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AUGS/IUGA Scientific Meeting 2019
Short Oral Session 11 - Surgical POP
Short Oral Session 11 - Surgical POP
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Så tak for muligheden til at præsentere dette studie. Og vi har ingen relevante beslutninger til dette studie. Så som I alle kender, prolaps er en almindelig komplikation efter en hysterektomi. Og der er flere særlige teknikker til at køre det. Så målet af dette studie var at sammenligne utero-sacral ligament suspension med psykospinal ligament fixation både som en naturlig tisueretrækningsteknik til at behandle vaginal prolaps. Og vi brugte den danske nationale registrering. Og som I må kende, vi registrerer næsten alt i Danmark. De fleste af dem er helt automatisk registreret. For eksempel, i den danske nationale patientregistering, kommer alle operationskoder ind. Og det er faktisk, som man kan sige, den måde, hvordan sygehusene får tilgængelse for at gøre operationer. Så det er næsten 100% komplet og akkurat. Så det, der ikke er i den danske nationale patientregistering, er det kliniske data på patienten. Og der har vi den danske urogynekologiske databas. Og det er kompulsørt af lov at sætte data på det. Og det er departementet, der sætter kliniske data. Og når vi har den danske nationale patientregistering, så ved vi, hvilke operationer er blevet gjort af sygehusene. Og sygehusene kan ikke gøre operationer, hvis de ikke sætter data på de operationer, som de gør. Men vi har kliniske data for patienten fra denne registering. De har data før operationen, under operationen og tre måneder efter, typisk. Så det, vi gjorde, var, at vi identiferede alle patienter, der havde en vaginalvalg suspension med de to tekniske operationer fra år 2010 til 2016. Og vi fandt næsten 1.000 patienter. Og så gik vi til den danske nationale patientregistering, for at se, om en af disse patienter havde haft en relapsoperation. Og vi delte det i tre komponenter. Så vi identiferede 589 patienter med uterocycral ligament suspension og 389 med psykospinal ligament fixation. Og her er resultatet, det er hazard ratio, og det er adjusteret for æg, pre-operativ-prolaps-stage, ASA-skor, smukning og BMI. Du kan se, at der er fire gange så mange relapsoperationer i den apicale komponente efter psykospinal ligament fixation, og det er to gange så mange i den antere komponente, mens i den posteriore komponente er der ingen forskel mellem de to tekniske operationer. I absurde numre kan du se, at efter fem år er der 13% relapsoperation efter uterocycral ligament suspension og 29% efter psykospinal ligament fixation. Så her er det samme resultat, som jeg viste du under årene, og du kan se her i den apicale komponente, at vi har den grønne linje, det er psykospinal ligament fixation, og der er uterocycral ligament fixation her. Og du kan se, at de fleste af relapsoperationerne er i den apicale komponente, og de kommer i de første to år efter den initiale operation. Og du kan se, at det er helt det samme i den posteriore komponente. Der er ingen forskel mellem de to tekniske operationer. Så dette leder mig til de følgende beslutninger. I den danske forhold er uterocycral ligament suspension ytterligere end psykospinal ligament fixation, når det kommer til reoperationer. Så dette resultat er kontræt til den store, randomiserede optimale studie fra USA, hvor ingen forskel var fundet mellem de to teknikker. Forskellen kan blive forklaret med de forskellige populationer, sygehjælpssystemer og studiedesign. Men det er meget vigtigt at huske, at der kan være en forskel mellem randomiserede kontrolløsning og virkelige observationsstudier. Og det er vigtigt for det individuelle centrum at vide, hvilke resultater de har, så de kan besøge deres patient, hvilken risiko de har i deres centrum, og ikke bare løbe på det, der har været fundet i randomiserede kontrolløsning. Tak for vores opmærksomhed. Tak. Hvordan fungerer det med søgerne? Skal alle søgerne opføre begge procedurer? Jeg noterede, at vores samleside på denne psykospinus var mindre. Var det en mindre nummer af søgerne? Nej, det er meget reguleret i Danmark. Så det er få søgerne, der gør denne operation, og de er, jeg vil sige, nok trænet. Og jeg kan sige det, fordi jeg selv ikke vil gøre en af disse operationer. Så jeg tror, det er færdigt at sige. Men det er ikke... Nej, så nogle mennesker vil gøre den utero-psykologiske ligamentfixering, og nogle vil altid gøre den psykospinus-ligamentfixering. Og det hænger på kulturen, på departementet, vil jeg sige. Okay, dr. Lucas. Så det er fantastisk, og jeg er enig med dig, at virkeligheden og randomiserede træninger er forskellige, men en af de ting, der var uklart til mig, var, om utero-psykologiske ligamentfixeringer forhandledes originalt på tiden af en hysterektomi, og så var det utero-psykologiske ligamentfixeringer på VOLT-prolapsen alene. Perfekt. En spørgsmål. Alle de patienter inkluderet havde deres hysterektomi før de relapsede deres... Så alle de patienter havde en relaps af deres køft, vaginal-køft, og kom ind for deres kurs efter en primær hysterektomi. Og grunden til den primære hysterektomi, jeg ved ikke, det kunne have været blødeskader og ting som det. Og så, ved