A comparative study in learning curves of laparoscopic lateral suspension vs. laparoscopic sacrocolpopexy: preliminary results

BackgroundDetermination of the learning curve of new techniques is essential to improve safety and efficiency. Limited information is available regarding learning curves of different techniques in laparoscopic pelvic floor surgery.ObjectiveThe aim of this study was to compare the learning curve of two operative techniques, laparoscopic lateral suspension (LLS) and laparoscopic sacrocolpopexy (LSC).Material and methodsWe conducted a prospective study to assess the learning curve of LLS and LSC by implementing a structured urogynecologic surgical training program with the use of pelvic trainers for our urogynecology fellow. The fellow was an experienced urogynecologic surgeon, but was laparoscopic suturing and dissection naive at the beginning of the study. She was required to assist in 20 laparoscopic urogynecologic surgeries and undertake laparoscopic suturing and knot tying training with mesh positioning on a laparoscopic trainer for 4 h/week during the trial period. After the completion of this structured training program, the fellow performed LLS and LSC under the supervision of an experienced subspecialist as the primary surgeon. Linear regression analysis was used to compare the data of LLS and LSC learning curves. Subjective pre- and post-operative evaluation of pelvic organ prolapse (POP) and pelvic floor disorders was undertaken preoperatively and 12 months postoperatively using the PFDI-20-Quality of Life validated questionnaire. Follow-up was scheduled 12 months after the surgery and performed by a skilled urogynecologist. Objective cure was defined as Pelvic Organ Prolapse-Qualification (POP-Q) stage <II in any compartment.ResultsThe mean operative times of laparoscopic sacrocolpopexy and lateral suspension were 168.26 and 160.33 min, respectively. According to linear regression analysis after 43 procedures, the learning curve for laparoscopic lateral suspension was shorter than for laparoscopic sacrocolpopexy (OPTime 134.69 min). In both groups, there was a significant reduction in bothersome POP symptoms (p ≤ 0.005). Bladder injuries in two cases and lumbar pain in one case were recorded during the study. Overall objective success at 12 months was 90.7% for LSC and 89.1% for LLS.ConclusionLaparoscopic lateral suspension could be an alternative to laparoscopic sacrocolpopexy in the treatment of POP with its good objective and subjective outcomes. Lateral suspension has a shorter learning curve, and it is technically less demanding than LSC. Procedure-dedicated training can accelerate the move from a novice to a master laparoscopic surgeon

The impact of EAES Fellowship Programme:a five-year review and evaluation

Background: The European Association of Endoscopic Surgery (EAES) fellowship programme was established in 2014, allowing nine surgeons annually to obtain experience and skills in minimally invasive surgery (MIS) from specialist centres across the Europe and United States. It aligns with the strategic focus of EAES Education and Training Committee on enabling Learning Mobility opportunities. To assess the impact of the programme, a survey was conducted aiming to evaluate the experience and impact of the programme and receive feedback for improvements.Methods: A survey using a 5-point Likert scale was used to evaluate clinical, education and research experience. The impact on acquisition of new technical skills, change in clinical practice and ongoing collaboration with the host institute was assessed. The fellows selected between 2014 and 2018 were included. Ratings were analysed in percentage; thematic analysis was applied to the free-text feedbacks using qualitative analysis.Results: All the fellows had good access to observing in operating theatres and 70.6% were able to assist. 91.2% participated in educational activities and 23.5% were able to contribute through teaching. 44.1% participated in research activities and 41.2% became an author/co-author of a publication from the host. 97.1% of fellows stated that their operative competency had increased, 94.3% gained new surgical skills and 85.7% was able to introduce new techniques in their hospitals. 74.29% agreed that the clinical experience led to a change in their practices. The most commonly suggested improvements were setting realistic target in clinical and research areas, increasing fellowship duration, and maximising theatre assisting opportunities. Nevertheless, 100% of fellows would recommend the fellowship to their peers.Conclusion: EAES fellowship programme has shown a positive impact on acquiring and adopting new MIS techniques. To further refine the programme, an individualised approach should be adopted to set achievable learning objectives in clinical skills, education and research.</p

Assessment of Overactive Bladder after Laparoscopic Lateral Suspension for Pelvic Organ Prolapse

