Pelvic Prolapse in Gynecology

Long-term outcome of vaginal sacrospinous colpopexy for marked uterovaginal and vault prolapse.
Hefni MA, El-Toukhy TA
Eur J Obstet Gynecol Reprod Biol. 2005 Dec 22;.

BACKGROUND: This study was carried out to evaluate the safety and long-term outcome of sacrospinous colpopexy in marked genital prolapse. SETTING: Gynaecology Department, Benenden Hospital, Kent, UK. METHODS: A prospective observational study was conducted between September 1993 and May 2000 on 305 women who underwent transvaginal sacrospinous colpopexy. The indications for surgery were marked vault prolapse in 43% and uterovaginal prolapse or enterocele in 57%. Patient follow up was at 6 weeks, 6 months, 1 year and then annually. Data was collected prospectively at the time of initial recruitment, during hospital stay and at the end of each follow up visit. RESULTS: Hysterectomy was performed in 117 patients and anterior colporrhaphy in 182. The mean operative time for the entire surgery was 65.6min (S.D. 27.4, range 20-160min) and estimated blood loss was 81.8ml (S.D. 92, range 20-800ml). After a mean follow up period of 57 months (range 24-84), vault support was maintained in 96%; recurrent vault prolapse occurred in 12 patients (4%) and the mean vaginal length at 1 and 5 years of follow up was 8+/-0.9 and 7.8+/-1.2cm. Symptomatic cystocele occurred in 15 patients (5%). There were six recurrences of rectocele (2%) and there was no enterocele recurrence. Sexual function was maintained in all sexually active women and 43% reported improvement in sexual function. Out of 14 women who complained of fecal incontinence, 10 (71%) reported cure and 3 (21%) improved after surgery. CONCLUSIONS: Vaginal sacrospinous colpopexy is associated with a high long-term success rate in correcting upper genital prolapse.

Treatment of genital prolapse by hammock using porcine skin collagen implant (Pelvicol).
David-Montefiore E, Barranger E, Dubernard G, Detchev R, Nizard V, Darai E
Urology. 2005 Dec;66(6):1314-8.

INTRODUCTION: To assess the feasibility and efficacy of the hammock using a porcine skin collagen (Pelvicol) implant for the treatment of genital prolapse by the vaginal route. A total of 47 women with Stage III or IV genital prolapse underwent surgical treatment with porcine skin collagen implantation using anterior transobturator and posterior bilateral sacrospinous fixations. Genital prolapse treatment was combined with hysterectomy in 34 patients (72%). TECHNICAL CONSIDERATIONS: Porcine skin collagen implantation was feasible in every case. The surgical procedure lasted a median of 90 minutes (range 80 to 150). No vessel injuries, one bladder injury, and one rectal injury not requiring additional surgery occurred. One pararectal hematoma required a second procedure. The median follow-up was 24.6 +/- 8.5 months (range 6 to 42). No rejection of the porcine grafts occurred. Of the 47 women, 39 (83%) had optimal anatomic results, 5 had asymptomatic Stage I prolapse, and 2 had Stage II prolapse. The subjective cure rate was 93.6% (44 of 47 patients). The postoperative scores for lifestyle and urinary discomfort improved significantly after the procedure (P < 0.0001 and P < 0.0002, respectively). Of the 18 patients who were sexually active, an improvement in sexual discomfort occurred (P = 0.04). CONCLUSIONS: These short-term results suggest that hammock using porcine skin collagen implantation by the transobturator route and bilateral sacrospinous fixation is a safe and effective treatment for genital prolapse.

Surgical outcome of abdominal sacrocolpopexy with synthetic mesh versus abdominal sacrocolpopexy with cadaveric fascia lata.
Gregory WT, Otto LN, Bergstrom JO, Clark AL
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):369-74. Epub 2005 Jan 12.

Nineteen women who had an abdominal sacrocolpopexy (ASC) with synthetic mesh and 18 women who had an ASC with freeze-dried, irradiated cadaveric fascia lata returned for blinded pelvic organ prolapse quantification (POPQ) examinations. The mean relative vaginal descent (delta) from perfect total vaginal length in the mesh group was 1.1 (0.3) cm, and the delta in the fascia group was 2.8 (0.8) cm (p=0.02, Mann-Whitney U). The proportion of women with "optimal" surgical outcome in the mesh group was 89% and 61% in the fascia group (p=0.06, Fischer's exact test). This study suggests that cadaveric fascia lata may not be a good choice for ASC.

Patient characteristics and management of dermal allograft extrusions.
Drake NL, Weidner AC, Webster GD, Amundsen CL
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):375-7. Epub 2005 Jan 13.

The objective of this study was to describe our rate of extrusion of dermal allograft material when used in anterior or posterior colporrhaphy and to review our success in treating extrusions with conservative management. A retrospective review of all subjects who underwent vaginal reconstruction using dermal allograft material from 1 January 2000 to 31 August 2003 was performed. Demographics, medical history, and follow-up were evaluated. For subjects who developed an extrusion, treatment details were recorded. Sixty-nine subjects underwent colporrhaphy using dermal allograft material during the defined time period: 21 anterior, 45 posterior, and 3 both. Five subjects did not appear for follow-up. Seven subjects (10.9%) developed an extrusion: three subjects anteriorly and four subjects posteriorly. There were no differences between subjects with and without extrusions based on recorded risk factors. Median time to the discovery of extrusion was 4 weeks (range: 1-6 weeks). All patients were managed with estrogen vaginal cream. Median documented healing time was 13 weeks (range: 5-40 weeks), and no serious morbidity was encountered. Graft extrusion is an uncommon complication when reinforcing vaginal tissue with dermal allograft material and can be safely and effectively managed with vaginal estrogen and expectant management.

Prolapse of neovagina created with labia minora: a case report.
Coulon C, Orazi G, Nayama M, Cosson M
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):409-11. Epub 2005 Jan 13.

Prolapse of a neovagina created in patients with congenital vaginal aplasia is rare. A 55-year-old woman with a neovagina was referred for management of complete prolapse and stress urinary incontinence. At the age of 19 she had undergone surgery for creation of a neovagina using the labia minora. She accepted vaginal surgical treatment to correct her prolapse. A posterior intravaginal slingplasty was successfully performed, associated with tension-free vaginal tape through the obturator foramens. There is no other case of prolapse of a labia minora neovagina described in the literature. The common procedures were not adapted in this case. Indeed, the vaginal tissues were extremely fragile, making the dissection more difficult. The vaginal approach sounded interesting to us to correct this prolapse.

Risk factors for mesh erosion after transvaginal surgery using polypropylene (Atrium) or composite polypropylene/polyglactin 910 (Vypro II) mesh.
Achtari C, Hiscock R, O'Reilly BA, Schierlitz L, Dwyer PL
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):389-94. Epub 2005 Jan 19.

