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Uterine Prolapse [keywords]
- Robotically assisted laparoscopic repair of anterior vaginal wall and uterine prolapse by lateral suspension with mesh: initial experience and video. [JOURNAL ARTICLE]
- Int Urogynecol J 2014 Apr 17.
Sacral colpopexy/hysteropexy is a well-established approach to vaginal apex support and was the first technique used to treat pelvic organ prolapse (POP) with robotic assistance. However, dissection at the level of the promontory may be difficult, especially in obese patients, and associated with rare but potential serious morbidity such as life-threatening vascular injury. In an attempt to avoid this risk, we describe a new robotic approach for POP repair with lateral suspension.From March 2012 through June 2013, ten patients with symptomatic anterior vaginal wall and uterine prolapse were operated by a single surgeon. The video presents the different steps of robotically assisted laparoscopic repair of POP by lateral suspension with mesh and uterine conservation using da Vinci S or Si system.POP repair was successfully completed in all ten patients without any perioperative or postoperative complication.Robotically assisted laparoscopic repair of POP by lateral suspension with mesh is a novel and feasible technique with promising short-term results. It may have several theoretical advantages over sacral colpopexy/hysteropexy and may represent an alternative in cases of difficult dissection of the promontory.
- Prevalence, etiology and risk factors of pelvic organ prolapse in premenopausal primiparous women. [JOURNAL ARTICLE]
- Int Urogynecol J 2014 Apr 16.
The natural history of pelvic organ prolapse (POP) is poorly understood. We investigated the prevalence and risk factors of postnatal POP in premenopausal primiparous women and the associated effect of mode of delivery.We conducted a prospective cohort study in a tertiary teaching hospital attending 9,000 deliveries annually. Collagen-diseases history and clinical assessment was performed in 202 primiparae at ≥1 year postnatally. Assessment included Pelvic Organ Prolapse Quantification (POP-Q) system, Beighton mobility score, 2/3D-transperineal ultrasound (US) and quantification of collagen type III levels. Association with POP was assessed using various statistical tests, including logistic regression, where results with p < 0.1 in univariate analysis were included in multivariate analysis.POP had a high prevalence: uterine prolapse 89 %, cystocele 90 %, rectocele 70 % and up to 65 % having grade two on POP-Q staging. The majority had multicompartment involvement, and 80 % were asymptomatic. POP was significantly associated with joint hypermobility, vertebral hernia, varicose veins, asthma and high collagen type III levels (p < 0.05). In multivariate logistic regression, only levator ani muscle (LAM) avulsion was significant in selected cases (p < 0.05). Caesarean section (CS) was significantly protective against cystocele and rectocele but not for uterine prolapse.Mild to moderate POP has a very high prevalence in premenopausal primiparous women. There is a significant association between POP, collagen levels, history of collagen disease and childbirth-related pelvic floor trauma. These findings support a congenital contribution to POP etiology, especially for uterine prolapse; however, pelvic trauma seems to play paramount role. CS is significantly protective against some types of prolapse only.
- Prolapse of the small intestine from the uterine perforation at dilatation and curettage. [Journal Article]
- Case Rep Obstet Gynecol 2014.:164356.
Dilatation and curettage (D&C) sometimes causes uterine perforation, which usually does not cause a serious problem. Here, we report uterine perforation caused by D&C, in which the small intestine prolapsed from the uterus, requiring intestinal resection. D&C was performed for missed abortion at 9 weeks. After dilating the cervix, forceps grasped tissue that, upon being pulled, resulted in the intestine being prolapsed into the vagina. Laparotomy revealed a perforation at the low anterior uterine wall, through which the ileum had prolapsed. The mesentery of the prolapsed ileum was completely detached and the ileum was necrotic, which was resected. The uterus and the intestine were reconstructed. Although intestinal prolapse is considered to be caused by "unsafe" D&C performed by inexperienced persons or even by nonphysicians in developing countries, this occurred in a tertiary center of a developed country. We must be aware that adverse events such as uterine perforation with intestinal prolapse can occur even during routine D&C.