vi, hvad indikationerne var? Har du nogen idé om, hvad deres stage af prolaps var? For vi ved, at en masse mennesker vil gøre en psykospinus med mere forventet prolaps, fordi man ikke kan finde utersikralerne, for at faktisk attage dem. Og så er man allerede biaset til højere færdigheder, fordi de har mere svære prolaps til at begynde. Så de havde ikke mere svære. Dette resultat viser både det råe data og det adjusterede data. Og der er nærmest ingen forskel mellem det råe og det adjusterede data. Og det er, fordi de har nærmest helt samme stage af prolaps før operationen. Jeg tror, at det er, fordi det er den samme type patient, der kommer ind, men nogle center bruger en teknik, og andre center bruger en anden teknik. Så jeg tror ikke, at der skal være nogen forskel mellem at vælge en teknik over den anden teknik. Det er mere, hvad doktoren er trænet til at gøre. I dit papir, hvis du kunne beskrive exakt, hvordan disse procedurer var gjort, ville det være virkelig hjælpende for os, fordi nu har vi dataet, som blev præsenteret på onsdag, med 5-årige udgifter, der viser, at sækre spindel har en 4% reoperation. Så måske er der også en teknik forskel. Selvfølgelig, og det er altid et problem med registrering, fordi jeg kan kun se, hvad doktorerne sætter i. Normalt er spindelfixering i Danmark gjort unilateralt. På den tid, tror jeg, at de fleste af procedurerne var med absorberet spindel. Men der er lavet et studie i Danmark, hvor de tog en video for at se, hvad de gjorde, og operatøren sagde, hvad han gjorde, og eksperten så, hvad de troede, de gjorde. Det var ikke altid det samme, men vi har kun resultatet for, hvad folk siger, de gør i operationen. Selvfølgelig er det en limitation, men det er en limitation for alle studier, at du faktisk ikke ved, hvad de gjorde, du ved kun, hvad de siger, de gjorde. Lad os tage en anden spørgsmål. Jeg har en spørgsmål fra Canada. Bare for at følge op lidt med denne spørgsmål, jeg har den samme puzzle. Der er bare et par mennesker, der faktisk har et antal urogynekologer, som har gjort de procedurer. Det er sikkert en rart standard uniform måde at gøre ting. Så fra det, du ved fra dine kolleger i landet, når de gør utero-seksuel ligament fixation, er det gennem vagina, ikke? Og gør de det, når de åbner paranæl-kaviterne? Går de over til paranæl? Hvilke typer suturer bruger de? Hvilke typiske teknikker bruger de? Så i min departement, alle doktorer, der gør utero-seksuel ligament suspension, har besøgt doktor Bob Schull i Texas, og det er mere eller mindre den samme teknik, vi bruger. Og min indtryk er, at det er det samme i hele landet. Jeg har nogle af mine kolleger derinde, som siger, at de vil gøre det samme. Så det er mere eller mindre exakt som Bob Schull gør. Og typisk er det med deltagende, absorberende suturer, du gør det? Det er absorberende suturer, men langtidige absorberende suturer. Okay, og dr. Klaskoff, du vil være tilfældig efter at snakke lidt mere til de tilfældige spørgsmål vi har? Jeg vil gerne gøre det. Okay, tak. Gratulerer. Tak. Godmorgen alle. Tak så meget for muligheden til at præsentere vores arbejde, og også for at holde på til sidste ende, og for at blive med denne morgen. Vi har ingen beslutninger. Så for en lille smule bakgrund. Uretægt infektionsrater ranger fra 11 til 40% efter uretægt infektionsrater. Denne risiko er størret ved at fjerne uretægt infektionsrater, samt uretægt infektionsrater. 25% af kvinderne vil have uretægt infektionsrater efter urogynekologisk infektionsrater, som ofte er nødt til at bruge en indvendig infektionsrater. Indvendige infektionsrater, givet postoperativ uretægt infektionsrater, har været vist til at mindre patienter satisfaktion, samt hindre postoperativ mobilitet. En uretægt infektionsrater-valve er en 3-inch-apparat, der sammenhænger med en folie, som anvender en kontinuerlig dræningsbag. Valvet betyder, at patienterne får en kontrolleret uretægt infektionsrater med intermittent batterfilling og dræning. Uretægt infektionsrater skal sammenhænges med en traditionel kontinuerlig uretægt infektionsrater, samt en uretægt infektionsrater efter prolaps eller kontinuerlig dræning. Uretægt infektionsrater skal sammenhænges med en kontinuerlig uretægt infektionsrater. Uretægt infektionsrater skal sammenhænges med en kontinuerlig uretægt infektionsrater. Uretægt infektionsrater skal sammenhænges med en kontinuerlig uretægt infektionsrater. Uretægt infektionsrater skal sammenhænges med en kontinuerlig uretægt infektionsrater. 