Patrick J. Woodman

Does the Prolift system cause dyspareunia

OBJECTIVE The purpose of this study was to determine the de novo dyspareunia rate with the Prolift procedure. STUDY DESIGN All Prolift cases performed between August 2005 and August 2007 were evaluated. The rate of de novo dyspareunia was calculated by chart review. Type and degree of dyspareunia were assessed by self-administered questionnaire. Demographics, use of hormone therapy, failure rate, and willingness to have the surgery again were summarized using descriptive statistics. RESULTS The rate of de novo dyspareunia was 16.7%. Over 75% of patients with de novo dyspareunia described the pain as mild or moderate. Most described dyspareunia with insertion. Eighty-three percent of respondents with de novo dyspareunia would have the procedure done again. CONCLUSION The Prolift is associated with a 17% de novo dyspareunia rate. Despite this, most would have the surgery done again.

The integral theory of continence

The Integral Theory was originally met with a great deal of skepticism, that is, until the tension-free vaginal tape (TVT) was introduced. This remarkably successful technology was born out of the observations from this theory. Following the success of the TVT, skeptics became fewer and fewer and the tenets of the Integral Theory became accepted as truth. However, this has also had a deleterious effect, hampering research into the other aspects of the Integral Theory. As often happens, once something is “understood and verified” it is inviolate and research slows down or stops. We, researchers into pelvic floor disorders, have failed in our fiduciary responsibility to study and prove or disprove the various observations that have been proposed by the Integral Theory. The two commentaries that follow will hopefully serve to re-invigorate discussion and investigations into the Integral Theory of incontinence. Professor Petros provides an excellent short description of the Integral Theory and how various pelvic floor disorders are explained by this theory. Dr Woodman’s commentary serves as a reality check into what we can and cannot attribute to the various tenets of the Integral Theory. One thing that comes through in both is that we need more research in this area. We should not fall back on the success of the TVT but should look forward at this theory to help us improve our treatment of other pelvic floor disorders.

Tobacco use is a risk factor for mesh erosion after abdominal sacral colpoperineopexy

OBJECTIVE The purpose of this study was to evaluate the association between smoking and vaginal mesh erosion after abdominal sacral colpoperineopexy with the use of type 1 polypropylene mesh. STUDY DESIGN All cases of mesh erosion (n = 27) that were diagnosed between October 2003 and June 2006 were identified and compared with matched control cases (n = 81). Control cases were matched for age, diabetes mellitus status, hypoestrogenic state (menopausal status, chronic steroid use, use of hormone therapy), abdominal-vaginal rectocele repair, culdoplasty, and concomitant hysterectomy. Demographic data, surgical characteristics, and postoperative complications were also compared between groups. Continuous data were compared using 2-sample Student t tests. Categoric data were compared with the use of Pearson Chi-square tests. RESULTS The odds of experiencing mesh erosion was significantly greater in smokers than in nonsmokers (odds ratio, 4.4; 95% CI, 1.3, 14.4; P = .010) when potential confounders were similar between groups. CONCLUSION Tobacco use is a risk factor for vaginal mesh erosion after abdominal sacral colpoperineopexy with the use of type 1 polypropylene mesh.

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.

High uterosacral ligament vaginal vault suspension: comparison of absorbable vs. permanent suture for apical fixation

Introduction and hypothesisThe primary objective of this study was to compare outcomes of absorbable and permanent suture for apical support with high uterosacral ligament vaginal vault suspension (HUSLS). The secondary objective was to investigate the rate of suture erosion.MethodsThis was a retrospective study of patients who underwent HUSLS with delayed absorbable and primarily permanent suture. Apical support was calculated as a new variable: Percent of Perfect Ratio (POP-R). This variable measures apical support as the position of the apex in relation to vaginal length.ResultsAt 1-year follow-up, there was no significant difference in apical support between the two groups. The number of patients who suffered from suture erosion in the cohort that received permanent suture was 11 (22%).ConclusionsPermanent suture, in comparison with delayed absorbable suture, for HUSLS does not offer significantly better apical support at short-term follow-up. It is also associated with a high rate of suture erosion.

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.

Recurrence of prolapse after transvaginal mesh excision

Objective Recurrence of pelvic organ prolapse (POP) is a potential complication after mesh removal. We evaluated anatomical and functional outcomes preoperatively and postoperatively in patients undergoing mesh excision. Materials and Methods We conducted a retrospective cohort analysis of consecutive patients who underwent mesh excision from years 2005 to 2009. Anatomical outcomes were evaluated using the POP quantification (POP-Q) system. Recurrence of prolapse was defined as stage II or higher-stage prolapse on the POP-Q system, reoperation for prolapse, or postoperative use of a pessary for prolapse reduction. Functional outcomes were assessed using the pelvic floor distress inventory and pelvic floor impact questionnaire scores. Results Data were analyzed from 71 patients who underwent either partial or complete mesh excision. Most (44/70 [63%]) of the patients underwent partial mesh excision, and 26 patients (37%) underwent total mesh removal. Nineteen patients (26.7%) had preoperative prolapse and 27 (38.0%) of the 71 patients underwent concomitant native tissue prolapse repair. Overall change in POP-Q stage in women who underwent partial removal (median, 0 [−1 to 2]) was less advanced than in women with total excision. (median, −1 [−3 to 0]; P = 0.006) at 1 year postoperatively. Four patients prolapsed to the hymen, with all patients having defects in the anterior compartment. No patients required a second surgery, and one patient was treated with a pessary. Total pelvic floor distress inventory and pelvic floor impact questionnaire scores before mesh excision were significantly improved 6 months after mesh removal (P < 0.05). Dyspareunia improved significantly after mesh excision (P = 0.034). Conclusion In our patient population, total and partial mesh excision is associated with re-treatment of POP in 1.4% of the patients. Patient functional outcomes significantly improved after mesh removal.