The objective of this study was to identify the risk factors associated with the occurrence of mesh erosion (ME) during the first 6 post-operative months in patients having undergone transvaginal repair of pelvic organ prolapse (POP) with Atrium or Vypro II mesh. We retrospectively reviewed the records of 198 consecutive patients who underwent vaginal reconstructive surgery reinforced either by Atrium or Vypro II mesh between February 1999 and July 2003. Univariable and multivariable logistic regression was performed to assess associations between measured covariates and ME. Fourteen patients [7.1%, 95% confidence interval (CI): 3.9-11.6] developed vaginal ME. We found that, in the Vypro II mesh patients, the surgeon experienced in the technique had less erosions than less experienced surgeons (2.9 vs 15.6%, p=0.02). There was no statistically significant difference between the monofilament polypropylene (Atrium) and the composite polypropylene/polyglactin 910 (Vypro II) mesh (7.2 vs 6.9%, p=0.41) when adjusted for surgeon experience and patient age. There was no association between mesh type (Atrium or Vypro II) and vaginal ME following transvaginal repair of POP. Surgeon experience and patient age were associated with ME.

Uterine prolapse in a young nulligravida with scleroderma and premature ovarian failure.
Vural B, Caliskan E, Doger E, Ercin C
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):415-7. Epub 2005 Jan 15.

We report a case of pelvic organ prolapse quantification (POPQ) stage III uterine prolapse in a 25-year-old nulligravida. Premature ovarian failure was diagnosed after 1 year of amenorrhea. Localized scleroderma was noticed on her thigh and lower back. We discuss the possible role of scleroderma and ovarian failure on the occurrence of uterine prolapse in light of the literature.

Increased expression of matrix metalloproteinase 2 in uterosacral ligaments is associated with pelvic organ prolapse.
Gabriel B, Watermann D, Hancke K, Gitsch G, Werner M, Tempfer C, Hausen AZ
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Dec 8;:1-5.

The uterosacral ligaments are an important part of the pelvic support system and connective tissue alterations are thought to contribute to the development of pelvic organ prolapse (POP). The objective of this study was to compare the expression of matrix metalloproteinases (MMPs) 1 and 2 in these ligaments in women with and without POP. We analyzed the tissue samples obtained from left and/or right uterosacral ligaments of 17 women with POP and 18 controls by immunohistochemistry. There was no difference in MMP-1 expression between women with POP and those without. In contrast, the MMP-2 expression was significantly related to the presence of POP (p=0.004) rather than to age or parity. There was no difference in MMP-1 and MMP-2 expression between left and right uterosacral ligaments in women with POP compared to controls. Our findings strongly indicate that increased MMP-2 expression in uterosacral ligaments is associated with POP.

The retroverted uterus: ignored to date but core to prolapse.
Haylen BT
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Dec 8;:1-4.

The retroverted uterus has been largely ignored in urogynaecological research to date. The prevalence of the retroverted uterus is 79% more common in the urogynaecological patient population (34%) than in the general gynaecological population (19%). Its diagnosis requires the use of (a) transvaginal ultrasound with (b) an empty bladder. Recent data demonstrate that the prevalence of grade 2-4 uterine prolapse for a retroverted uterus is 4.5 times that for an anteverted uterus. Alternatively, 69% grade 2-4 uterine prolapse involves the retroverted uterus. The retroverted uterus, when diagnosed by transvaginal ultrasound (bladder empty), is far more common in urogynecology patients due to their higher incidence of prolapse.

Acute pelvic organ prolapse in an 11-month-old infant.
Chien WH, Tseng MR, Lin YH
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Dec 17;:1-2.

There exist several reports of pelvic organ prolapse in high-risk neonates, but acute pelvic organ prolapse in a healthy infant has never been reported. In the current case, the parents first noted their 11-month-old infant with a mass protruding from the vagina after playing in a baby walker. Third-degree uterine prolapse was subsequently diagnosed after careful physical examination and pelvic ultrasonography. Under general anesthesia, the uterus was replaced after emptying the bladder. No sequelae were noted during 6 months of follow-up.

Translevator posterior intravaginal slingplasty: anatomical landmarks and safety margins.
Smajda S, Vanormelingen L, Vandewalle G, Ombelet W, de Jonge E, Hinoul P
Int Urogynecol J Pelvic Floor Dysfunct. 2005 Sep-Oct;16(5):364-8. Epub 2005 Jan 27.

The posterior intravaginal sling is a new tension-free needle suspension technique. It is used for the treatment of middle compartment (vaginal vault or uterine) prolapse. The Prolene sling suspends the vagina at the upper border of level II support as described by DeLancey (Am J Obstet Gynecol 166:1717, 1992). Human cadaveric dissections were undertaken to explore the pertinent anatomy that is involved when using this blind needle technique. Pre-dissected cadaveric material was used to obtain didactic illustrations of the anatomy of the procedure. Description of the surgical technique using anatomical landmarks and relative distances of the needle to these landmarks will improve the surgeon's visual understanding of the procedure. The measurements obtained demonstrate that the needle stays at a minimal distance of 4 cm away from the major (pudendal) vessels that could potentially cause life-threatening haemorrhage.

Regret, satisfaction, and symptom improvement: analysis of the impact of partial colpocleisis for the management of severe pelvic organ prolapse.
Wheeler TL 2nd, Richter HE, Burgio KL, Redden DT, Chen CC, Goode PS, Varner RE
Am J Obstet Gynecol 2005 Dec;193(6):2067-70.

OBJECTIVE: The purpose of this study was to assess a cohort of patients who underwent a colpocleisis procedure more than 1 year post operation to determine: 1) the proportion of patients who regretted having the procedure, 2) patient satisfaction with the procedure, and 3) changes in symptom severity after surgery. STUDY DESIGN: Using the University of Alabama at Birmingham (UAB) Genitourinary Disorders Center database, a prospective analysis was performed on 54 patients who underwent colpocleisis between August 1996 and April 2003. From August to October of 2004, participants were contacted by an investigator not involved with the surgery and were asked 1) "do you regret having your surgery, and, if so, why?," 2) "how satisfied are you with your progress (completely, somewhat, or not)?," and 3) to repeat the short form Incontinence Impact Questionnaire/Urogenital Distress Inventory (IIQ-7/UDI-6). RESULTS: Fifty-nine percent (32/54) of potential candidates participated in the study. Nine percent (3/32) of patients regretted having colpocleisis performed. Fifty-seven percent (16/28) were completely satisfied, 29% (8/28) somewhat satisfied, and 14% (4/28) not satisfied. Mean IIQ score improved significantly from 40.9 (+/-31.7) at baseline to 14.1 (+/-26.7) at last interview (P = .003). Mean UDI score improved significantly from 63.1 (+/-24.3) at baseline to 24.2 (+/-26.7) at last interview (P = .001). There was a negative correlation between change in UDI scores with time since procedure (r = -.397, P = .055) and age (r = -.435, P = .034). CONCLUSION: Few patients reported regret after partial colpocleisis. There was a high rate of patient satisfaction and significant symptom improvement more than a year post surgery. Stable but smaller improvements were reported with longer time from surgery and increasing age.

Local anesthesia with sedation for transvaginal correction of advanced genital prolapse.
Buchsbaum GM, Duecy EE
Am J Obstet Gynecol 2005 Dec;193(6):2173-6.

