Jennifer C. Thompson

Surgical Management for Pelvic Organ Prolapse and Its Impact on Sexual Function

INTRODUCTION Female sexual function is complex, incorporating physical, emotional, and psychological factors. Pelvic organ prolapse, descent of the pelvic organs to or through the vaginal opening, is a common condition that affects quality of life, including sexual function. Symptomatic prolapse is most commonly treated with reconstructive surgery. AIM To address the surgical management of pelvic organ prolapse and its impact on sexual function and include recommendations for evaluating sexual function, use of validated questionnaires to assess function, preoperative counseling, and postoperative follow-up. METHODS A literature search was performed for articles evaluating sexual function after pelvic organ prolapse surgery. Priority was given to larger studies, including systematic reviews, and use of validated questionnaires. MAIN OUTCOME MEASURES The main outcome was postoperative sexual function after pelvic organ prolapse repair. RESULTS Multiple surgical approaches are used for the treatment of pelvic organ prolapse, including native tissue and grafted repairs. An evaluation of sexual function preoperatively is necessary to decide on type of surgery and to establish appropriate postoperative expectations. Postoperatively, most patients report sexual function as improved or unchanged. CONCLUSION Thorough preoperative counseling allows patients and their physicians to develop appropriate, individualized treatment plans for pelvic organ prolapse that consider womens preoperative sexual function and sexual function goals.

Urogynecology digest: Presented by Jennifer C. Thompson

Polypropylene mesh is commonly used in urogynecologic surgery for the treatment of pelvic organ prolapse and urinary incontinence. Macrophages are responsible for both proinflammatory (M1) and proremodeling (M2) responses to vaginal mesh. The objective of this study was to compare macrophage responses in women undergoing mesh excision surgery for pain or mesh exposure with those in women undergoing gynecologic surgery without mesh. The mesh–vagina complex was excised from 27 patients with mesh complications: 15 incontinence midurethral slings and 12 prolapse meshes. Biopsies were obtained from a control group of 30 patients with stage II or III prolapse with or without incontinence who had undergone gynecologic surgery without mesh. No significant differences were identified among the three groups. All M1 and M2 cytokines and chemokines were increased in mesh explants compared to the control biopsies. Active matrix metalloproteinase-2 and pro-matrix metalloproteinase-9 were also significantly increased in the mesh group. The levels of pro-matrix metalloproteinase-9 were higher in explants from patients with exposure than in explants from patients with pain. No other statistically significant differences were identified between the mesh groups based on the indication for mesh removal. In conclusion, patients with mesh complications have a marked proinflammatory response compared with patients without a mesh implant. Although postoperative complications such as chronic pain and mesh exposure are rare following incontinence and prolapse surgery, they significantly affect quality of life and often require surgical management. It would be very beneficial to surgeons to understand why this happens and how these patients inherently differ from those who do not develop pain or erosion. Identifying differences at the cellular level among patients who experience these complications is necessary to identify risk factors and even develop treatments in the future. This study thoroughly explores the proinflammatory state of patients with mesh complications. Clinically relevant information would be the timing of surgical excision of mesh due to complications and biopsies of control subjects. Did patients with mesh complications have persistently elevated proinflammatory and remodeling responses? Is the inflammatory or remodeling response in patients who develop pain and/or erosion immediately postoperatively different from that in patients who develop these conditions after, say, a year? Did patients in the control group initially have similar inflammatory responses postoperatively? Biopsies from the control group were obtained from the anterior vaginal wall at the apex. This location is appropriate for comparing responses to those in patients with mesh complications after prolapse repair. However, because the distal third of the vagina is embryologically different, the apex may not be a suitable control biopsy location for investigating mesh complications from midurethral incontinence procedures. A more accurate assessment would be obtained using the distal third of the vagina as the biopsy location for investigating midurethral mesh complications. Overall, this paper contributes to the growing body of literature identifying the mechanisms involved in the development of mesh complications following incontinence and prolapse surgery.

16: Vaginal evisceration remote from pelvic surgery

bias. There are a number of ways that a left-handed surgeon can overcome this right-handed bias. We describe five techniques. CONCLUSION: Left-handed individuals comprise a minority of gynecologic surgeons and trainees. Though many such individuals develop varying degrees of ambidexterity with experience, preferential use of their dominant hand is inevitable. Despite the hands-on nature of the gynecologist’s practice both in and out of the OR, tailored instruction for those with left-hand dominance is uncommon. Consequences, if any, of this missing training are unknown as left-handed gynecologists seem to adapt to environments biased to right-handed surgeons. Comparative studies are necessary to determine differences in performance, skill, and outcomes that may exist between left-handed gynecologists and their right-handed counterparts.