Search

Introduction and hypothesisOur aim was to determine the intraoperative feasibility and complication rate of laparoscopic sacrocolpopexy (LSC) in overweight and obese women compared with women of normal weight.MethodsThis was a retrospective observational cohort study (Canadian Task Force classification II-2) conducted at a tertiary urogyaenocology unit evaluating 119 women who underwent LSC between March 2005 and January 2013.ResultsBody mass index (BMI) was classified as normal (22.89 ± 1.55), overweight (27.12 ± 1.40) and obese (33.47 ± 3.26) according to the World Health Organisation (WHO) classification. There was no difference in intraoperative complication rates for bladder, bowel, ureteric or vascular injury; haemorrhage; conversion to laparotomy; or anaesthetic complications for normal weight, overweight or obese women. Similarly there was no difference in operating time, duration of anaesthetic or hospital stay between BMI class (p = 0.070, p = 0.464, p = 0.898, respectively) postoperative or mesh complication rates. At 6-months’ follow-up, there was no difference in Patient Global Impression of Improvement scale (PGI-I) (defined as very much better or much better) between normal weight, overweight and obese women (76.9, 72 and 65.4%, p = .669) or objective cure using the Pelvic Organ Prolapse Quantification (POP-Q) examination (p = 0.402).ConclusionsLSC is feasible, with equivalent intraoperative complication rates for normal weight, overweight and obese women when performed by experienced laparoscopic urogynaecologists. Given the benefits of a laparoscopic approach in obese women, the authors suggest they should be offered LSC as an option to treat vault prolapse when surgical management is being considered.

Background Mesh surgery for stress urinary incontinence or pelvic organ prolapse can result in complications such as mesh exposure, mesh extrusion, voiding dysfunction, dyspareunia, and pain. There is limited knowledge or guidance on the effective management for mesh-related complications. Objective To determine the best management of mesh complications; a systematic review was conducted as part of the national clinical guideline 'Urinary incontinence (update) and pelvic organ prolapse in women: management'. Search strategy Search strategies were developed for each indication for referral. Selection criteria Relevant interventions included complete or partial mesh removal, mesh division, and non-surgical treatments such as vaginal estrogen. Data collection and analysis Characteristics and outcome data were extracted, and as a result of the heterogeneous nature of the data a narrative synthesis was conducted. Main results Twenty-four studies were included; five provided comparative data and four studies stated the indication for referral. Reported outcomes (including pain, dyspareunia, satisfaction, quality of life, incontinence, mesh exposure, and recurrence) and the reported incidences of these varied widely. Conclusions The current evidence base is limited in quantity and quality and does not permit firm recommendations to be made on the most effective management for mesh-related complications. Robust data are needed so that mesh complications can be managed effectively in the future. Tweetable abstract Systematic review demonstrates that the outcomes following mesh revision surgery are highly variable.

Aims: Defects in the pubovisceral portion of the levator ani muscle are seen with MR imaging. This study aims to determine interrater reliability of physical examination in detecting these defects, and to validate ¢ndings from physical examination using comparisons with MR images. Methods: Two examiners palpated the pubovisceral muscles of 29 women to assess for defects in this muscle. Each examiner was blinded to the others ¢ndings. MR scans were acquired on a further 24 women after structured clinical examination by one examiner. These images were read to determine pubovisceral muscle defects, blinded to patient identi¢ers. Agreement between raters and between MR imaging and clinical examination were calculated. Results: The two examiners had positive agreement (presence of a defect) of 72.7% and negative agreement (absence of a defect) of 83.3%. The positive agreement between physical examination and MR imaging was 27.3% and the negative agreement 86.5%. Conclusion: The structured physical examination to detect defects in the pubovisceral portion of the levator ani muscle can be learned as shown by good interrater agreement. However, examination alone underestimates these defects compared with MR imaging. Neurourol. Urodynam. 25:50 ^54, 2006. 2005 Wiley-Liss, Inc.

Objective To describe the variations in the location of the vaginal apex and the length of vagina excised in women undergoing the Michigan four-wall sacrospinous suspension for posthysterectomy vaginal vault prolapse. Methods A prospective observational study of 76 women who had the Michigan modification sacrospinous suspension performed between 1998 and 2001 for posthysterectomy vaginal vault prolapse was carried out. Demographics and preoperative, operative, and postoperative findings were noted, including the pelvic organ prolapse quantification score. The locations of the suspension points relative to the hysterectomy scar were recorded. The amount of vagina excised at surgery and the pre- and postoperative vaginal lengths are reported. Results The mean length and standard deviation of vagina excised was 4.6 ± 2.5 cm. The apex created at sacrospinous fixation was at the hysterectomy scar in only seven women (9%). It was most often situated behind the hysterectomy scar, in 58 cases (76%); it was situated in front of it in 11 (14%). In seven women no vagina was excised, and in the remaining 69 women a mean length of 5.1 ± 2.2 cm was removed. The mean vaginal lengths were 9.7 ± 1.7 cm preoperatively and 9.4 cm ± 0.8 postoperatively, a 0.3-cm difference. Conclusion When one performs the Michigan modification sacrospinous suspension, the chosen suspension points are often not at the hysterectomy scar, and in women with large prolapses excess vagina frequently is excised without compromising postoperative vaginal length.

To compare levator ani defects and pelvic floor function among women with prolapse and controls.Levator ani structure and function were measured in a case-control study with group matching for age, race, and hysterectomy status among 151 women with prolapse (cases) and 135 controls with normal support (controls) determined by pelvic organ prolapse quantification examination. Magnetic resonance imaging was used to determine whether there were "major" (more than half missing), "minor" (less than half of the muscle missing), or no defects in the levator ani muscles. Vaginal closure force at rest and during maximal pelvic muscle contraction was measured with an instrumented vaginal speculum.Cases were more likely to have major levator ani defects than controls (55% compared with 16%), with an adjusted odds ratio of 7.3 (95% confidence interval 3.9-13.6, P.001) but equally likely to have minor defects (16% compared with 22%). Of women who reported delivery by forceps, 53% had major defects compared with 28% for the nonforceps women, adjusted odds ratio 3.4 (95% confidence interval 1.95-5.78). Women with prolapse generated less vaginal closure force during pelvic muscle contraction than controls (2.0 Newtons compared with 3.2 Newtons P.001), whereas those with defects generated less force than women without defects (2.0 Newtons compared with 3.1 Newtons, P.001). The genital hiatus was 50% longer in cases than controls (4.7+/-1.4 cm compared with 3.1+/-1.0 cm, P.001).Women with prolapse more often have defects in the levator ani and generate less vaginal closure force during a maximal contraction than controls.II.