- Complete uterine prolapse without uterine mucosal eversion in a queen. [JOURNAL ARTICLE]
- J Small Anim Pract 2014 Feb 12.
A five-year-old female cat weighing 3 kg was presented by the owner after noticing a large pink, bilobed mass protruding through the vulva during labour. The cat was in good condition, with appropriate lactation, and the newborn kittens were nursing normally. The uterus was not reverted or invaginated at examination, and there was rupture of the mesovarium, mesometrium and uterine-vaginal connection around the cervix. Manual reduction of the prolapsed uterus was not possible because of torn ligaments. A coeliotomy was performed to remove the ovaries, and the apex of the uterine horns was passed by the vaginal route. The remaining part of the mesometrium was disconnected, and the prolapsed uterus was removed. The queen and kittens were discharged from the hospital on the second day after surgery. An unusual feature of this case is that the prolapse was complete, without eversion of any part of the uterus through a vaginal tear.
- Laparoscopic hysterectomy and prolapse: a multiprocedural concept. [Journal Article]
- JSLS 2014; 18(1):89-101.
Today, laparoscopic intrafascial hysterectomy and laparoscopic supracervical hysterectomy are well-accepted techniques. With our multimodal concept of laparoscopic hysterectomy for benign indications, preservation of the pelvic floor as well as reconstruction of pelvic floor structures and pre-existing prolapse situations can be achieved.The multimodal concept consists of 3 steps: 1. Intrafascial hysterectomy with preservation of existing structures A. Technique 1: Primary uterine artery ligation B. Technique 2: Classic intrafascial hysterectomy 2. A technique for the stable fixation of the vaginal or cervical stump 3. A new method of pectopexy to correct a pre-existing descensus situation Results and Conclustion: This well-balanced concept can be used by advanced endoscopic gynecologic surgeons as well as by novices in our field.
- Risk factors for 30-day perioperative complications after Le Fort colpocleisis. [JOURNAL ARTICLE]
- J Urol 2014 Mar 15.
To identify rates of and risk factors for complications after colpocleisis using the National Surgical Quality Improvement Program (ACS-NSQIP) database.Women undergoing Le Fort colpocleisis from 2005 to 2011 were identified in the NSQIP database. Primary outcomes were 30-day complication rates. Secondary outcomes were risk factors for complications and impact of age and concomitant sling on morbidity. Clinical and procedural characteristics were compared using χ(2) and one-way ANOVA tests.Two hundred eighty-three women were identified. Twenty-three women (8.1%) experienced complications. The most common complication was UTI (18/283, 6.4%). There was one death, for a mortality rate of 0.4%. Increased complications were associated with age < 75 years (p=0.03), COPD (p=0.03), hemiplegia (p=0.03), disseminated cancer (p=0.03), and open wound infection (p=0.02). Six patients (2.1%) required return to the operating room within 30 days. Complication rates did not differ based on operative time (p=0.78), inpatient status (p=0.24), resident involvement (p=0.35), concomitant sling placement (p=0.81), or type of anesthesia (p=0.27). Women undergoing colpocleisis without (n=191) and with (n=92) sling had similar baseline characteristics. Colpocleisis without and with sling had similar rates of complications (7.9% versus 8.7%, p=0.81), UTI (5.8% versus 7.6%, p=0.55), return to the OR (2.1% versus 2.2%, p=0.97), and mortality (0% versus 1.1%, p=0.15).Mortality and complication rates after colpocleisis are low, with UTI being the most common postoperative complication. Concomitant sling placement does not increase 30-day complication rates.
- The outcome of Manchester-Fotergill operation for uterine decensus repair: a single center experience. [JOURNAL ARTICLE]
- Arch Gynecol Obstet 2014 Mar 18.