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With the current controversy involving vaginal mesh, dermal allograft matrices have been used in an attempt to improve success rates and decrease recurrence. With all this in mind, we sought to compare prolapsed recurrence rates after unilateral as compared to bilateral, both with and without the use of a dermal graph. We conducted a retrospective chart review of all sacrospinous ligament fixations performed at our institution from January 1, 2012 to October 31, 2016. The patients were 18 to 89 and all surgeries were performed by FPMRS-trained physicians. This time frame allowed us for at least a two-year follow-up for recurrence. Our primary outcome was recurrence of pelvic organ prolapse. For our study, we defined that as prolapse requiring repeat operation, prolapse at or beyond the hymen in any compartment, or any degree of symptomatic prolapse. Our secondary outcomes involved composite complication rate, a change in bowel function, or a change in sexual activity. The patients were excluded if they had a history of pain syndrome or a history of prior apical vaginal fault repair. Prior to our collection, we conducted a power analysis. We determined that we needed 275 participants per group to detect a 50% reduction in recurrence. We compared our data two ways. First, we looked at all bilateral sacrospinous group together and compared them to the unilateral group using student's t-test. Secondly, we compared the data using three groups, bilateral, bilateral sacrospinous with a graft, and bilateral sacrospinous without a graft. These three groups were compared using ANOVA. If a difference was detected, then a Chafet test was run to determine between which groups the difference lies. We reviewed 374 charts in total. 57 charts were excluded. There were 186 in the unilateral group and 131 in the bilateral. The bilateral group was further split into 59 with a graft and 72 without. In looking at the demographics of our groups, we noticed that the unilateral group was significantly older by an average of 8 years. And not surprisingly, with that, they were also more likely to be post-menopausal. The unilateral group was also more likely to trial a pessary prior to pursuing their surgery. The bilateral group was more likely to be sexually active, and they were also more likely to have a uterus or retain the uterus at the time of their surgery. These are the results for our two group analyses. We found no difference in the recurrent rate between groups. The recurrence rate for our study was 18%, which is in line with prior published data for recurrence rate for sacrospinous. We also found no difference in complication rate. There was no difference in the change in sexual function between groups or the difference between their bowel function. When the bilateral group was then further subdivided into those with a graft and those without, similar findings persisted. The limitations of our study include its retrospective nature. The two groups could have been better matched, and we were only able to collect 57% of the cases needed to meet our power analysis. In conclusion, we found no difference in the recurrence rate between the unilateral and bilateral sacrospinous. The graft augmentation did not show any additional benefit on decreasing recurrence rate. The traditional thinking of difficulty of dissection, increased complication, or bowel complaints associated with a bilateral placement should not preclude you from performing the bilateral sacrospinous. Further studies are necessary to determine if a group of women for which the bilateral sacrospinous may provide additional benefit. Thank you for your time, and I welcome any questions. We did a study here with the Pelvic Floor Disorders Network. This is our disclosures. The objectives of this study were really to look at sexual activity and dyspareunia rates and risks for post-operative dyspareunia after a variety of pelvic organ prolapse surgeries. As many of you know, the Pelvic Floor Disorders Network has been involved in collecting data from numerous women who have undergone pelvic organ prolapse repair, including transvaginal native tissue repairs, transvaginal graft augmentative repairs, as well as abdominal sacrocopalpexes. We really had a unique opportunity to pool data from all four of the Pelvic Floor Disorders Network trials between 2002 and 2018. Many of you know already the CARE study was an open sacrocopalpexy procedure, looking at urinary incontinence outcomes. The OPUS trial was incontinence outcomes after vaginal surgery. The Optimal trial was native tissue apical support comparison, and the SUPER trial recently published this month in the JAMA. The nice thing is that we used really common outcome assessments at baseline, including demographics, medical and surgical history, prolapse surgical approach by many of the same surgeons throughout all four of those trials, and evaluators as well, and similar concomitant urinary incontinence procedures. We had baseline and one-year follow-up data in all of these trials with the question of dyspareunia of activity, I'm sorry, with the question of activity in the last three months based on the PISQ-12, or more recently the PISQ-IR. So dyspareunia was defined as usually or always do you feel pain during sexual intercourse in women who are sexually active, or does fear of pain during intercourse restrict your activity? So we wanted to capture women who were not active because of pain. De novo dyspareunia and persistent dyspareunia were defined similarly. We used bivariate and adjusted logistic regression models to predict outcomes for dyspareunia. So of all of these women, 1,337 women who were enrolled in all these trials, 97% of them actually underwent their prolapse prior and were a reconstruction as opposed to an obliteration procedure. And that 932 had baseline and 12-month PISQ data available for analysis. Of these women, 57% were sexually active at baseline. 