Colleen D. McDermott

Abdominal, laparoscopic, and robotic surgery for pelvic organ prolapse.

Abdominal correction of pelvic organ prolapse remains a viable option for patients and surgeons. The transition from open procedures to less invasive laparoscopic and robotic-assisted surgeries is evident in the literature. This article reviews the surgical options available for pelvic organ prolapse repair and their reported outcomes. Procedures reviewed include apical support (sacral, uterosacral, and others), and abdominal anterior and posterior vaginal wall support. Long-term follow-up and appropriately designed studies will further help direct surgeons in deciding which approach to incorporate into their practice.

De novo stress urinary incontinence after negative prolapse reduction stress testing for total vaginal mesh procedures: incidence and risk factors

OBJECTIVE The primary objective was to estimate the incidence of de novo stress urinary incontinence after total vaginal mesh procedures in women with negative preoperative urodynamics with prolapse reduction. Secondary objective was to identify associated risk factors. STUDY DESIGN A retrospective cohort study with a nested case-control study of women who underwent total vaginal mesh procedures without midurethral sling after a negative preoperative urodynamics. RESULT Sixty patients were included in the final analysis. Fifteen (25%) patients were diagnosed with de novo stress urinary incontinence. Although no significant associated risk factors were identified, there was a trend for higher gravidity and better anterior wall support among women who had stress urinary incontinence develop. CONCLUSION The incidence of de novo stress urinary incontinence after total vaginal mesh procedures in this cohort was 25%. Patients should be appropriately counseled regarding the same.

Surgical outcomes following total Prolift: colpopexy versus hysteropexy.

Background:  Total Prolift® is a pelvic floor repair system that is performed transvaginally and can be carried out with or without the uterus in situ.

Use of preoperative prolapse reduction stress testing and the risk of a second surgery for urinary symptoms following laparoscopic sacral colpoperineopexy.

Introduction and hypothesisThe aim of this study was to determine the reoperation rate for sling placement or revision in patients who had primary continence procedures based on prolapse reduction stress testing (RST) prior to laparoscopic sacral colpoperineopexy (LSCP).MethodsThis was a retrospective cohort study of women who had RST prior to LSCP for symptomatic pelvic organ prolapse. Patients with positive test (Pos RST) had a concomitant midurethral sling procedure and those with negative test (Neg RST) did not. Variables were compared with either Student’s t test or Fisher’s exact test.ResultsIn Neg RST group (n = 70), the rate of surgery for de novo urodynamic stress incontinence was 18.6%. In Pos RST group (n = 82), the rate of sling revision for bladder outlet obstruction was 7.3%. Overall, 88% of patients did not require a second surgery.ConclusionsThe use of RST to recommend concomitant continence procedures during LSCP results in a single surgery for the majority of our patients.

Surgical Outcomes of Abdominal Versus Laparoscopic Sacral Colpopexy Related to Body Mass Index

OBJECTIVE Obesity can predispose women to pelvic organ prolapse and can also affect the success of prolapse surgery. Sacral colpopexy is a common surgical approach used to treat significant prolapse, and may be performed by laparotomy or laparoscopy. The objective of this study was to determine whether surgical outcomes following abdominal sacral colpopexy (ASC) and laparoscopic sacral colpopexy (LSC) varied according to BMI. METHODS We conducted a retrospective cohort study of women who had undergone ASC (n = 90) and LSC (n = 150). Preoperative, perioperative, and postoperative information was collected from patient charts and entered into a database according to BMI category (normal weight 18.5 to 24.9 kg/m², overweight = 25 to 29.9 kg/m², obese ≥ 30 kg/m²). Within each BMI group, outcomes were compared between ASC and LSC patients using Student t, Mann-Whitney U, and Fisher exact tests, and analyses of covariance. RESULTS In normal weight patients, postoperative apical measurements were worse in ASC patients (P = 0.01). In overweight patients, the ASC group had worse posterior measurements (P = 0.05) and fewer mesh/suture erosions (P = 0.03) but more recurrent prolapse symptoms (P = 0.007). In obese patients, the ASC group had better anterior measurements (P = 0.008). There were no differences in any BMI category for prolapse stage, surgical satisfaction, or classification of surgical success or failure (P > 0.05). CONCLUSION Differences between ASC and LSC were identified when patients were categorized according to BMI. These findings may be useful in counselling patients and planning the appropriate surgical approach for sacral colpopexy based on BMI.