OBJECTIVE: The purpose of this study was to evaluate local anesthesia with sedation for vaginal surgery for advanced genital prolapse. STUDY DESIGN: Five sacrospinous ligament suspensions and 12 vaginal paravaginal defect repairs performed under local anesthesia in 2004 were identified. Medical records and patient satisfaction questionnaire were reviewed. Patient demographics, degree of prolapse, duration of surgery, hospital stay, and responses to an anesthesia satisfaction questionnaires were recorded. RESULTS: All repairs incorporated placement of dermal allograft. Concomitant procedures included: 6 tension-free vaginal tape (TVTs), 12 posterior and 4 enterocele repairs. Mean patient age was 66.1 years. All patients had prolapse of apex or anterior wall > or = grade 3. Mean OR time was 132 minutes. Average hospital stay was 1.2 days. No patient was converted to general anesthesia. All 17 patients were "very satisfied" with their surgical experience. CONCLUSION: Local anesthesia with sedation can be successfully employed for most vaginal reconstructive surgeries with advanced genital prolapse. Patients report a high level of satisfaction.

Pelvic Organ Prolapse Complicating Third Trimester Pregnancy. A Case Report.
Meydanli MM, Ustun Y, Yalcin OT
Gynecol Obstet Invest 2005 Nov 29;61(3):133-134.

The concomitant phenomenon of a third trimester pregnancy with a significant degree of pelvic organ prolapse is extremely rare. We report on a patient with pelvic organ prolapse complicating third trimester pregnancy treated by concomitant cesarean hysterectomy and abdominal sacrocolpopexy. A 30-year-old woman, gravida 6, parity 5, was admitted to the hospital with uterine contractions in week 35 of gestation. Pelvic examination in the dorsal lithotomy position revealed a stage 3 pelvic organ prolapse. A cesarean hysterectomy was performed. After hysterectomy, the vaginal cuff was suspended to the periosteum overlying the sacral promontory. Cesarean hysterectomy might be a therapeutic option for women who have completed their families and are suffering from severe pelvic organ prolapse complicating third trimester pregnancy, particularly in developing countries where access to health care is limited. Copyright (c) 2006 S. Karger AG, Basel.

Uterus-sparing vaginal surgery of genitourinary prolapse employing biocompatible material.
Nicita G, Li Marzi V, Filocamo MT, Dattolo E, Marzocco M, Paoletti MC, Villari D
Urol Int 2005;75(4):314-8.

Objective: The study presents an original uterus sparing technique for transvaginal repair of total genitourinary prolapse. The technique employs a synthetic mesh of mixed polypropylene and 910 polyglactin fibers. Methods: The prosthesis creates a support for the cystocele, the cervix and the enterocele. It has four anchoring sites: two at the rear in the sacrospinous ligaments and two at the front in the arcus tendineous of the levator ani muscle. Between February 2001 and December 2004, 24 patients (mean age 66.9 years), presenting symptoms of uterine prolapse, cystocele and enterocele (POP-Q stage III-IV Aa associated to II-III-IV C), were treated with our procedure. Pre- and postoperative parameters were evaluated statistically. Results: No patient had any serious complications. The mean follow-up was 31.1 months (range 6-52). 19 patients (79.1%) have shown excellent results and have been completely cured. In 5 other cases (20.8%), the cystocele was completely cured and there was a significant improvement in the hysterocele and the enterocele. One patient required surgical treatment for postoperative stress incontinence. Statistical analysis of data regarding the pre- and postoperative prolapse stage demonstrated a high degree of objective cure rates (p < 0.0001). Conclusions: While hysterectomy remains the habitual treatment for severe uterine prolapse, our technique provides a promising alternative solution. It is also significant that there were no complications of erosion or infection associated with the prosthesis.

Anatomical outcome and quality of life following posterior vaginal wall prolapse repair using collagen xenograft.
Altman D, Lopez A, Gustafsson C, Falconer C, Nordenstam J, Zetterstrom J
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul-Aug;16(4):298-303. Epub 2005 Apr 5.

The aim of this study was to evaluate quality of life, sexual function, and anatomical outcome after posterior vaginal wall prolapse repair using a collagen xenograft. Thirty-three patients were evaluated preoperatively and at 6 and 12 months follow-up (FU). Quality of life and sexual function were assessed using a self-reported questionnaire. Prolapse staging was performed using the pelvic organ prolapse quantification system (POPQ). Preoperatively 3 patients had stage I, 26 patients stage II, and 4 patients stage III prolapse of the posterior vaginal wall. Prolapse of the posterior vaginal wall > or = stage II was observed in 7 patients (21%) at the 6-month FU and in 13 patients (39%) at the 12-month FU. Mean point Bp was reduced from -1.1 preoperatively to -2.5 at 6 months FU (p < 0.01) and -1.8 at 12 months FU (p < 0.01). Previous abdominal surgery was associated with a less favorable anatomical outcome (odds ratio: 2.0, 95% confidence interval: 1.5-3.8). There were no significant changes in sexual function or dyspareunia during the 1-year FU. Preoperatively 76% of the patients reported a negative impact on quality of life as a result of genital prolapse. There was a significant improvement in several variables associated with quality of life at 6 and 12 months FU. Posterior vaginal wall prolapse repair using a collagen xenograft was associated with an unsatisfying anatomical outcome at 1-year FU although several quality of life-associated variables affecting psychosocial function were improved. Improvement was not restricted to postoperative restoration of vaginal topography, and previous surgery had a negative effect on anatomical outcome.

Safety and effectiveness of Colpexin Sphere in the treatment of pelvic organ prolapse.
Lukban JC, Aguirre OA, Davila GW, Sand PK
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 19;:1-6.

Our objective was to determine the safety and effectiveness of Colpexin Sphere in women with advanced genital prolapse. A total of 39 subjects were enrolled in our prospective multicenter clinical trial, and 27 completed the full 16-week assessment. At baseline, subjects were fitted with a sphere, instructed on insertion and removal, and educated on a regimen of pelvic floor muscle exercises performed with the device in place. Efficacy was evaluated by a baseline vs 16-week comparison of pelvic organ prolapse staging and pelvic floor muscle strength assessment. Safety evaluation included, but was not limited to, an assessment of vaginal mucosal integrity. Subjects also completed a patient satisfaction questionnaire at the end of the study. Improvement in the prolapse of at least one vaginal segment was seen in 81.5% of the subjects, while 63% exhibited improved muscle function on digital examination at 16 weeks. Twenty-five (92.6%) would recommend the device to treat prolapse, and most found it easy to insert (96.3%) and remove (100%). In short-term usage, problems with urination (29.6%) and defecation (72%) were reported, primarily due to device displacement. Two subjects developed superficial vaginal mucosal ulceration, which resolved spontaneously. No significant adverse events were reported.

Laparoscopic sacral suture hysteropexy for uterine prolapse.
Krause HG, Goh JT, Sloane K, Higgs P, Carey MP
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 30;:1-4.

This study aims to describe and review a new method of uterine conservation in pelvic reconstruction for women with uterine prolapse. This is a prospective study of women who have undergone laparoscopic sacral suture hysteropexy. Structured questions, visual analogue patient satisfaction score (VAS), and vaginal examination were undertaken. Follow-up was performed by non-surgical reviewers. From July 2001 until August 2003, a total of 81 women underwent laparoscopic sacral suture hysteropexy for uterine prolapse. At a mean of 20.3 months follow-up, 76 women (93.8%) were available for questioning and 57 (70.3%) attended for examination. Sixty-five women (87.8%) had no symptoms of pelvic floor prolapse, 54 women (94.7%) had no objective evidence of uterine prolapse, and 61 women (82.4%) were satisfied with their surgery (VAS>/=80%). Laparoscopic sacral suture hysteropexy attaches the posterior cervix to the sacral promontory via the right uterosacral ligament. Follow-up data of laparoscopic sacral suture hysteropexy indicate it to be an effective method in the management of uterine prolapse.