48% of these were active without dyspareunia. 9% were active with dyspareunia. And 10% were active, or were not active due to dyspareunia or fear of dyspareunia. And there were no other, 33% who were not active for other reasons. So that baseline rate of activity increased from 57% to 63%, which was statistically significant. And 25% of women became newly sexually active by one year after surgery, and 9% stopped having sexual activity at one year. So for looking at the risk factors for dyspareunia, the 627 women who were either active or not active due to fear of dyspareunia, we included in this analysis, and these had a mean age of 58, mostly overweight, parity of 3, Caucasian, postmenopausal with advanced prolapse. And overall at baseline, the dyspareunia rate was 29%, and this decreased overall to 10% by one year, which was statistically significant. And only 4% of all of these women developed de novo dyspareunia, and 75% actually resolved by one year. So in your abstract booklet, there's a full table of all of the factors that we used to identify potential risk factors and these are the select ones that I chose for this presentation with the closest significance levels and really the only variable on univariate analysis that showed a relationship between dyspareunia and no dyspareunia was the fact that you had it to start with, which kind of makes sense. We did ask about bothersome pelvic pain using the UDI-6 question, do you have any pain and we used the same definition of moderate to severe bother. We also wanted to look at specific types of surgeries and we had to, there were lots of different surgeries that were performed particularly within the OPUS trial and we grouped these into anterior apical with native tissue, transvaginal mesh, particularly the uphold mesh that was in the super trial and then sacrocopalpexy and then we also looked at posterior compartment and concomitant sling and because there was a slight increase rate of dyspareunia in the transvaginal mesh, we did include that in our regression model, but it ultimately fell out and really the only increased risk of 7.8 associated with baseline dyspareunia. None of the other factors remained. There were no significant factors associated with persistent dyspareunia, which I'll spare you the details on the data cells and there were too few women, only 17, who had de novo that we couldn't perform any kind of modeling. So dyspareunia is common. 1 in 5 of these women enrolled in these trials undergoing surgery for prolapse had dyspareunia at baseline and de novo dyspareunia rates were low at less than 5%. Dyspareunia improved in 3 of 4 women after their repair and the presence of baseline dyspareunia was really the only significant risk factor for persistent symptoms at 12 months. The type of repair was not associated with dyspareunia and no predictors for persistent dyspareunia existed. Surgeons hopefully can use these data in shared decision-making regarding surgical approach and post-operative expectations. Thanks. Hi, my name is Dr. Moore. I'm from Israel. I'm presenting our group's work at a randomized control study to compare the robotic endoscopic single site versus the multi-port for sarcoplaxy for apical compartment prolapse. Our hospital is in the city of Haifa in north of Israel. It's a tertiary hospital. The robotic endoscopic single site surgery is markedly in the top of the list. It's aggressively marketed and widely adopted across numerous gynecology subspecialties, but we identified a lack of comparative perspective randomized control studies to compare the single site approach with the multi-port robotic approach. And our objective was to compare these approaches in performing sarcoplaxy for treating uterus or post-hysterectomy vaginal prolapse in the randomized control study. In this picture you can see the single site approach and in this picture you can see the multi-port approach. The inclusion criteria was uterine or post-hysterectomy vaginal apex prolapse, POPQ stages of two to four, and the desired robotic assisted laparoscopic surgical management. It was performed from January 2017 to December 2018, and we had a one-to-one ratio of one of the two treatment groups. We enrolled a total of 70 patients, 35 patients in each group. The randomization was, there was no difference between the two groups, hence I'm not showing the demographic characteristics. The primary outcomes was operative time. And secondary outcomes were intraoperative bleeding, surgical complications, hospitalization length, POPQ stages, and postoperative. And assessments of quality of life, quality of life, quality of life, scar assessment scales, and activity assessment scales, which were administrated at baseline at six weeks and at six months after the surgery. The results. The operative time in the single site group was longer compared with the multi-port in all parameters measured. As you can see, 24 minutes longer total operative time, and the supracervical hysterectomy time was eight minutes longer, and so was the mesh suturing and fixation time. And peritoneum suturing time was also about five minutes longer. Hospitalization days and level of pain, 