Deborah R. Karp

Outcomes of Robotic Sacrocolpopexy: A Systematic Review and Meta-Analysis

Objectives Robotic sacrocolpopexy has been rapidly incorporated into surgical practice without comprehensive and systematically published outcome data. The aim of this study was to systematically review the currently published peer-reviewed literature on robotic-assisted laparoscopic sacrocolpopexy with more than 6 months of anatomic outcome data. Methods Studies were selected after applying predetermined inclusion and exclusion criteria to a MEDLINE search. Two independent reviewers blinded to each other’s results abstracted demographic data, perioperative information, and postoperative outcomes. The primary outcome assessed was anatomic success rate defined as less than or equal to pelvic organ prolapse quantification system (POP-Q) stage 1. A random effects model was performed for the meta-analysis of selected outcomes. Results Thirteen studies were selected for the systematic review. Meta-analysis yielded a combined estimated success rate of 98.6% (95% confidence interval, 97.0%–100%). The combined estimated rate of mesh exposure/erosion was 4.1% (95% confidence interval, 1.4%–6.9%), and the rate of reoperation for mesh revision was 1.7%. The rates of reoperation for recurrent apical and nonapical prolapse were 0.8% and 2.5%, respectively. The most common surgical complication (excluding mesh erosion) was cystotomy (2.8%), followed by wound infection (2.4%). Conclusions The outcomes of this analysis indicate that robotic sacrocolpopexy is an effective surgical treatment of apical prolapse with high anatomic cure rate and low rate of complications.

A randomized clinical trial of the impact of local estrogen on postoperative tissue quality after vaginal reconstructive surgery.

Objective To evaluate the use and effect of early administration of vaginal estrogen via a continuous low-dose estradiol vaginal ring placed immediately after pelvic reconstructive surgery. Methods This was a randomized controlled trial of 65 postmenopausal women undergoing vaginal reconstructive surgery. The subjects were randomly assigned to receive an estradiol-releasing vaginal ring, placebo vaginal ring, or control without vaginal ring for 12 weeks immediately after vaginal reconstructive surgery. The primary outcome was tissue quality based on vaginal maturation 3 months postoperatively. Secondary outcome measures were subjective and objective signs of atrophy; vaginal pH; the presence of granulation tissue, microscopic inflammation, and major healing abnormalities; and the ability to tolerate an intravaginal ring. Results At 12 weeks, the estradiol ring group had a significantly improved maturation value (P<0.01) and objective atrophy assessment (P<0.01) compared with the placebo ring and control arms. Granulation tissue was increased in the placebo ring arm (P<0.01). Subjective atrophy scores did not differ among the groups (P=0.39). Conclusions Early administration of vaginal estrogen after vaginal surgery via an estradiol-releasing ring is feasible and results in improved markers of tissue quality postoperatively compared to placebo and controls.

Predictors of successful salpingo-oophorectomy at the time of vaginal hysterectomy.

STUDY OBJECTIVE To determine prognostic factors related to successful salpingo-oophorectomy in menopausal women at the time of vaginal hysterectomy. DESIGN Retrospective cohort study (Canadian Task Force Classification II-2). SETTING Tertiary care center. PATIENTS A total of 309 postmenopausal ≥60 years old with pelvic floor disorders. INTERVENTIONS Vaginal hysterectomy with attempted prophylactic salpingo-oophorectomy. MEASUREMENTS Factors associated with ability to achieve vaginal salpingo-oophorectomy. MAIN RESULTS 203 (65.7%) achieved successful removal of 1 or both ovaries, and 106 (34.3%) were not amenable to removal. Younger age and shorter cervical length were predictors of salpingo-oophorectomy. Cervical elongation of ≥7 cm, exteriorized cervical/uterine prolapse, and anterior vaginal wall prolapse beyond the hymen were associated with lower likelihood of achieving salpingo-oophorectomy. CONCLUSIONS Patient age and cervical length are independent factors that influence the success of accomplishing salpingo-oophorectomy at the time of vaginal hysterectomy.