Not the surgery for a young person: women's experience with vaginal closure surgery for severe prolapse.
O'Dell KK, Jacelon CS
Urol Nurs 2005 Oct;25(5):345-51.

INTRODUCTION: Vaginal prolapse can be debilitating, due to pelvic organ prolapse and herniation of the bladder, uterus, intestines and/or support tissues in the vaginal opening. However, there is little published information that documents women's experiences in the months and years after surgery to correct prolapse. OBJECTIVE: This phenomenologic study aimed to increase understanding of the specific experiences that patients report after vaginal closure surgery. METHOD: Participants were recruited via a mailing to surgical patients from a large urogynecologic practice. Semi-structured interviews were tape-recorded and transcribed for analysis. RESULTS: Six women participated in the study. After analyzing the results, five major themes emerged: awareness and confusion, feeling alone in silence, trusting recommendation, acceptance of changed sexuality, and still coping. CONCLUSIONS: This small study shows that vaginal closure affects an intimate body part and can impact self-image, but the women did not regret their changed sexuality. The larger issues for these women were ones of communication, information, and isolation, particularly during their followup care.

Transvaginal mesh technique for pelvic organ prolapse repair: mesh exposure management and risk factors.
Collinet P, Belot F, Debodinance P, Ha Duc E, Lucot JP, Cosson M
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 15;:1-6.

Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is not devoid of tolerability-related problems such as vaginal erosion. The purposes of our study are to define the risk factors for exposure of the mesh material, to describe advances and to recommend a therapeutic strategy. Two hundred and seventy-seven patients undergoing surgery due to pelvic prolapse with transvaginal mesh technique were included in a continuous, retrospective study between January 2002 and December 2003. Thirty-four cases of mesh exposure were observed within the 2 months following surgery, which represents an incidence of 12.27%. All the patients were medically treated, nine of whom were found to have completely healed during the check-up performed at 2 months. In contrast, 25 patients required partial mesh exeresis. Risk factors of erosion were concomitant hysterectomy [OR=5.17 (p=10(-3))] and inverted T colpotomy [OR=6.06 (p=10(-2))]. Two technical guidelines can be defined from this study as regards the surgical procedure required in order to limit mesh exposure via the vaginal route. The uterus must be preserved, and the number and extent of colpotomies needed to insert the mesh must be limited.

Vaginal vault prolapse: Choice of operation.
Arbel R, Lavy Y
Best Pract Res Clin Obstet Gynaecol 2005 Oct 9;.

The surgeon who faces a patient with vaginal vault prolapse is dealing with a complex and intriguing challenge. Part of the complexity is due to the lack of standardization and routine application of tools to assess pre- and postoperative anatomical and functional outcomes. Patient satisfaction is a major endpoint for surgical success; thus all aspects of the prolapse pathology and the patient's lifestyle should be considered. The surgeon needs to be well versed and flexible in order to choose the most appropriate operative approach to achieve optimal results for an individual patient. In this chapter we present the vaginal and abdominal approaches for the correction of vaginal vault prolapse, with discussion of the surgical outcomes and complications for each technique. A comprehensive comparison of the various techniques is offered on the basis of current published literature. In addition, we focus on various controversies, including the prevention of vault prolapse at the time of hysterectomy, issues regarding uterine preservation, the management of overt or occult concomitant stress incontinence, and the place-if any-for combined anti-incontinence procedures at the time of prolapse surgery. New minimally invasive techniques for vault prolapse are also reviewed. We emphasize areas that call for further research and for standardized outcome criteria.

Prevalence of severe pelvic organ prolapse in relation to job description and socioeconomic status: a multicenter cross-sectional study.
Woodman PJ, Swift SE, O'boyle AL, Valley MT, Bland DR, Kahn MA, Schaffer JI
Int Urogynecol J Pelvic Floor Dysfunct 2005 Nov 1;:1-6.

The aim of this study was to determine if certain occupations or socioeconomic levels are associated with pelvic organ prolapse. Investigators at six American sites performed pelvic organ prolapse quantification examinations on women presenting for routine gynecologic care. Between September 1999 and March 2002, 1,004 patients were examined. Severe pelvic organ prolapse was defined as the leading edge being 1 cm or more beyond the hymeneal ring. The data was analyzed with the Kruskal-Wallis analysis of variance, Bonferroni test, multiple logistic regression, and descriptive statistics. The prevalence of severe pelvic organ prolapse in our group was 4.3%. Women who were laborers/factory workers had significantly more severe prolapse than the other job categories (p<0.001). Women with annual income of $10,000 or less had significantly more severe pelvic organ prolapse than other income groups (p<0.001). These differences persisted even when controlling for age, race, number of deliveries, body mass index >30, and smoking status (all p<0.001). Laborers/factory worker jobs and an annual household income of $10,000 or less are associated with severe pelvic organ prolapse.

The development of pelvic organ prolapse after colposuspension: a prospective, long-term follow-up study on the prevalence and predisposing factors.
Auwad W, Bombieri L, Adekanmi O, Waterfield M, Freeman R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Oct 26;:1-6.

The objectives of this prospective study were to determine the prevalence of pelvic organ prolapse (POP) after colposuspension and to investigate possible preoperative and operative risk factors. Seventy-seven women who underwent colposuspension between 1996 and 1997 were investigated. POP was assessed before colposuspension using the pelvic organ prolapse quantification system (POPQ). Women were reassessed at one and seven to eight years (or when referred with symptomatic POP). By seven to eight years, of the 77 women, 29 (38%) had developed symptomatic prolapse, 29 (38%) had asymptomatic prolapse, 7 (9%) had no symptoms and no prolapse, and 12 (15%) could not be assessed. POP at one year was significantly associated with the presence of posterior vaginal descent before colposuspension (odds ratio 3.07, 95% CI 1.10-8.60, p=0.03). No variable reached statistical significance by eight years postcolposuspension. In conclusion, this is the first study to assess POP prospectively using a validated method before and after colposuspension. The results add support to the view that there is an association between colposuspension and the development of symptomatic POP (requiring surgery).

Remodeling of vaginal connective tissue in patients with prolapse.
Moalli PA, Shand SH, Zyczynski HM, Gordy SC, Meyn LA
Obstet Gynecol 2005 Nov;106(5):953-63.