24 hours postoperative according to a one to ten visual analog scale did not differ. There were no adverse events in both groups, and no other statistically, no other differences that were statistically significant between the two operations with the parameters I discussed earlier. So in conclusion, the single site approach had longer operative times compared with the multi-port approach. That was basically the bottom line of this randomized control study. Both approaches were feasible, and either short or long-term outcomes are equivalent. Dr. Chen? Hi, Dr. Moore. With adoption of new technologies, a lot of the times it's a surgeon preference of what they like, the new technology or not. Did you find out if the surgeons preferred the single site over the traditional method? In our medical institute, the same surgeon did all these 70 surgeries, and in normal day life he normally performed a multi-port approach. But we didn't see improvement time improvement rate of time, the learning curve for the single site was not as good as we expected. You know, I'm trying to do the math kind of quick, and add all those up. When you add all those different things up, how much more time was it? It looks like it was over an hour. It was 24 minutes longer. Yeah, it was 24 minutes longer. Just in terms of learning curve, how many of the single port site sacral copalpexies were done prior to the start of the study, so the surgeon could practice? So this included his learning curve after multiple years of experience with multi-port sacral copalpexies? He prior to this study went to observe a couple of these, and then started to do them. So theoretically, years from now, his single port could be a lot faster? Theoretically, yes, but we also did not see a learning curve through these 35, a good enough learning curve through these 35 operations. So we don't think it's a surgeon bias. Thank you. Congratulations. Thank you very much, and thank you for the opportunity to tell something about our research work. This study is funded by a research grant from the Isola Hospital in the Netherlands. Level 1 support is important to treat prolapse. Studies have demonstrated that hystereopexy is comparable to vaginal hysterectomy. Several techniques are available for hystereopexy, including the abdominal, vaginal, and laparoscopic route. Although nowadays, no RCTs have been performed to compare these techniques. Therefore, we have conducted the LAFA trial. This study compares the laparoscopic sacrohystereopexy to the vaginal sacrospinous hystereopexy in patients with uterine descent, POPQ, stage 2 or higher. The study is an open-label, non-inferiority trial. One academic hospital in Belgium and five large non-academic teaching hospitals in the Netherlands participated in this trial. A total of 126 women with uterine descent without previous prolapse surgery were enrolled in the study and randomized between the laparoscopic and the vaginal procedure. A description of the surgical techniques had been published in our BMC research protocol. In short, vaginal sacrospinous hystereopexy is performed by attaching the cervix to the right sacrospinous ligament using non-absorbable sutures. In case of laparoscopic sacrohystereopexy, the uterus is attached to the promontory using a bifurcated polypropylene mesh. Data is collected at baseline, six weeks after surgery, six months, and yearly thereafter. The total duration of the study is 60 months. At baseline and at follow-up, women underwent a vaginal POPQ examination. Furthermore, women were asked to fill out questionnaires regarding functional outcome, sexual functioning, and quality of life. The study is still ongoing. Today I will present anatomical and functional outcomes at two years follow-up. The primary outcome of the study was surgical failure, which was defined as a reoccurrence of POPQ stage 2 or higher of the uterus with bothersome bilge complaints and or repeat surgery or pessary for the apical compartment. Overall surgical success as a secondary outcome was defined as no prolapse beyond the heme in any compartment, absence of bothersome bilging symptoms, and no repeat surgery or pessary use. Other secondary outcomes were health-related quality of life, functional outcome, and sexual functioning. Data were analyzed according to the intention to treat principle. In total, 64 women were randomized for laparoscopic hystereopexy and 62 women were randomized for the vaginal procedure. Six women allocated to the laparoscopic procedure underwent a vaginal sacrospinous hystereopexy or a Manchester photogil due to technical difficulties. Baseline characteristics like age, comorbidity, and prolapse states were comparable in both groups. When looking at the primary outcome, no differences was found in the surgical failure between the both studies. Overall surgical success rates were comparable as well. Regarding urogenital symptoms, women after the laparoscopic procedure had higher urinary incontinence scores, which reflect more bothersome urinary incontinence. Furthermore, women who underwent the laparoscopic procedure reported more bothersome fecal incontinence. Health-related quality of life and sexual functioning were comparable in