The aim of this study was to evaluate the clinical characteristics, peri- and post-operative outcomes, and clinical effectiveness of the Manchester-Fothergill (MF) procedure for uterine descensus as a uterine-sparing surgery.In this study, 49 patients underwent the MF procedure as a uterine-sparing surgery for uterine descensus during 2008-2012 in the Department of Urogynecology at Kanuni Sultan Süleyman Research and Teaching Hospital, Istanbul, Turkey.Medical records and follow-up data were collected from 24 of the 49 patients (48.9 %). The mean age was 49.3 ± 9.1 years, and parity 3.6 ± 1.5; 41.6 % were post-menopausal; 6 patients (25 %) had grade II, and 18 (75 %) had grade III uterine prolapse; 95.8 % had associated cystoceles, and 79.1 % had associated rectoceles; 66.6 % complained of urinary incontinence. On follow-up examination, the cervical stumps were satisfactorily situated in 23 of 24 patients, and recurrent prolapse was seen in 1 patient (4.1 %). Bladder perforation was repaired at the time of the operation in 1 patient, and one complained of post-operative urinary retention.The MF procedure is a viable option to surgically correct uterine descent while preserving the uterus to treat recurrent prolapse with a low complication rate and low morbidity.
- Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. [Comparative Study, Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, N.I.H., Extramural]
- JAMA 2014 Mar 12; 311(10):1023-34.
More than 300,000 surgeries are performed annually in the United States for pelvic organ prolapse. Sacrospinous ligament fixation (SSLF) and uterosacral ligament suspension (ULS) are commonly performed transvaginal surgeries to correct apical prolapse. Little is known about their comparative efficacy and safety, and it is unknown whether perioperative behavioral therapy with pelvic floor muscle training (BPMT) improves outcomes of prolapse surgery.To compare outcomes between (1) SSLF and ULS and (2) perioperative BPMT and usual care in women undergoing surgery for vaginal prolapse and stress urinary incontinence.Multicenter, 2 × 2 factorial, randomized trial of 374 women undergoing surgery to treat both apical vaginal prolapse and stress urinary incontinence was conducted between 2008 and 2013 at 9 US medical centers. Two-year follow-up rate was 84.5%.The surgical intervention was transvaginal surgery including midurethral sling with randomization to SSLF (n = 186) or ULS (n = 188); the behavioral intervention was randomization to receive perioperative BPMT (n = 186) or usual care (n = 188).The primary outcome for the surgical intervention (surgical success) was defined as (1) no apical descent greater than one-third into vaginal canal or anterior or posterior vaginal wall beyond the hymen (anatomic success), (2) no bothersome vaginal bulge symptoms, and (3) no re-treatment for prolapse at 2 years. For the behavioral intervention, primary outcome at 6 months was urinary symptom scores (Urinary Distress Inventory; range 0-300, higher scores worse), and primary outcomes at 2 years were prolapse symptom scores (Pelvic Organ Prolapse Distress Inventory; range 0-300, higher scores worse) and anatomic success.At 2 years, surgical group was not significantly associated with surgical success rates (ULS, 59.2% [93/157] vs SSLF, 60.5% [92/152]; unadjusted difference, -1.3%; 95% CI, -12.2% to 9.6%; adjusted odds ratio [OR], 0.9; 95% CI, 0.6 to 1.5) or serious adverse event rates (ULS, 16.5% [31/188] vs SSLF, 16.7% [31/186]; unadjusted difference, -0.2%; 95% CI, -7.7% to 7.4%; adjusted OR, 0.9; 95% CI, 0.5 to 1.6). Perioperative BPMT was not associated with greater improvements in urinary scores at 6 months (adjusted treatment difference, -6.7; 95% CI, -19.7 to 6.2), prolapse scores at 24 months (adjusted treatment difference, -8.0; 95% CI, -22.1 to 6.1), or anatomic success at 24 months.Two years after vaginal surgery for prolapse and stress urinary incontinence, neither ULS nor SSLF was significantly superior to the other for anatomic, functional, or adverse event outcomes. Perioperative BPMT did not improve urinary symptoms at 6 months or prolapse outcomes at 2 years.clinicaltrials.gov Identifier: NCT00597935.
