Robotically assisted laparoscopic repair of anterior vaginal wall and uterine prolapse by lateral suspension with mesh: initial experience and video

Abstract Introduction and hypothesis 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. Methods 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. Results POP repair was successfully completed in all ten patients without any perioperative or postoperative complication. Conclusion 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. Keywords Pelvic organ prolapse . Sacrocolpopexy . Hysteropexy . Robotic surgery . da Vinci system . Uterine prolapse Aim of the video Sacral colpopexy/hysteropexy is the method of choice for the treatment of apical vaginal and uterine prolapse. It was the first technique described to treat pelvic organ prolapse (POP) with robotic assistance. It offers similar results as abdominal sacrocolpopexy Electronic supplementary material The online version of this articl

Laparoscopic repair of vaginal vault prolapse by lateral suspension with mesh

Background: To evaluate the long-term outcomes of laparoscopic lateral suspension using mesh reinforcement for symptomatic posthysterectomy vaginal vault prolapse. Materials and methods: We analyzed in a prospective cohort study all the women treated by laparoscopic lateral suspension with mesh for symptomatic vaginal vault prolapse between January 2004 and September 2010. In this procedure, the mesh is laterally suspended to the abdominal wall, posterior to the anterior superior iliac spine. We performed systematic follow-up examinations at 4weeks, 6months and yearly postoperatively. Clinical evaluation of pelvic organ support was assessed by the pelvic organ prolapse quantification (POP-Q) grading system. Main outcome measures were recurrence rate, reoperation rate for symptomatic recurrence or de novo prolapse, mesh erosion rate, reoperation rate for mesh erosion, total reoperation rate. Observations and results: Of the 73 patients seen at a mean 17.5months follow-up, recurrent vaginal vault prolapse was registered in only one woman (success rate of 98.6%). When considering all vaginal sites, we observed a total of 13 patients with recurrent or de novo prolapse (17.8%). The non-previously treated posterior compartment was involved in eight cases (new appearance rate of 11%). Of these 13 women, only 6 were symptomatic, requiring surgical management (reoperation rate for genital prolapse of 8.2%). Four patients presented with mesh erosion into the vagina (5.5%). Two required partial vaginal excision of the mesh in the operating room (2.7%). There were no mesh-related infections. The total reoperation rate was 11%. Conclusion: Laparoscopic lateral suspension with mesh interposition is a safe and effective technique for the treatment of vaginal vault prolapse. This approach represents an alternative procedure to the laparoscopic sacrocolpopex

Incidence and risk factors for reoperation of surgically treated urinary incontinence

Introduction and hypothesis: The objective of our study was to estimate the incidence and to identify the risk factors for reoperation of surgically treated stress urinary incontinence (SUI). Methods: We conducted a nested case-control study among 1,132 women who underwent SUI surgery from January 1988 to June 2007. Cases (n = 35) were women who required reoperation for SUI following the first intervention up to December 2008. Controls (n = 89) were women randomly selected from the same cohort who did not require reoperation. Results: The cumulative incidence of SUI reoperation was 3.1% with a mean follow-up of 10.9years (range 1.7-21.0). The main risk factor was the history of more than one vaginal delivery [adjusted odds ratio (OR) 3.5; 95% confidence interval (CI) 1.0-12.6]. The use of synthetic midurethral slings was a protective factor compared to other surgical procedures for urinary incontinence (adjusted OR 0.1; 95% CI 0.0-0.6). Conclusions: The risk of reoperation after SUI surgery appears to be low and associated with multiple vaginal deliveries. Synthetic slings at index surgery are associated with a lower risk of reoperatio

Robotically assisted laparoscopic repair of anterior vaginal wall and uterine prolapse by lateral suspension with mesh: initial experience and video

Introduction and hypothesis: 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. Methods: 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. Results: POP repair was successfully completed in all ten patients without any perioperative or postoperative complication. Conclusion: 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

Incidence and risk factors for reoperation of surgically treated pelvic organ prolapse

Introduction and hypothesis: The objective of our study was to estimate the incidence and to identify the risk factors for reoperation of surgically treated pelvic organ prolapse (POP). Methods: We conducted a nested case-control study among 1,811 women who underwent POP surgery from January 1988 to June 2007. Cases (n = 102) were women who required reoperation for POP following the first intervention through December 2008. Controls (n = 226) were women randomly selected from the same cohort who did not require reoperation. Results: The incidence of POP reoperation was 5.1 per 1,000 women-years. The cumulative incidence was 5.6%. Risk factors included preoperative prolapse in more than two vaginal compartments (adjusted OR 5.2; 95% CI 2.8-9.7), history of surgery for POP and/or urinary incontinence (adjusted OR 3.2; 95% CI 1.5-7.1), and sexual activity (adjusted OR 2.0; 95% CI 1.0-3.7). Conclusions: The risk of POP reoperation is relatively low and is associated with preexisting weakness of pelvic tissue

Incidence rate and risk factors for vaginal vault prolapse repair after hysterectomy