both groups. However, of the sexually active women, there were more women reporting dyspareunia after the vaginal procedure as compared to the laparoscopic procedure. To come to conclusions, at 24 months follow-up, no differences were found in surgical failure and health-related quality of life after laparoscopic sacrohisteropexy as compared to vaginal sacrospinous sacrohisteropexy. Women undergoing the laparoscopic procedure reported more bother from urinary and fecal incontinence. However, dyspareunia was more frequently reported after the vaginal procedure. Thank you for listening, and I welcome any questions. Thank you for your study. This is a very important study and will provide very important information, especially with your final 16 months. I'm looking at your analysis, and you state that it's a non-inferiority trial, but your analysis suggests a superiority trial analysis, where you compared one better than the other. And I'm also not clear if you've done an intent-to-treat or a per-protocol. Which one did you do? Yeah, well, in fact, we did both. We have our one-year results, will be published hopefully very soon. And in that paper, we performed a per-protocol and intent-to-treat analysis, because that's what common sense is in a non-inferiority trial, although five minutes was too short to lift out all the analysis I did. So to really be able to identify non-inferiority, you have to use a per-protocol analysis, because that will increase the differences. So if you see that, as much as possible, they are as different as possible, you still see that they are similar, and it increases your strength of your results. So we really encourage you to primarily report a per-protocol analysis. Yes, well, to comment on that, for the two-years result, I did not perform the per-protocol, but I did it on the one-years result. Well, one and five-year are the endpoints of the study. We saw no differences in the per-protocol analysis as well. We demonstrated a non-inferiority of the laparoscopic procedure as compared to the vagina, which is the golden standard in medicine nowadays. Thank you. Thank you for this question. Thank you. Congratulations on your study. Thank you very much. Good afternoon. I'd like to thank the opportunity for us to present our work on the mesh repair should be considered in women with levator adenomyosal abortion and advanced pelvic organ prolapse. And thanks to my research team, and we have no disclosure. So this is just a very light piece of mesh. However, it leads to a very heavy and also very intensive discussion nowadays. We understand it was a warning put out by the FDA, and also there was suspension and restricted over in the most part of the Western world. And it upset a lot of women and caused a lot of complications. However, we should never forget actually there's a group of lady who will benefit and have a successful operation by using this piece of mesh. So I'd like to give you some background in our local protocol. When our women come in with a symptomatic stage three or stage four prolapse at the anterior and or apical compartment, in our unit, we will offer the options of having mesh surgery or native tissue repair. If they choose for native tissue repair, vaginal hysterectomy and also coporaphy together with sacral spinous fixation will be performed. For the mesh surgery, depends on their age and also their sexual activity. For the younger patients who are sexually active, we will offer sacral cocopexy, while for the elder patients and also a sexually inactive one, we will offer the option of vaginal mesh repair. Just for your information, for our local population in Hong Kong, actually we have the longest life expectancy for our women in the world, and the mean age is up to 86. So 65 is relatively young in our population. And also over 90% of our lady were sexually inactive in our patient group. So the objective of our study was to assess the subjective and objective outcome following pelvic organ prolapse repair with and without mesh in our patient with stage three or four prolapse. This is an observational study of women, recruited women, who received prolapse surgery over from year 2013 to 18. Besides the standard consultation and also physical examination, we also performed 3D and 4D transperineal ultrasound scan in all pre-op patients to assess the genital hiatus and also the assessment of the levator ani muscle. As mentioned before in the previous slide, options of mesh versus native tissue repair were discussed. In the post-operative follow-up, we will assess the subjective outcome defined by prolapse symptoms using three scales, and also objective outcome will be defined by the propagate staging. In comparison, we made between women with and without levator ani muscle injury. For the patient who received native tissue versus a mesh surgery, essentially the demographic were similar, including the age, parity, BMI, and also majority of them were having levator ani muscle injury as expected. For the follow-up time, we intentionally have longer follow-up in our mesh group. For the objective recurrence, actually there's a tendency with a higher recurrence rate in the native tissue repair group. However, it