- Alteration of apoptosis-related genes in postmenopausal women with uterine prolapse. [JOURNAL ARTICLE]
- Int Urogynecol J 2014 Mar 11.
We aimed to compare expression levels of antiapoptotic and proapoptotic genes in parametrial and vaginal tissues from postmenopausal women with and without pelvic organ prolapse (POP). We hypothesized that the expression of genes that induce apoptosis may be altered in vaginal and parametrial tissues in postmenopausal women with POP.Samples of vaginal and parametrial tissues were obtained from postmenopausal women with (n = 10) and without (n = 10) POP who underwent vaginal or abdominal hysterectomy. Expression levels of antiapoptotic (BCL-2, BCL-XL) and proapoptotic (BAX, BAD) genes were studied by real-time reverse-transcription polymerase chain reaction (RT-PCR).Gene expression levels of BCL-2 (P < 0.001), BCL-XL (P < 0.001), BAX (p = 0.001), and BAD (p = 0.004) were all higher in vaginal tissues from the POP group compared with the non-POP group. Similarly, gene expression levels of BCL-2 (p < 0.001), BCL-XL (p < 0.001), BAX (p < 0.001), and BAD (p < 0.001) in parametrial tissues were also significantly higher in the POP group compared with the non-POP group. Additionally, expression levels of BCL-2 (p = 0.05), BCL-XL (p < 0.05), BAX (p = 0.05), and BAD (p = 0.07) in the POP group were higher in parametrial tissue than in vaginal tissue samples.Antiapoptotic and proapoptotic gene expression levels differed significantly between postmenopausal women with and without POP. Bcl-2 family genes were overexpressed in the parametrium of patients with POP compared with vaginal tissue, suggesting that the processes responsible for POP have a greater effect on parametrial tissue than vaginal tissue during the development of POP.
- Does traction on the cervix under anaesthesia tell us when to perform a concomitant hysterectomy? A 2-year follow-up of a prospective cohort study. [JOURNAL ARTICLE]
- Int Urogynecol J 2014 Mar 6.
Variations exist in urogynaecological practice to decide on hysterectomy in managing prolapse. This study evaluates the outcomes of uterine preservation during anterior colporrhaphy with apparent uterine descent with cervical traction under anaesthesia. We hypothesize that cervical traction should not be used to assess uterine prolapse.Thirty-five women opting for surgery for symptomatic anterior prolapse (≥ stage 2) with no uterine prolapse (point C at -3 or above) were recruited. "Validated cervical traction" was applied under anaesthesia. Only an anterior repair was performed. Incontinence Modular Questionnaire Vaginal Symptoms (ICIQ-VS) questionnaires were used for follow-up. Wilcoxon test was used for statistical analysis.Stage 2 uterine prolapse (POPQ) was demonstrated in all women with traction under anaesthesia. Follow-up was possible in 29 women, 5 did not respond and 1 needed a hysterectomy at 6 months (2.86 %, 95 % CI 0.07-14.91 %). The mean follow-up time was 23 months (range: 13-34 months). There was a significant reduction in the ICIQ-VS scores from 22.7 (pre-operative) to 7.97 at 23 months (p < 0.001) and a significant improvement in the quality of life scores (4.3 to 1.86; p < 0.0001). There was also a significant reduction in the complaint of a bulge in the vagina (question 5a-ICIQ-VS; 2.91 to 0.89; p < 0.0001).The "cervical traction" test seems unnecessary, and the decision for a hysterectomy should be based on examination findings in the clinic. Larger RCTs are needed to evaluate cervical traction in the assessment of prolapse.