Our objective was to estimate the incidence and identify the risk factors for vaginal vault prolapse repair after hysterectomy. We conducted a case control study among 6,214 women who underwent hysterectomy from 1982 to 2002. Cases (n = 32) were women who required vaginal vault suspension following the hysterectomy through December 2005. Controls (n = 236) were women, randomly selected from the same cohort, who did not require pelvic organ prolapse surgery. The incidence of vaginal vault prolapse repair was 0.36 per 1,000 women-years. The cumulative incidence was 0.5%. Risk factors included preoperative prolapse (odds ratio (OR) 6.6; 95% confidence interval (CI) 1.5-28.4) and sexual activity (OR 1.3; 95% CI 1.0-1.5). Vaginal hysterectomy was not a risk factor when preoperative prolapse was taken into account (OR 0.9; 95% CI 0.5-1.8).Vaginal vault prolapse repair after hysterectomy is an infrequent event and is due to preexisting weakness of pelvic tissue

Complications associated with transobturator sling procedures: analysis of 233 consecutive cases with a 27 months follow-up

<p>Abstract</p> <p>Backround</p> <p>The transobturator tape procedure (TOT) is an effective surgical treatment of female stress urinary incontinence. However data concerning safety are rare, follow-up is often less than two years, and complications are probably underreported. The aim of this study was to describe early and late complications associated with TOT procedures and identify risk factors for erosions.</p> <p>Methods</p> <p>It was a 27 months follow-up of a cohort of 233 women who underwent TOT with three different types of slings (Aris^®, Obtape^®, TVT-O^®). Follow-up information was available for 225 (96.6%) women.</p> <p>Results</p> <p>There were few per operative complications. Forty-eight women (21.3%) reported late complications including <it>de novo </it>or worsening of preexisting urgencies (10.2%), perineal pain (2.2%), <it>de novo </it>dyspareunia (9%), and vaginal erosion (7.6%). The risk of erosion significantly differed between the three types of slings and was 4%, 17% and 0% for Aris^®, Obtape^®and TVT-O^®respectively (P = 0.001). The overall proportion of women satisfied by the procedure was 72.1%. The percentage of women satisfied was significantly lower in women who experienced erosion (29.4%) compared to women who did not (78.4%) (RR 0.14, 95% CI 0.05-0.38, P < 0.001).</p> <p>Conclusion</p> <p>Late post operative complications are relatively frequent after TOT and can impair patient's satisfaction. Women should be informed of these potential complications preoperatively and require careful follow-up after the procedure. Choice of the safest sling material is crucial as it is a risk factor for erosion.</p

Comparison of gene expression profiles in core biopsies and corresponding surgical breast cancer samples

INTRODUCTION: Gene expression profiling has been successfully used to classify breast cancer into clinically distinct subtypes, and to predict the risk of recurrence and treatment response. The aim of this study was to investigate whether the gene expression profile (GEP) detected in a core biopsy (CB) is representative for the entire tumor, since CB is an important tool in breast cancer diagnosis. Moreover, we investigated whether performing CBs prior to the surgical excision could influence the GEP of the respective tumor. METHODS: We quantified the RNA expression of 60 relevant genes by quantitative real-time PCR in paired CBs and surgical specimens from 22 untreated primary breast cancer patients. Subsequently, expression data were compared with independent GEPs obtained from tumors of 317 patients without preceding CB. RESULTS: In 82% of the cases the GEP detected in the CB correlated very well with the corresponding profile in the surgical sample (r(s )≥ 0.95, p < 0.001). Gene-by-gene analysis revealed four genes significantly elevated in the surgical sample compared to the CB; these comprised genes mainly involved in inflammation and the wound repair process as well as in tumor invasion and metastasis. CONCLUSION: A GEP detected in a CB are representative for the entire tumor and is, therefore, of clinical relevance. The observed alterations of individual genes after performance of CB deserve attention since they might impact the clinical interpretation with respect to prognosis and therapy prediction of the GEP as detected in the surgical specimen following CB performance

Is intracrinology of endometriosis relevant in clinical practice?:A systematic review on estrogen metabolism

Endometriosis is a chronic, multifactorial, estrogen-dependent disease. The abnormal endocrine microenvironment of endometriosis lesions is considered a main feature and multiple enzymatic pathways leading to local increased synthesis of estrogens have been identified. However, the relevance of intracrinology in clinical practice is still lacking. Medline, Embase, Scopus database were systematically searched for studies reporting on local estrogens metabolism of endometriotic lesions. The main enzymatic pathways involved in the intracrinology of endometriosis such as aromatase (CYP19A1), 17β-hydroxysteroid dehydrogenase (HSD17B) type 1, type 2 and type 5, steroid sulfatase (STS), estrogen sulfotransferase (SULT1E1) were assessed with a critical perspective on their role in disease endocrine phenotyping, drug resistance and as therapeutic targets. Overall, studies heterogeneity and missing clinical data affect the interpretation of the clinical role of these enzymes. Although the use of some drugs such as aromatase inhibitors has been proposed in clinical practice for two decades, their potential clinical value is still under investigation as well as their modality of administration. A closer look at new, more realistic drug targets is provided and discussed. Altered expression of these key enzymes in the lesions have far reaching implication in the development of new drugs aimed at decreasing local estrogenic activity with a minimal effect on gonadal function; however, given the complexity of the evaluation of the expression of the enzymes, multiple aspects still remains to be clarified. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022311329, identifier CRD42022311329

Unadjusted HRs of studies (white circles) and pooled HRs (black boxes) of death for urinary incontinence by (published) UI severity.

<p>Circle-sizes are inversely proportional to studies' standard error. UI severity subgroups are bounded by solid lines. UI: urinary incontinence.</p