treatment. The mean PFDI-20 score was 72.2. Among sexually active women, the mean PISQ 12 was 33.9 but 56.2% had dyspareunia. After surgery, 6 patients had de novo intercourse. Our results show that the use of Pelvisoft® biomaterial associated with anterior colporrhaphy for cystocele repair appears to be safe with acceptable failure and complication rates at long term. Nevertheless, an adverse impact on sexual function was reported by the majority of patients. .

Intraoperative maximal urethral closing pressure measurement: a new technique of tape tension adjustment in transobturator sling surgery?

PURPOSE: Tape tension adjustment is an essential procedure in mid-urethral sling surgery. The goal of this study was to determine if intraoperative maximal urethral closing pressure (MUCP) elevation could be used as a reference value for adequate tape tension adjustment and predict transobturator (TOT) sling surgery outcome. MATERIALS AND METHODS: A prospective study was performed using MUCP measurements just before tape insertion and just after tension adjustment during surgery. Clinical data including preoperative urodynamic results were collected. The cure rate was determined by questionnaire. Patients were divided into two groups. The MUCP elevation group included patients with a MUCP elevation of more than 10 cmH2O before tape insertion; the others were regarded as the non-elevation group. The cure rate and pre- and postoperative clinical variables were compared between the two groups. RESULTS: A total of 48 patients had TOT surgery. The MUCP elevation group (n=19) and the non-elevation group (n=29) were similar with regard to patient characteristics and the preoperative parameters including age, mixed incontinence prevalence, Q-tip angle, peak flow rate, MUCP and the valsalva leak point pressure (VLPP). The mean follow-up period was nine months. The cure rate was significantly higher in the group with MUCP elevation than in the non-elevation group (84 percent vs. 52 percent, p=0.02). There was no significant difference in the mean postoperative peak flow rate between the two groups and there was no retention episode. CONCLUSIONS: MUCP elevation of more than 10 cmH2O just after tape insertion was a prognostic factor.

Comparative study of polypropylene and aponeurotic slings in the treatment of female urinary incontinence

PURPOSE: Female stress urinary incontinence (SUI), the involuntary leakage of urine, is a highly prevalent social and hygiene problem, and various surgical techniques have been developed to correct it. This study used the technique of an aponeurosis sling made from the rectus abdominis muscle as a standard and compared the technique to a sling made with a polypropylene mesh, (Marlex®). MATERIALS AND METHODS: From 2000 to 2007, 158 women who underwent surgery for SUI with an aponeurosis sling, (average age 55 years), were used as a standard for comparison with 316 women who underwent surgery with a polypropylene sling (average age 55 years). RESULTS: The mean follow-up period was 3.65 and 3.56 years for the respective groups. The aponeurosis group showed a cure of SUI in 128 (81.0 percent), improvement in 23 (14.6 percent), and failure in 7 (4.4 percent). The polypropylene group showed a cure in 281 (88.9 percent), improvement in 23 (7.3 percent), and failure in 10 (3.2 percent) (p = 0.083). Urgency was observed in 19 (12 percent) of the aponeurosis group, and 28 (8.9 percent) in the polypropylene group (p = 0.320). CONCLUSIONS: This study showed that the polypropylene mesh is an effective alternative to construct a sling for SUI in women. The results and rates of complication were comparable to the fascial sling from the rectus abdominis muscle aponeurosis.

Suspensión transvaginal alta a ligamentos uterosacros para el tratamiento de defectos apicales (stalus): descripción de la técnica y resultados anatómicos a mediano plazo / High uterosacral vaginal vault suspension for the treatment of apical prolapse: anatomical outcomes

Objetivos: Describir una técnica quirúrgica, novedosa en el medio nacional, de abordaje vaginal, para el tratamiento del prolapso apical: la suspensión transvaginal alta a ligamentos úterosacros (STALUS). Método: Estudio descriptivo longitudinal, de 57 pacientes con defectos apicales, a los cuales se les realizó esa técnica entre Diciembre de 2002 y Octubre 2005. Se realizó estadística descriptiva y test t (2 muestras) para análisis de pronóstico anatómico (POP-Q). Para análisis de potenciales factores pronósticos se utilizó ANOVA, regresión lineal y logística. Resultados: El tiempo operatorio promedio fue de 151 minutos. El resultado anatómico (POP-Q), pre y postoperatorio, resultó favorable y estadísticamente significativo, en los nueve puntos evaluados, 49 de las 54 pacientes fueron seguidas en promedio durante 15 meses. En el compartimiento apical (punto C) obtuvimos curación del 89 por ciento y no hubo fracasos. En la pared anterior, 22 por ciento de las pacientes recidivaron. En cuanto a las complicaciones, se produjo una fístula ureterovaginal. Conclusiones: Tomando las precauciones necesarias, es una técnica segura y reproducible, con buenas tasa de curación. Asegurar la indemnidad del uréter, siempre será una obligación. La recidiva en pared anterior, aunque sea asintomática, resulta ser extremadamente alta, lo que nos obliga a pensar en nuevas técnicas de abordaje de este compartimiento.

Objective: To describe a novel surgery technique in the national ground, of vaginal approach for the treatment of apical prolapse: the transvaginal high suspension to the uterosacral ligaments (STALUS). Method: It is a longitudinal descriptive study that included 57 patients with apical support defects, in which this technique was performed between December 2002 and October 2005. Descriptive statistics and t test were per-formed for the anatomical outcome (POP-Q). For the potential prognosis factors, ANOVA, lineal regression and logistic, were used. Results: The average surgery time was 151 minutes. The anatomical result (POP-Q), before and after surgery, was favourable and significant in the nine points evaluated. 49 of 54 patients were followed for 15 months in average. In the apical compartment (C point) we got an 89 percent of cure and there were no failure. In the anterior wall, instead, 22 percent of our patients recurred. About complications, there was an ureterovaginal fistula. Conclusions: If all precautions are taking, there is a secure and reproducible technique, with good cure rate. To secure the ureter it is always an obligation. The recurrence in the anterior wall, even been asymptomatic, is too high, that make us think in new techniques in order to manage this compartment.