OBJECTIVE: As pelvic organ prolapse progresses, the morphology of the vagina dramatically changes. The objective of this study was to determine whether these changes observed clinically correlate with histologic and biochemical evidence of tissue remodeling METHODS: After informed consent, full-thickness biopsies of the vaginal apex were obtained at the time of surgery from 77 women. The tissue of 15 premenopausal women with less than stage II prolapse (controls) was compared with that of 62 women with prolapse divided according to their menopausal status. All specimens were examined histologically. Scanning confocal microscopic analysis of fluorescent micrographs was used to quantitate collagen subtypes I, III, and V. Collagen fiber orientation was analyzed by scanning electron microscopy. Gelatin zymography was used to quantitate the expression of the proenzyme and active forms of matrix metalloproteinases (MMP) -2 and -9. Median values were compared using Mann-Whitney U or Kruskal-Wallis tests, where appropriate RESULTS: Vaginal collagen fibers are arranged in a whorled pattern, with collagen III as the predominant fibrillar collagen. The amount of total collagen in the vagina was increased in women with prolapse relative to women without prolapse (P = .054) primarily due to increased expression of collagen III (P = .031). There was no difference in the expression of proMMP-2, active MMP-2, or proMMP-9; however, active MMP-9 was increased in patients with prolapse (P = .030) CONCLUSION: The increase in collagen III and active MMP-9 expression in the vaginal tissues of patients with prolapse suggests that this tissue is actively remodeling under the biomechanical stresses associated with prolapse. Level of Evidence: II-2.

A Randomized, Controlled Trial Comparing Fascia Lata and Synthetic Mesh for Sacral Colpopexy.
Culligan PJ, Blackwell L, Goldsmith LJ, Graham CA, Rogers A, Heit MH
Obstet Gynecol Surv 2005 Oct;60(10):643-644.

One hundred women with posthysterectomy vaginal vault prolapse who were scheduled for sacral colpopexy at the University of Louisville Health Sciences Center participated in this double-blind, randomized trial comparing the use of cadaveric fascia lata and polypropylene mesh. The Pelvic Organ Prolapse Quantification system (POP-Q) was used for patient evaluation preoperatively and at 3 months, 6 months, and 1 year postoperatively.Fascial lata was used in 46 patients and polypropylene mesh was used in 54. Eighty-nine women, 44 in the fascia group and 45 in the mesh group, completed the 1-year study period. The 2 groups were similar in social demographics, clinical characteristics, and operative data. Adverse events possibly related to the graft were experienced by 26% of women who received mesh and 15% of women who received fascia (P = .19). Other surgical procedures, in tension-free tape procedures, posterior repairs, and paravaginal repairs were performed frequently and at similar rates in the 2 groups.At the 1-year examination, the rate of objective anatomic failure, as defined by Weber et al, was greater in the women who received fascia (14 of 44; 32%) compared with those who received mesh (4 of 45; 9%) (P = .007). There were 15 instances of POP-Q point Aa (point along the distal anterior vaginal wall) and 3 of POP-Q point Ap (posterior vaginal wall) reaching at least the -1 position. There were no point C (vaginal cuff) failures.The results of the POP-Q evaluations changed over the year of observation. At the end of 12 months, significant differences in between the 2 groups were seen for the mean values of point Aa (P = .02), point C (P = .04), and prolapse stage (P = .03). No differences were seen in total vaginal length, genital hiatus, perineal body, or points Ap or Bp (points along the posterior vaginal wall).When risk factors for surgical failure of sacral colpopexy, other than graft material (age, body mass index, prior prolapse or continence surgery), were subjected to univariate analysis, no significant predictors of failure were seen.

Abdominal sacral colpopexy: an independent prospective long-term follow-up study.
Higgs P, Goh J, Krause H, Sloane K, Carey M
Aust N Z J Obstet Gynaecol 2005 Oct;45(5):430-4.

Aims: The aim of the study was to provide a long-term follow up of subjective and objective outcomes following sacral colpopexy. Methods: A cohort of 148 women who had undergone sacral colpopexy in a tertiary unit between 1998 and 2001 were contacted for follow-up. Women were questioned about current symptoms including patient determined subjective measures and the Baden-Walker site specific examination for vaginal prolapse was performed. Results: Ninety-three women were able to be contacted for review. Of these, 64 were available for clinical examination and a further 29 were available for telephone interview. Of those women examined 62 had good vault support. Therefore, recurrent vault prolapse was uncommon at 3%. Recurrent prolapse was present in other vaginal compartments in 40.6% of women. Subjectively 78% of women felt that their prolapse symptoms had resolved and 65% had a visual analogue score (VAS) >/= 80, indicating satisfaction with the surgery. Stress urinary incontinence symptoms decreased at this long-term review, however, 24% of women required further incontinence surgery. Conclusions: Abdominal sacral colpopexy is an effective technique for the management of vaginal vault prolapse, with a two-year successful outcome in excess of 90%. Further study is required to investigate recurrent prolapse in other vaginal compartments and the functional aspects following surgery.

17{beta}-Estradiol suppresses proliferation of fibroblasts derived from cardinal ligaments in patients with or without pelvic organ prolapse.
Liu YM, Choy KW, Lui WT, Pang MW, Wong YF, Yip SK
Hum Reprod 2005 Sep 9;.

BACKGROUND: Estrogen replacement therapy (ERT) has been used in the treatment of pelvic organ prolapse (POP) but clinical results are inconclusive. The purpose of this study was to investigate the effect of 17beta-estradiol (E2) on the proliferation of fibroblasts derived from cardinal ligaments in women with or without POP. METHODS: Fibroblasts were derived from seven patients with POP and seven age-matched controls. The growth rate of POP fibroblasts was compared with that of control by 3-(4,5,-dimethyl thiazolyl-2)-2,5-diphenyl tetrazolium bromide (MTT) assay. Four cell strains from each patient and control group were treated with different concentrations of E2 (10(-4), 10(-8), 10(-9) and 10(-10) mol/l). The effect of E2 on cell proliferation was then measured by MTT assay. RESULTS: The overall growth rate of POP fibroblasts was significantly slower than that of controls under normal culture conditions. Addition of E2 suppressed cell proliferation of all the fibroblasts, especially in POP fibroblasts. POP fibroblasts showed a significantly lower proliferative rate than that of controls at all E2 concentrations, with the most prominent inhibitory effect at physiological concentration (10.83 +/- 34.41% versus 81.56 +/- 48.10% at 10(-8) mol/l). CONCLUSIONS: Our results suggest that decreased fibroblast turnover may contribute to the development of POP; and ERT may not be an effective POP treatment.

Vaginal wall descensus and pelvic floor symptoms in older women.
Bradley CS, Nygaard IE
Obstet Gynecol 2005 Oct;106(4):759-66.

OBJECTIVE: To understand the clinical significance of early pelvic organ prolapse in older women, we studied associations between vaginal descensus and pelvic floor symptoms. METHODS: In this cross-sectional study, 270 women enrolled at one site of the Women's Health Initiative clinical trial completed a questionnaire modified from the Pelvic Floor Distress Inventory on pelvic floor symptoms and underwent a Pelvic Organ Prolapse Quantification (POP-Q) examination. We tested associations between symptoms (individual and grouped) with anterior, posterior, uterine, and maximum vaginal descensus. RESULTS: Mean age was 68 years. Ninety-six percent had POP-Q stages I or II. Only obstructive urinary symptoms and feeling a bulge were associated with vaginal descensus. Obstructive urinary symptom scores increased as anterior (P = .04), posterior (P < .01), and maximal (P = .01) vaginal descensus increased. Urinary incontinence or bowel symptoms were not associated with descensus of any vaginal compartment. ''See or feel a bulge,'' reported by 11 women (4%), was associated with descensus in all compartments (P </= .04 for all) and with prolapse at or beyond the hymen (P < .001). This symptom was specific (100%), but not sensitive (16%) for prolapse, defined as descensus at or beyond the hymen. CONCLUSION: Vaginal support defects in older women are associated with obstructive urinary symptoms and the symptom of seeing or feeling a bulge. However, symptoms are not useful in discriminating between women with and without milder vaginal wall descensus. Based on these results, we suggest that other etiologies for bothersome bladder or bowel complaints be considered before performing surgery for early pelvic organ prolapse. LEVEL OF EVIDENCE: II-2.