was statistically insignificant. For the subjective recurrence, it was significantly higher in the native tissue repair. So after running a univariate and multivariate analysis, we noticed for the recurrence as defined by propagate staging at stage two or above, the two significant factors were levator ani muscle injury and also the use of mesh. And this was the same for the subjective recurrence. So when we are defining for our future management in our patients for prolapse surgery, we define them into levator ani muscle injury or not. And we noticed that in this way of analysis, we noticed that on your left-hand side, for the patient who have the muscle injury, in fact they receive mesh surgery, they will have a much lower recurrence rate, which is one half of those without the mesh being used. So in conclusion, women with stage three or four pelvic organ prolapse together with the levator ani muscle abulsion, they have a lower objective and subjective recurrence rate after receiving the prolapse surgery with the mesh. So because of the very high complication rate from the mesh, we should not be just stopping using all the mesh for a patient. Instead, we should select those high risk of recurrence and who is the lady with the most benefit to use the mesh. Thank you very much. Dr. Panga will be presenting outcomes of vaginal and laparoscopic uterus sacral ligament suspension, a systematic review. Thank you for allowing us to present our work. We have no relevant financial relationships to disclose. Pelvic organ prolapse is a common debilitating condition that is experienced by women across all age groups. There are a variety of approaches for surgical management of pelvic organ prolapse, including vaginal, laparoscopic, and robotic. A common vaginal apical suspension performed is the uterus sacral ligament suspension. This procedure has been traditionally carried out using the Schultz technique, and it involves the use of the uterus sacral ligament to suspend the vaginal apex. More recently, surgeons have offered and performed the uterus sacral ligament suspension laparoscopically or robotically, which we will refer to as minimally invasively for the purposes of this review. Using the increasing number of robotic and laparoscopic performed procedures, we sought to systematically review the currently published literature on outcomes after vaginal versus laparoscopic uterus sacral ligament suspension. We conducted a search using the listed terms to identify studies which evaluated vaginal and or laparoscopic approach to the uterus sacral ligament suspension. We did exclude studies that included the use of mesh and concomitant hystereopexy procedures. We grouped studies with similar definitions of long-term outcomes. We did adhere to PRISMA guidelines, and this study was registered to the Prospero database. Our initial search yielded 843 articles. Title review by one author led to the exclusion of 323 articles. 293 abstracts were reviewed by two authors, and 34 articles were included in the analysis. Data was abstracted by three of the authors, blinded to each other's abstraction. Any variables with conflicting data were re-reviewed by the first author. In all, 85 full-text articles were reviewed. As I mentioned, 34 full-text articles were included in the analysis. The majority were of a retrospective nature, and most assessed the vaginal approach. More than 5,000 participants received a vaginal approach with mean follow-up of 16 months, and almost 500 received a minimally invasive approach with mean follow-up of 12 months. Women undergoing a vaginal approach were slightly older, but BMI and parity were similar to laparoscopic group. Estimated blood loss was higher in the vaginal group, and operative time was longer in the MIS group. However, these are likely affected by the types of concomitant procedures performed. Concomitant hysterectomy was higher in the vaginal group, but was overall high in both groups. As expected, vaginal anterior repairs were common in the vaginal group. Additionally, anti-incontinence procedures were slightly more common in the vaginal group. Both ureteral injuries corrected intra-op and post-op were higher in the vaginal group, with none in the minimally invasive group, although the number of ureteral injuries was overall very low. We also looked at longer-term outcomes. Twelve vaginal studies and two laparoscopic studies reported on sensation of bothersome vaginal bulge postoperatively. This was 10% at follow-up of 31.8 months in the vaginal group, and 10.4% at 6.4 months in the laparoscopic group. Eight vaginal and two laparoscopic studies reported recurrence of prolapse, defined as POPQ stage greater than or equal to stage 2. The vaginal pooled percentage was 6.6% at a follow-up of 29.2 months, and laparoscopic was 13.5% at a mean follow-up of 34.5 months. Reoperation for prolapse in any compartment was reported by 18 vaginal studies at 6.4% at 21.5 months, and by two laparoscopic studies to be 8.7% at 21.7 months. Four vaginal studies and one laparoscopic study reported total recruitment, including reoperation for prolapse or path replacement. This was 13.8% at up to 20 months in the vaginal group, and 7.4% at 5 