Sacral Colpopexy Versus Transvaginal Mesh Colpopexy in Obese Patients

OBJECTIVES Obesity can predispose women to pelvic organ prolapse and can also affect the success of pelvic organ prolapse surgery. The purpose of this study was to compare the postoperative anatomical outcomes following sacral colpopexy (SC) and transvaginal mesh colpopexy in a group of obese women with pelvic organ prolapse. METHODS We conducted a retrospective cohort study of obese women who underwent SC (n = 56) or transvaginal mesh colpopexy (n = 35). Follow-up ranged from 6 to 12 months. Preoperative, perioperative, and postoperative variables were compared using Student t, Mann-Whitney U, and Fisher exact tests, and by analysis of covariance. RESULTS The women in the SC group had significantly higher mean apical vaginal measurements (P < 0.05), and significantly fewer stage II recurrences than women in the transvaginal mesh colpopexy group. There were no significant differences between the groups for other postoperative outcomes, including mesh erosion, recurrent prolapse symptoms, dyspareunia, and surgical satisfaction (P > 0.05). CONCLUSION In these 91 obese patients with pelvic organ prolapse, SC resulted in better anatomical outcomes than transvaginal mesh colpopexy. However, the two procedures had similar outcomes with regard to recurrent symptoms and surgical satisfaction.

Female Pelvic Medicine and Reconstructive Surgery in Canada: A Survey of Obstetrician-Gynecologists and Urologists

Objective The aim of this study was to assess the current status of female pelvic medicine and reconstructive surgery (FPMRS) in Canada, including level of training, practice patterns, barriers to practice and opinions among obstetrician-gynecologists (OB/GYNs) and urologists. Methods Electronic surveys were distributed to 737 OB/GYNs through the Society of Obstetricians and Gynaecologists of Canada and to 489 urologists through the Canadian Urological Association. Results Complete responses were collected from 301 (41%) OB/GYNs and 39 (8%) urologists. Of the OB/GYN respondents, 57% were generalists (GEN), and 22% completed FPMRS fellowship training (FPMRS-GYN). OB/GYN GENs were less likely than FPMRS-GYNs to report comfort with pelvic organ prolapse quantification assessment, urodynamic testing, cystoscopy, treatment of mesh complications, and management of overactive bladder. Urologists were less likely than FPMRS-GYNs to report comfort completing a pelvic organ prolapse quantification assessment, fitting pessaries, and treating mesh complications but more likely to report comfort managing overactive bladder. FPMRS-GYNs were more likely than other providers to report high volumes (>20 cases in the past year) of vaginal hysterectomy, as well as incontinence and prolapse procedures. OB/GYN GENs and urologists frequently cited lack of formal training in residency as a barrier to performing FPMRS procedures, whereas FPMRS-GYNs reported a lack of operating room facilities and support personnel. Overall, 76% of the respondents were of the opinion that FPMRS should be a credentialed Canadian subspecialty (92% FPMRS-GYN, 69% OB/GYN GEN, 59% urologists). Conclusions OB/GYN GENs reported low case volumes and cited inadequate training in residency as a barrier to surgically managing pelvic floor disorders. Most respondents felt that FPMRS should be a credentialed subspecialty.

Does tension-free vaginal tape placement at the time of total prolift colpopexy affect distal anterior vaginal support?

Objectives: Pelvic organ prolapse (POP) and stress urinary incontinence often require concomitant procedures to treat both conditions. The purpose of this study was to determine whether tension-free vaginal tape (TVT) at the time of total Prolift colpopexy (TPC) affected distal anterior vaginal wall support. Methods: This was a retrospective cohort study of women that had TPC (n = 62) between January 2005 and December 2007. All patients had no uterus and underwent TPC with mesh placement in the anterior and posterior vaginal compartments. A concomitant TVT was placed only in those who had a preoperative diagnosis of urodynamic stress urinary incontinence with prolapse reduction. Patients were subdivided into those with (n = 26) and without TVT (n = 36). Data were compared between groups using Student t, Wilcoxon rank sum, and Fisher exact tests (P ≤ 0.05). Results: There were no significant differences between groups for all preoperative variables. Patients were observed for 6 to 12 months after TPC. Postoperatively, those with and without TVT had similar anterior POP quantification measurements (points Aa and Ba; P > 0.05), although the group with TVT had significantly more patients with anterior stage 2 and 3 recurrences (23%) when compared with the group without TVT (5%, P = 0.04). Conclusions: Tension-free vaginal tape does not provide additional distal anterior vaginal wall support for patients undergoing TPC.