Background. Pelvic organ prolapses (POP) and overactive bladder (OAB) may coexist and both negatively impact quality of life in women. The correlation between POP and OAB remains unclear, but these patients may have the OAB resolution after the surgical treatment of POP. Aim of our study was to assess the anatomical results and the effect on OAB symptoms in women who underwent laparoscopic lateral suspension for POP. Materials and Methods. This prospective study included all women with apical POP who underwent surgical repair with laparoscopic uterine lateral suspension from January 2016 to December 2017. The baseline and the 1-year follow-up included post-void residual measurement, urinalysis, vaginal examination, OAB symptoms evaluation, and administration of questionnaires (PFDI-20, UDI 6). Results. 64 women underwent laparoscopic lateral suspension for uterine prolapse and 78.1% had concomitant anterior vaginal wall defect. At 1-year follow-up the anatomic success rates were 84.4% for the apical and 76.2% for the anterior compartment. The comparison between OAB symptoms before and after the surgical procedure showed the resolution of OAB in 76% of the women, while de novo OAB was present in 2.6%. With the questionnaires 95.3% (61/64) of our patients were satisfied after the POP repair. We documented a trend in ameliorating of OAB regardless of the POP-Q stage. However, the Pearson test showed this correlation as statistically significant only in women with anterior vaginal wall defect stage III and apical stage II. No patient had vaginal exposure of the polypropylene mesh. Conclusion. Our data show how laparoscopic lateral suspension is an effective procedure for apical and anterior vaginal wall defects. This study provides further evidence for the concept that OAB in women with POP >II stage improves after a successful POP surgery. These women may benefit from a resolution of OAB and POP symptoms with the improvement of patient’s quality of life

A Randomized Clinical Trial Comparing Dubuisson Laparoscopic Lateral Suspension with Laparoscopic Sacropexy for Pelvic Organ Prolapse: Short-Term Results

Background: Laparoscopic sacrocolpopexy (LSC) is the gold standard for the treatment of apical prolapse, although dissection of the promontory may be challenging. Laparoscopic lateral suspension (LLS) with mesh is an alternative technique for apical repair with similar anatomical and functional outcomes, according to recent studies. The purpose of this study was to compare these operative techniques. Methods: Women with uterine Pelvic Organ Prolapse Quantification (POP-Q) stage 2 were enrolled in this prospective study and were randomly allocated to the LLS or LSC group. At the 12-month follow-up, primary measures included both anatomical and functional outcomes. Perioperative parameters and complications were recorded. Results: A total of 93 women were randomized, 48 in the LLS group and 45 in the LSC group, with 2 women lost to follow-up in both groups. LSC anatomic success rates were 81.82% for the apical compartment and 95.22% for the anterior compartment. LLS anatomic success rates for the apical and anterior compartments were 90% and 92.30%, respectively. The mean operative time for LLS was 160.3 min, while for LSC it was 168.3 min. The mean blood loss was 100 mL in both procedures. Conversion to laparotomy was necessary in three women. Mesh erosion was not observed in any of the cases. In terms of the complication, Clavien–Dindo grade 1 was observed in two patients in the LLS group and a complication rated grade 3b was observed in one patient in LSC group. Conclusions: LLS is a good alternative to LSC, with promising anatomical and quality-of-life results

The role of the apical defect in the pathogenesis of pelvic organ prolapse: cystocele with apical defect