Validation of a global pelvic floor symptom bother questionnaire

Introduction and hypothesisThis study aimed to validate a symptom questionnaire to assess presence and patient bother as related to common pelvic floor disorders.MethodsThe validation of the Pelvic Floor Bother Questionnaire (PFBQ) included evaluation of internal reliability, test-retest reliability, and validity of the items.ResultsA total of 141 patients with mean age of 61.8 ± 13.2 were included in the study. Twenty-four percent of patients complained of stress urinary incontinence, 14.9% mixed incontinence, 14.9% urge incontinence, 10% fecal incontinence, 5.7% obstructed defecation, 28.4% pelvic organ prolapse, and 2.1% dyspareunia. The PFBQ demonstrated good reliability (α = 0.61-0.74; ICC = 0.94). There was a strong agreement beyond chance observed for each question (k = 0.77-0.91). PFBQ correlated with stage of prolapse (ρ = 0.73, p < 0.0001), number of urinary and fecal incontinence episodes (ρ = 0.81, p < 0.0001; ρ = 0.54, p < 0.0001), and obstructed defecation (ρ = 0.55, p < 0.0001).ConclusionThe PFBQ is a useful tool that can be easily used for identification and severity or bother assessment of various pelvic floor symptoms.

Bowel and bladder dysfunction following surgery within the presacral space: an overview of neuroanatomy, function, and dysfunction

Introduction and hypothesisThe presacral space contains a dense and complex network of nerves that have significant effects on the innervation of the pelvic viscera and support structures. The proximity of this space to the bony promontory of the sacrum has lead to its involvement in an array of corrective surgical procedures for pelvic floor disorders including sacrocolpopexy and rectopexy. Other procedures involving the same space include presacral neurectomy which involves intentional transection of the contained neural plexus to relieve refractory pelvic pain and resection of retrorectal or presacral tumors. Potential complications of these procedures are postoperative constipation and voiding dysfunction.MethodsOur aim was to review the current published literature on outcomes following a variety of procedures involving the presacral space and review postoperative bowel and urinary function. We also include an overview of the functional and structural anatomy of the presacral space and its corresponding neural plexi.Results/ConclusionsWe conclude that quality data are lacking on the short-term and long-term rates for bowel and bladder dysfunction following surgical procedures involving the presacral space.

Rectovaginal fistula as a complication to a Bartholin gland excision.

BACKGROUND: Rectovaginal fistula is a rare complication of inflammatory bowel disease, obstetric trauma, pelvic surgery, radiation, and trauma. We present a rectovaginal fistula occurring after an excision of a Bartholin gland. CASE: A healthy 43-year-old woman presented with flatus per vagina immediately after a Bartholin gland excision. She had a history of recurrent Bartholin abscess and had undergone multiple incision and drainage procedures of this cyst over the past 6 years. On rectovaginal examination, the patient was found to have a rectovaginal fistula and subsequently underwent successful transvaginal repair. CONCLUSION: Rectovaginal fistula can occur after excision of a Bartholin gland. This case report illustrates a rare and serious complication to a commonly performed gynecologic procedure.

Urinary neurotrophic peptides in postmenopausal women with and without overactive bladder

The aim of this study was to compare the expression of urinary nerve growth factor (NGF), brain derived neurotrophic factor (BDNF), substance P (SP), and calcitonin‐gene related peptide (CGRP) in women with and without overactive bladder (OAB). We sought to determine factors associated with higher expression of these neuropeptides.