Repair of recurrent vaginal vault prolapse using sacrospinous ligament fixation with mesh interposition and reinforcement.
Lo TS, Horng SG, Huang HJ, Lee SJ, Liang CC
Acta Obstet Gynecol Scand 2005 Oct;84(10):992-5.

Objective. Our goal was to study the efficacy of performing the repeated sacrospinous ligament fixation with mesh interposition and reinforcement in women with recurrent vaginal vault prolapse. Materials and methods. Fifteen consecutive patients with symptomatic severe vaginal vault or uterus prolapse after previous sacrospinous ligament fixation were enrolled. The sacrospinous ligament fixation was performed with a mesh interposition between sacrospinous ligament complex and vaginal apex. The mesh was extended to anterior and posterior vaginal wall for the repair of concurrent cystocele and rectocele, if indicated. The surgical results and complications were evaluated. The prolapse evaluation was performed according to International Continence Society (ICS) ordinal stages of pelvic organ prolapse. Results. The mean age was 55 years. The mean follow-up was 2.9 years (range 1.0-5.5 years). Repeated sacrospinous ligament fixation was performed for all patients. Eleven were performed unilaterally to the right and four to the left. The average time for sacrospinous fixation was 20 min. The average blood loss for sacrospinous fixation was 75 ml. No major complication except one accidental rectotomy was observed. It was repaired intraoperatively without sequel. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies, and tension-free vaginal tape procedures. No recurrence of apical prolapse was observed. However, two patients developed stage I prolapse on anterior vaginal wall (cystocele) and required no further repair. Minor postoperative complications were observed. Conclusion. Repeated sacrospinous ligament fixation with mesh interposition and reinforcement is a safe and effective procedure for the correction of recurrent vault prolapse. The extended implanted mesh can be used for the repair of concurrent cystorectocele effectively. A long-term follow-up is necessary to detect any late complication.


Inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair.
Lazarou G, Powers K, Pena C, Bruck L, Mikhail MS
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):242-4. Epub 2004 Sep 18.

Graft augmentation for repair of recurrent pelvic organ prolapse is commonly used in reconstructive pelvic surgery. The reported complications are mainly late onset. We report a case of early-onset inflammatory reaction following bovine pericardium graft augmentation for posterior vaginal wall defect repair. A 49-year-old presented with a recurrent and symptomatic posterior vaginal wall defect. She underwent an uneventful site-specific repair and bovine graft augmentation. Her early postoperative course was complicated by inflammatory response to the graft presenting as intense pelvic floor spasm and urinary retention. The condition was managed conservatively and resolved subsequently. One year later, the patient continues to be asymptomatic. Transient intense pelvic floor spasm and urinary retention can be the result of inflammatory reaction following graft augmentation with bovine pericardium for posterior vaginal wall defect repair.

Complete genital prolapse stage IV: Surgical emergency.
Boukerrou M, Phalippou J, Lambaudie E, Crepin G, Cosson M
Eur J Obstet Gynecol Reprod Biol 2005 Aug 10;.

Effectiveness of the McCall culdeplasty in maintaining support after vaginal hysterectomy.
Montella JM, Morrill MY
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):226-9. Epub 2004 Oct 28.

The aim of this study was to evaluate the effectiveness of a McCall culdeplasty in maintaining support of the post-hysterectomy vaginal cuff in women undergoing surgery for uterine prolapse. A retrospective chart review was performed on all patients who had a vaginal hysterectomy and McCall culdeplasty for uterine prolapse without prolapse of the posterior vaginal fornix. Patients were examined pre- and postoperatively using the International Continence Society (ICS) staging system. Data were analyzed using repeated measures analysis of variance (ANOVA) for correlation between preoperative point D and the two postoperative point C measurements. Of the 43 patients studied, 39 (90%) had stage 0 prolapse and 3 (7%) had stage I prolapse of the vaginal cuff 1 year postoperatively. In patients who have hysterectomies for uterine prolapse with good support of the posterior vaginal fornix, the McCall culdeplasty is a highly successful procedure in maintaining proper anatomic support of the vaginal cuff.

Survey of the characteristics and satisfaction degree of the patients using a pessary.
Bai SW, Yoon BS, Kwon JY, Shin JS, Kim SK, Park KH
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):182-6; discussion 186. Epub 2004 Dec 1

The objective of this study was to evaluate characteristics, satisfaction degree, and problems of patients using a pessary for pelvic organ prolapse. A total of 104 patients who had been fitted with a pessary and available for follow-up for pelvic organ prolapse management were enrolled. The patients answered questions on general characteristics, indications for pessary use, complications from pessary use, satisfaction degree, and frequency of removal. The results indicated that 76 (73.0%) patients had at least more than one medical illness and 86 (82.7%) patients complained of lower urinary symptoms such as incontinence, urgency, frequency, or nocturia. Eighty-four (80.7%) patients used pessaries as they were not surgical candidates due to poor medical status or old age. After using a pessary, 76 (73.1%) patients had symptoms such as bleeding, erosion, or foul odor; 70.2% of the women answered that they were satisfied or more than satisfied and 19.1% of the patients removed their pessaries, of whom 80.0% were unable to continue use due to repeated expulsion of the pessary and uncomfortable fitting. These data suggest that the pessary tends to be used for high-risk patients due to medical problems or old age. Despite the high frequency of complications from pessary use, it was seen that the frequency of removing the pessary was low and the satisfaction degree was high. Most of the complications were not thought to be serious. To decrease the frequency of complications, the regular follow-up visit and proper management of pessary use were thought to be needed. Further studies are warranted on tailor-fitting the pessary by variable use and relieving the symptoms associated with the lower urinary tract.

Surgical reinforcement of support for the vagina in pelvic organ prolapse: concurrent iliococcygeus fascia colpopexy (Inmon technique).
Koyama M, Yoshida S, Koyama S, Ogita K, Kimura T, Shimoya K, Murata Y, Nagata I
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):197-202. Epub 2004 Oct 23.

To reinforce the support of the vagina, concurrent use of iliococcygeus fascia colpopexy with the McCall culdeplasty was scheduled for primary uterine prolapse. Forty-five women with primary uterine prolapse without stress urinary incontinence were treated by McCall culdeplasty alone or McCall culdeplasty plus iliococcygeus fascia colpopexy for suspension of the upper portion of the vagina. Recurrence of vaginal support defects were carefully followed for 15-50 months. Additional iliococcygeus fascia colpopexy did not change with the axis of the vagina obtained by McCall culdeplasty, although it prolonged total operation time by 32 min and increased blood loss by 94 ml. Two cases (8.3%) had postoperative vaginal defects in the group undergoing combined procedures and seven recurrent cases (33.3%) were observed in the group undergoing McCall culdeplasty alone. The durability of the combined procedures was superior to that of the modified McCall culdeplasty alone by Kaplan-Meier analysis. These results suggest that iliococcygeus fascia colpopexy is reasonably safe and strengthens not only the attachment of the upper part of the vagina but also that of the anterolateral vaginal wall.