Publikacja recenzowana / Peer-reviewed publicationWprowadzenie: W uroginekologii, zarówno w literaturze, jak i w pracy klinicznej, stosowane są różne systemy oceny obniżenia narządów dna miednicy. Powoduje to trudności w planowaniu leczenia, jak również w ocenie skuteczności stosowanych metod operacyjnych. Do obiektywnej oceny stopnia zaburzeń statyki narządu płciowego służy skala POP-Q (Pelvic Organ Prolapse Quantification). Nie informuje ona jednak o rodzaju defektu. Z kolei podział kliniczny według DeLancey definiuje rodzaj defektu, wskazując anatomiczną przyczynę uszkodzenia, ale nie stopień jego nasilenia. Nie uwzględnia również pojęcia „cystocele z defektem apikalnym”. Materiał i metody: Autorzy zbadali 96 pacjentek, które zgłaszały się celem kwalifikacji do leczenia z powodu objawowego obniżenia narządów miednicy mniejszej. Zastosowano nowy, standaryzowany sposób badania uroginekologicznego. Badanie uwzględniało rodzaj defektu i stopień jego nasilenia na każdym z trzech poziomów dna miednicy. Wyniki: Ten sposób badania pozwolił zidentyfikować zarówno znane już cystocele z defektem środkowym i bocznym, jak również nieopisywane dotychczas cystocele z defektem apikalnym i mieszanym. Wnioski: Autorzy proponują nowy sposób badania uroginekologicznego z jednoczesnym zastosowaniem skali POP-Q i zmodyfikowanej klasyfikacji obniżenia narządów miednicy mniejszej według DeLancey, uwzględniającej wpływ defektu na poziomie I, czyli defektu apikalnego, na obniżenie na poziomie II. Wydaje się, iż taki sposób postępowania daje możliwość skuteczniejszego planowania zabiegów uroginekologicznych, ograniczając jednocześnie odsetek wznów.Introduction: In urogynecology, both in subject literature and in clinical work, different systems for the assessment of pelvic organ prolapse are used. The lack of standardization causes difficulties in treatment planning and in the evaluation of the effectiveness of applied surgical methods. The most commonly used scale is the POP-Q System which describes the severity of the prolapse without taking the type of defect into account. On the other hand, the clinical classification by DeLancey defines the type of defect but does not take its severity into account. The latter classification system also does not include cystocele with apical defect. Material and methods: The authors examined 96 patients presenting for advice of treatment due to symptomatic pelvic floor disease. A new, standardized method of urogycological examination was implemented. The evaluation included the type of defect and its severity at all three pelvic floor levels. Results: This method of examination allowed the identification of both already known cystocele with middle and lateral defects, as well as not yet described cystocele with apical and mixed defects. Conclusions: The authors propose a new, standardized method of urogynecological examination which assumes the simultaneous application of the POP-Q System and the modified classification of lower pelvic organ prolapse by DeLancey which also describes the impact of level I defects (apical defects) on level II prolapse. It seems that this approach allows for more effective planning of urogynecological procedures, while reducing the rate of recurrence

The role of the apical defect in the parthenogenesis of pelvic organ prolapse: cystocele with apical defect

Wprowadzenie: W uroginekologii, zarówno w literaturze, jak i w pracy klinicznej, stosowane są różne systemy oceny obniżenia narządów dna miednicy. Powoduje to trudności w planowaniu leczenia, jak również w ocenie skuteczności stosowanych metod operacyjnych. Do obiektywnej oceny stopnia zaburzeń statyki narządu płciowego służy skala POP-Q (Pelvic Organ Prolapse Quantifi cation). Nie informuje ona jednak o rodzaju defektu. Z kolei podział kliniczny według DeLancey defi niuje rodzaj defektu, wskazując anatomiczną przyczynę uszkodzenia, ale nie stopień jego nasilenia. Nie uwzględnia również pojęcia „cystocele z defektem apikalnym”. Materiał i metody: Autorzy zbadali 96 pacjentek, które zgłaszały się celem kwalifi kacji do leczenia z powodu objawowego obniżenia narządów miednicy mniejszej. Zastosowano nowy, standaryzowany sposób badania uroginekologicznego. Badanie uwzględniało rodzaj defektu i stopień jego nasilenia na każdym z trzech poziomów dna miednicy. Wyniki: Ten sposób badania pozwolił zidentyfi kować zarówno znane już cystocele z defektem środkowym i bocznym, jak również nieopisywane dotychczas cystocele z defektem apikalnym i mieszanym. Wnioski: Autorzy proponują nowy sposób badania uroginekologicznego z jednoczesnym zastosowaniem skali POP-Q i zmodyfi kowanej klasyfi kacji obniżenia narządów miednicy mniejszej według DeLancey, uwzględniającej wpływ defektu na poziomie I, czyli defektu apikalnego, na obniżenie na poziomie II. Wydaje się, iż taki sposób postępowania daje możliwość skuteczniejszego planowania zabiegów uroginekologicznych, ograniczając jednocześnie odsetek wznów.Introduction: In urogynecology, both in subject literature and in clinical work, different systems for the assessment of pelvic organ prolapse are used. The lack of standardization causes diffi culties in treatment planning and in the evaluation of the effectiveness of applied surgical methods. The most commonly used scale is the POP-Q System which describes the severity of the prolapse without taking the type of defect into account. On the other hand, the clinical classifi cation by DeLancey defi nes the type of defect but does not take its severity into account. The latter classifi cation system also does not include cystocele with apical defect. Material and methods: The authors examined 96 patients presenting for advice of treatment due to symptomatic pelvic fl oor disease. A new, standardized method of urogycological examination was implemented. The evaluation included the type of defect and its severity at all three pelvic fl oor levels. Results: This method of examination allowed the identifi cation of both already known cystocele with middle and lateral defects, as well as not yet described cystocele with apical and mixed defects. Conclusions: The authors propose a new, standardized method of urogynecological examination which assumes the simultaneous application of the POP-Q System and the modifi ed classifi cation of lower pelvic organ prolapse by DeLancey which also describes the impact of level I defects (apical defects) on level II prolapse. It seems that this approach allows for more effective planning of urogynecological procedures, while reducing the rate of recurrence