The outcome of transobturator anterior vaginal wall prolapse repair using porcine dermis graft: intermediate term follow-up

INTRODUCTION AND HYPOTHESIS We evaluated the anatomical success and complications of Perigee® with porcine dermis Graft in the repair of anterior vaginal wall prolapse (AVWP) MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, the charts of all patients who underwent AVWP repair using the Perigee/InteXen® kit from July 2005 to July 2009 were reviewed. Patients who had less than 6-month follow-up were excluded. Preoperative data including patient age, previous AVWP repairs, hysterectomy status, preoperative dyspareunia and pertinent physical findings were collected and recorded. Postoperative success was defined as anatomical stage 0 or I using the Pelvic Organ Prolapse Quantification (POP-Q) scoring system. Graft related complications were also recorded. RESULTS Out of 89 patients, 69 completed at least 6-month follow-up. Median follow-up was 13 (6-48) months. Seventeen patients (25%) had previous AVWP repair and 32 (46%) had previous hysterectomy. Preoperatively, AVWP stage II was found in 9 (13%), stage III in 27 (39%) and stage IV in 33 (48%) patients. Anatomic success was found in 48 (69%) patients, with 23 (33%) having stage 0 and 25 (36%) stage I AVWP. Intraoperative complications included incidental cystotomy in one patient and bladder perforation in one. Postoperative complications included vaginal exposure and dyspareunia in one case, wound dehiscence in one and tenderness over the graft arm with dyspareunia in one. CONCLUSIONS The use of porcine dermis in AVWP repair is safe with minimal graft related complications; however, anatomical success is lower than that reported with the use of synthetic grafts.

Atypical Graft Infection Presenting as a Remote Draining Sinus

BACKGROUND: Synthetic materials are being used increasingly in reconstructive pelvic surgery. Multifilament polypropylene mesh in particular has been associated with healing abnormalities and other postoperative complications. This article describes an atypical infection presenting as a draining sinus tract to the lower extremity after intravaginal slingplasty. CASE: An otherwise healthy 75-year-old-woman presented with recurrent leg cellulitis 18 months after posterior intravaginal slingplasty for vaginal vault prolapse. A 35-cm fistulous tract draining from the pelvis to the lower thigh was identified. The patient underwent surgical debridement and was treated with 12 weeks of intravenous antibiotics with complete healing and no recurrence of symptoms. CONCLUSION: Complications associated with the multifilament mesh used in the intravaginal slingplasty tunneler device include pain, erosion, localized abscess, and genitourinary fistula.

Apical Suspension at the Time of Hysterectomy for Uterovaginal Prolapse: A Comparative Analysis of 2001 and 2011.

Objectives The primary aim of this study was to compare the proportion of concomitant apical procedures in women undergoing hysterectomy for uterovaginal prolapse in 2001 and 2011. The secondary aim was to identify factors associated with receiving concomitant apical procedures in 2001 and 2011. Methods The Nationwide Inpatient Sample database was queried for women with a primary diagnosis of uterovaginal prolapse who underwent hysterectomy in 2001 and 2011. The study cohort was analyzed for demographics, clinical factors, and concomitant procedures. Factors potentially associated with receiving concomitant apical procedure were evaluated using univariable analysis and multivariate logistic regression. Results A total of 14,647 women were identified (5867 in 2001 and 8780 in 2011). In 2001, 26.9% women received a concomitant apical procedure, and this proportion increased to 48.2% in 2011 (odds ratio, 2.53; 95% confidence interval, 2.36–2.72; P < 0.0001). In 2001, the mean (SD) age was 53.8 (14.1) years compared with 56.8 (13.3) years in 2011. Although vaginal hysterectomy was most common in both years, a concomitant apical procedure was more likely to be performed with abdominal hysterectomy (P < 0.001). On multivariate analysis, age older than 50 years (P = 0.0001), abdominal route of hysterectomy (P < 0.0001), and undergoing hysterectomy at an academic teaching hospital (P < 0.0001) were independently associated with concomitant apical procedures in both 2001 and 2011. Conclusions Although the proportion of concomitant apical repair was higher in 2011 compared with 2001, it is still low given the existing data demonstrating the importance of a concomitant apical procedure at the time of hysterectomy for uterovaginal prolapse.