months in the minimally invasive group. Subjective outcomes appear to be similar in both vaginal and laparoscopic groups at mid- to long-term follow-up. This review underscores the importance of defining common outcome measures as a group, as we were unable to utilize all articles to assess outcomes. Additional long-term studies with standardized outcome measures are needed. Thank you. Okay, now these abstracts are open for questions. Larry Bowen from Sacramento for Dr. O'Meara. Could you comment on your approach for the sacro-spinous ligament suspension? Were those all posterior approaches, or were you approaching it anteriorly at all? And how did you deal with the anterior compartment in all of these patients? Thank you for your question. There were both anterior and posterior approaches. We did analyze the data to look at that, and there was no difference whether or not there was an anterior or posterior approach. And what was the second part of your question? How did you deal with the anterior compartment? Cystocele? Yeah, we looked at concurrent surgeries that occurred at the time of the sacro-spinous, and the groups were actually well-matched for the proportion that had anterior repair at the same time. What type of anterior repair were you doing? Usually native tissue repair. Thanks. Thank you very much for your wonderful studies. I have a question for two different authors. Dr. O'Meara, I was wondering, a lot of the differences at baseline between your three groups were potential confounders in terms of success. And you can match them, I get that. But are you planning to perform a logistic regression or ANCOVA to assess for those variables and their impact on your end result? Yes, we are planning to do that. Because that will be important to really help to see a comfortable conclusion. And for Dr. Pandya, I was wondering, could you get from those different studies the method of surgery in terms of the type of sutures being used, if there were a difference between the laparoscopic and the vaginal? There were differences, and there were a variety of sutures reported and techniques reported in terms of number of sutures. But there was so much variation that it was hard to report consistently. Thanks. I have a question for Dr. O'Meara. For the bilateral sacrospinal suspensions, were these decided prior to the patient in the ORs? And was it surgeon-specific? So one surgeon always performed bilateral with or without graft? Or is it where they would go in and see whether or not it would make it and then do a unilateral or bilateral? There were actually both. There were situations where it was predetermined that it was going to be a bilateral approach, and that was predominantly one of the surgeons. And then in other cases, it was determined at the time of the case whether or not to do a unilateral or bilateral. The graft was predominantly one surgeon. I have one quick question for Dr. Lucas. For your study, did you guys look at vaginal estrogen use in any of the... or was that something that wasn't? Yeah, it's actually in the table, and there were no differences in vaginal estrogen use. This question is for Dr. Cheung. Can you explain how you diagnosed levator anus avulsion? We have a standard protocol for the diagnosis, and we take the TUI theme of the genital hiatus and we will take the definition mainly defined by Professor Peter Deese, published in the UOG Journal. Well, congratulations to our authors. Travel safe. Thank you.
Video Summary
The first video transcript summarized in the question is in Danish and discusses a study comparing utero-sacral ligament suspension with psycho-spinal ligament fixation for the treatment of vaginal prolapse. The speaker explains that the study used data from the Danish national patient registry and the Danish urogynecological database to analyze the outcomes of different surgical techniques. The study found that there was a higher risk of relapse after psycho-spinal ligament fixation compared to utero-sacral ligament suspension. The speaker emphasizes the importance of real-world observational studies in addition to randomized controlled trials. They note that individual centers should be aware of their own results and risks in order to provide the best care for their patients.<br /><br />The second video transcript summarized in the question is in English and discusses a study comparing different surgical approaches for pelvic organ prolapse repair. The study found that the laparoscopic approach had longer operative times compared to the multi-port approach. However, there were no differences in surgical failure rates, complication rates, or changes in bowel or sexual function between the two approaches. The study concludes that both approaches are feasible and have equivalent short-term outcomes.
Asset Caption
Laura Dhariwal, MD, Niels Klarskov, MD, DMSc, Lior Lowenstein, MD, MS, MHA, MBA, Mèlanie N. van IJsselmuiden, MD, Amanda O'Meara, MD, Yau Kar Rachel Cheung, Emily Lukacz, MD, MAS, Lopa K. Pandya, MD
Keywords
Danish
study
ligament suspension
ligament fixation
vaginal prolapse
surgical techniques
relapse risk
observational studies
operative times
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