Late Diagnosis of Swyer Syndrome in a Patient with Bilateral Germ Cell Tumor Treated with a Contraceptive Due to Primary Amenorrhea

Swyer syndrome is a special form of DSD (disorders of sex development), so-called pure gonadal dysgenesis with a karyotype 46, XY and a female phenotype. One of the most important problems in patients with DSD is the risk of gonadal tumors. We present a case of a 26-year-old patient with Swyer syndrome. The patient had primary amenorrhea and no puberty characteristics. In ultrasound imaging in the vicinity of the uterus, there were two homogeneous structures. A genetic diagnosis was also performed, which showed karyotype 46, XY. The patient underwent a bilateral gonadectomy. Histopathological examination revealed the presence of dysgerminoma in both dysgenetic gonads. The follow-up of five years now did not show any changes suspected of invasion. We concluded that the primary amenorrhea, along with the absence of development of sexual characteristics, should prompt an expanded diagnosis for disorders of sex development. Gonadal dysgerminoma should be suspected even in the absence of tumor features on ultrasound and blood laboratory tests. Early prophylactic gonadectomy could protect patients from developing tumors in dysgenetic gonads

Wound dehiscence prevalence and relationship with prosthetic material extrusion in women underwent anterior colpotomy

Aim: To assess the prevalence of anterior vaginal wall dehiscence in women who underwent anterior vaginal wall colpotomy for pelvic organ prolapse or stress urinary incontinence and to evaluate the influence of suture materials and techniques on wound dehiscence.Materials and Methods: This multicenter, prospective study enrolled naive women for urogynecological surgery affected by anterior vaginal wall defect or stress urinary incontinence. Performed surgical procedures were anterior vaginal wall repair (AVWR) with native tissue (N-AVWR) or polypropylene mesh (M-AVWR), trans-obturator polypropylene in-out middle urethral sling (MUS). Used suture materials were Vicryl 2-0, Vicryl Rapide 2-0, and Monocryl 3-0. Suture techniques were running interlocking or interrupted. Follow-up was performed daily during hospitalization and in outpatient clinic after 10-14, 30 days, and after 3 months.Results: A total of 1139 patients were enrolled. AVWR were 790: 89.1% N-AVWR, and 10.9% M-AVWR. Polypropylene MUS were 349. Women with prosthetic implantation were 38.2%, while 61.8% had native tissue repair. Overall Vicryl was used in 53.9%, Vicryl Rapide in 37.4%, and Monocryl in 8.7%. Overall running interlocking sutures were 66.5%, while interrupted were 33.5%. Overall wound dehiscence prevalence was 0.9% (10/1139). Wound dehiscence rate of 0.6% (5/790) was documented in AVWR: 0.3% (2/704) in N-AVWR, and 3.5% (3/86) in M-AVWR. Among women underwent MUS, 1.4% (5/349) showed wound dehiscence. In patients who underwent prosthetic surgery, the overall dehiscence prevalence was 1.8% (8/435). A statistically significant higher rate of wound dehiscence was found in women with implanted prosthetic materials.Discussion: We reported for the first time the prevalence of wound dehiscence in females who underwent colpotomy for AVWR or MUS. Wound dehiscence occurrence was low, but non-negligible. We found that this complication was poorly associated to the suture methods and materials, while prosthetic material represented a risk factor for wound healing

Państwo i Społeczeństwo nr 4, 2017 : Medycyna i zdrowie publiczne

ZE WSTĘPU: Niniejszy numer „Państwa i Społeczeństwa”, poświęcony medycynie i zdrowiu publicznemu, zawiera cztery prace oryginalne, pięć poglądowych i jeden opis przypadku. Istotne miejsce zajmują w nim prace przedstawione podczas XVII Konferencji Naukowej „Państwo, gospodarka, społeczeństwo” w Krakowskiej Akademii im. Andrzeja Frycza Modrzewskiego w czerwcu 2017 r