Uterine Prolapse in Pregnancy.
Guariglia L, Carducci B, Botta A, Ferrazzani S, Caruso A
Gynecol Obstet Invest 2005 Jul 13;60(4):192-194.

We present a case of a patient developing uterine prolapse during pregnancy. The cervix reached the introitus at 10 weeks gestation and subsequentely protruted progressively as the pregnancy advanced. The patient was conservatively treated with bed rest and the main maternal and fetal risks are avoided. At 4 months postpartum follow-up there was no evidence of uterine prolapse.

Prenatal diagnosis of fetal genital prolapse.
Cheng PJ, Shaw SW, Cheuh HY, Soong YK
Ultrasound Obstet Gynecol 2005 Aug;26(2):204-206.
No Abstract.

Morphologic study on levator ani muscle in patients with pelvic organ prolapse and stress urinary incontinence.
Zhu L, Lang JH, Chen J, Chen J
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 9;.

The objective of this study was to determine the morphologic changes of the levator ani muscle of patients with pelvic organ prolapse and stress urinary incontinence. Histological and histochemical analyses of the biopsy specimens of the levator ani muscle obtained from patients with stress urinary incontinence (SUI), pelvic organ prolapse (POP), and a control group were performed. The striated muscle-positive biopsy rate was 26.7% in the SUI group, 15.8% in the POP group, whereas it was 100% in the control group. The diameters of types I and II fibers decreased significantly with age and menopausal time in the control group. Splitting or fragmentation of fibers with red granules, which are called ragged-red fibers, were found in the SUI group. The diameters of levator ani muscle fibers in the control group were significantly larger than those in the SUI group (p=0.034<0.05). The degenerative change in histology and decrease in relative number of levator ani muscle might be associated with women suffering from SUI.

An ambispective observational study in the safety and efficacy of posterior colporrhaphy with composite Vicryl-Prolene mesh.
Lim YN, Rane A, Muller R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):126-31; discussion 131. Epub 2004 Sep 25.

There is increasing evidence to show that the use of surgical meshes reduces recurrence rates of hernia repair and anterior vaginal wall prolapse. The aim of this study was to determine the safety and efficacy of posterior colporrhaphy with mesh in patients with posterior vaginal prolapse. An ambispective observational study involving 90 patients was conducted with retrospective chart review and prospective subjective and objective assessments at the end of a 1-year study period. Apart from 2 of 90 (2.2%) minor hematoma incidents, there was no other major perioperative morbidity. Prevalence of common prolapse complaints of vaginal lump sensation, constipation, defecation difficulty and dyspareunia all improved significantly postoperatively (p<0.001). Surgical correction was achieved in 27 of 31 (83.9%) at 6 months and beyond. There was no mesh infection but minor vaginal mesh protrusion was found in 7 of 90 (7.8%) patients at 6-12 weeks and 4 of 31 (12.9%) patients at 6 months and beyond. All these were treated easily with trimming without the need of mesh removal. We conclude that posterior colporrhaphy with mesh is effective in treating posterior vaginal prolapse in short term.

Vaginal pessaries in managing women with pelvic organ prolapse and urinary incontinence: patient characteristics and factors contributing to success.
Hanson LA, Schulz JA, Flood CG, Cooley B, Tam F
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 26;.

Objective: An aging population has resulted in higher prevalence of urinary incontinence (UI) and pelvic organ prolapse (POP). This study examines a nurse-run clinic and analyzes the factors contributing to successful pessary use. Study design: A retrospective chart review of 1,216 patients was completed. History, pelvic examination and pessary fitting was done. Data was analyzed utilizing a categorical model of maximum-likelihood estimation to investigate relationships. Results: Median patient age was 63 years. Median number of pessaries tried was two. Eighty-five percent of post-menopausal women were on hormone replacement therapy (HRT) prior to fitting. Highest success rate of 78% was in the group on both systemic and local HRT. Success rates ranged from 58% for urge incontinence to 83% for uterine prolapse. Prior vaginal surgery was a factor impacting success. In our series highest success rates for fitting were obtained with ring pessaries, ring with support, and gellhorns. Conclusions: This model is a viable, option for the conservative management of UI and POP. Local HRT plays an important role in successful pessary fitting. Complications are rare.

Local anesthesia with sedation for vaginal reconstructive surgery.
Buchsbaum GM, Albushies DT, Schoenecker E, Duecy EE, Glantz JC
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 28;.

To evaluate local anesthesia with sedation for vaginal reconstructive surgery. All cases of vaginal surgery performed by the primary author for correction of pelvic organ prolapse with and without urinary incontinence between February 2000 and October 2004 were identified. From the medical record, data on age, duration of surgery, amount of local anesthetic used, estimated blood loss, hospital stay, urinary retention, and need for conversion to general anesthesia were recorded. Among 127 potential candidates, 98 (77.2%) opted for local with sedation. These cases included 18 anterior colporrhaphies, 47 posterior colporrhaphies with perineoplasties, 9 enterocele repairs, 32 total colpocleises, and 9 LeFort procedures. Tension-free vaginal tape (TVT) were concomitantly placed in 37 of the cases; 121 TVT-only cases done under local were not included. No cases were converted to general anesthesia. Surgical time ranged from 20 to 195 min (mean 99 min). Most patients were discharged within 24 h of surgery. Traditionally, local anesthesia with sedation has been reserved for superficial vaginal procedures. However, it can be successfully employed for more invasive vaginal reconstructive surgeries. Duration of surgery and patient acceptance have not been limiting factors. The advantages of local anesthesia include minimal interference with homeostasis and rapid recovery with patients often bypassing the recovery unit.

Assessment of posterior vaginal wall prolapse: comparison of physical findings to cystodefecoperitoneography.
Altman D, Lopez A, Kierkegaard J, Zetterstrom J, Falconer C, Pollack J, Mellgren A
Int Urogynecol J Pelvic Floor Dysfunct 2005 Mar-Apr;16(2):96-103; discussion 103. Epub 2004 Sep 14.

The aim of the present study was to compare clinical and radiological findings when assessing posterior vaginal wall prolapse. Defecography can be used to complement the clinical evaluation in patients with posterior vaginal wall prolapse. Further development of the defecography technique, using contrast medium in the urinary bladder and intraperitoneally, have resulted in cystodefecoperitoneography (CDP). Thirty-eight women underwent clinical examination using the pelvic organ prolapse quantification system (POP-Q) followed by CDP. All patients answered a standardized bowel function questionnaire. Statistical analysis measuring correlation between POP-Q and CDP using Pearson's correlation coefficient (r) and Spearman's rank order correlation coefficient (rs) demonstrated a poor to moderate correlation, r=0.49 and rs=0.55. Although there was a strong association between large rectoceles (>3 cm) at CDP and symptoms of rectal emptying difficulties (p<0.001), severity and prevalence of bowel dysfunction showed poor coherence with clinical prolapse staging and findings at radiological imaging. Vaginal topography and POP-Q staging predict neither radiological size nor visceral involvement in posterior vaginal wall prolapse. Radiological evaluation may therefore be a useful complement in selected patients.

Uterine Prolapse in Pregnancy.
Guariglia L, Carducci B, Botta A, Ferrazzani S, Caruso A
Gynecol Obstet Invest 2005 Jul 13;60(4):192-194.

We present a case of a patient developing uterine prolapse during pregnancy. The cervix reached the introitus at 10 weeks gestation and subsequentely protruted progressively as the pregnancy advanced. The patient was conservatively treated with bed rest and the main maternal and fetal risks are avoided. At 4 months postpartum follow-up there was no evidence of uterine prolapse. Copyright (c) 2005 S. Karger AG, Basel.

The use of laparoscopic sacrocolpopexy in the management of pelvic organ prolapse.
Gadonneix P, Ercoli A, Scambia G, Villet R
Curr Opin Obstet Gynecol 2005 Aug;17(4):376-380.

PURPOSE OF REVIEW: This paper aims to review and comment on the developments in laparoscopic sacrocolpopexy published during the last year. RECENT FINDINGS: We classified the findings reported recently in the literature for laparoscopic sacrocolpopexy as technical or tactical findings. Technical findings concern the material of the mesh, the methods of mesh fixation, the use of adapted vaginal retractors and the interest in robotic assistance. Tactical findings consist of specific modifications to the standard surgical procedure aimed at reducing the side effects and complications and ameliorating the effectiveness of this intervention. These modifications include the possibility of avoiding the placement of a posterior mesh and the fixation of the posterior mesh to the puborectal muscles or the perineal body instead of the posterior vaginal wall. A specific section has been dedicated to reviewing and commenting on those interventions associated routinely with laparoscopic sacrocolpopexy. SUMMARY: Laparoscopic sacrocolpopexy is a safe surgical procedure in constant evolution which allows excellent results in the treatment of utero-vaginal prolapse. Large prospective, randomized studies comparing the different technical and tactical modifications recently introduced are needed in order to further enhance the effectiveness of this intervention.

A Randomized Controlled Trial Comparing Fascia Lata and Synthetic Mesh for Sacral Colpopexy.
Culligan PJ, Blackwell L, Goldsmith LJ, Graham CA, Rogers A, Heit MH
Obstet Gynecol 2005 Jul;106(1):29-37.

Objective: To compare the objective anatomic outcomes after sacral colpopexy performed with cadaveric fascia lata and polypropylene mesh. Methods: Patients undergoing a sacral colpopexy were randomized to receive either fascia lata or polypropylene mesh in a double-blinded fashion. Data were collected at 6 weeks, 3 months, 6 months, and 1 year postoperatively. The main outcome measures were pelvic organ prolapse quantification (POP-Q) system stage and individual POP-Q points over time. Objective anatomic failure was defined as POP-Q stage 2 or more at any point during the follow-up period. Proportions of patients with objective anatomic failure at 1 year in each group were compared using the chi(2) test. Mean POP-Q points and stage at 1 year were compared by using the independent samples t test. Results: One hundred patients were randomized to receive either fascia (n = 46) or mesh (n = 54). Of the 89 patients returning for 1-year follow-up, 91% (41/45) of the mesh group and 68% (30/44) of the fascia group were classified as objectively cured (P = .007). We found significant differences between the mesh and fascia groups with respect to the 1-year postoperative comparisons of points Aa, C, and POP-Q stage. There were no differences between the 2 groups with respect to points TVL (total vaginal length), GH (genital hiatus), PB (perineal body), Ap or Bp (2 points along the posterior vaginal wall). Conclusions: Polypropylene mesh was superior to fascia lata in terms of POP-Q points, POP-Q stage, and objective anatomic failure rates. Level of Evidence: I.

Anterior vaginal wall surgery in elderly patients: outcomes and assessment.
Bukkapatnam R, Shah S, Raz S, Rodriguez L
Urology 2005 Jun;65(6):1104-8.

OBJECTIVES: To evaluate the efficacy, safety, and impact on quality of life of anterior vaginal surgery in the elderly. Incontinence in the elderly is a devastating medical and social condition accounting for 50% of admissions to nursing homes; the incidence of anterior vaginal wall prolapse also increases in the elderly. Most patients are treated conservatively, because of a reluctance to offer surgical treatment to this age group owing to the perceived increased risk of complications and decreased rate of treatment success. METHODS: We prospectively evaluated all consecutive elderly patients who underwent anterior vaginal wall surgery between November 1999 and May 2003. The surgical outcomes were determined by the symptom, bother, and quality-of-life questionnaires answered by the patients. The physicians were unaware of the patients' responses. RESULTS: A total of 209 patients were available for analysis. The mean age was 70 years (range 65 to 88) and the mean follow-up 15.3 months. All items in the symptom and bother questionnaires showed significant improvement. Significant improvement was also demonstrated in quality of life and pad use (P <0.005). No significant perioperative complications occurred. Only patients older than 71 years of age did not experience an improvement in the symptom scores for urge incontinence. Nevertheless, as for all other patients, older patients experienced improvement in stress urinary incontinence (SUI) symptoms, the bother scores of SUI and urge incontinence, and quality of life. CONCLUSIONS: Surgical treatment of anterior vaginal wall prolapse and SUI in the elderly is effective and safe and significantly improves the quality of life of these patients.

Colpocleisis: a review.
Fitzgerald MP, Richter HE, Siddique S, Thompson P, Zyczynski H
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 28;.

Objective: To summarize published data about colpocleisis and to highlight areas about which data are lacking. Data sources: We conducted a literature search on Medline using Ovid and PubMed, from 1966 to January 2004, using search terms "colpocleisis", "colpectomy", "vaginectomy", "pelvic organ prolapse (POP) and surgery", and "vaginal vault prolapse and surgery" and included articles with English-language abstracts. We examined reference lists of published articles to identify other articles not found on the electronic search. Methods of study selection: We examined all studies identified in our search that provided any outcome data on colpocleisis. Because of the heterogeneity of outcome measures and follow-up intervals in case series, we did not apply meta-analytic techniques to the data. Results: Colpocleisis for POP is apparently successful in nearly 100% of patients in recent series. The rate of reoperation for stress incontinence or POP after colpocleisis is unknown. Concomitant elective hysterectomy is associated with increased blood loss and length of hospital stay, without known improvement in outcomes. Few studies systematically assess pelvic symptoms. The role of preoperative urodynamic testing to direct optimal management of urinary incontinence and retention remains to be established in this setting. Conclusions: Colpocleisis is an effective procedure for treatment of advanced POP in patients who no longer desire preservation of coital function. Complications are relatively common in this group of elderly patients. Prospective trials are needed to understand the impact of colpocleisis on functional outcomes and patient satisfaction.

Prevalence of symptomatic pelvic organ prolapse in a Swedish population.
Tegerstedt G, Maehle-Schmidt M, Nyren O, Hammarstrom M
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun 29;.

Our aim was to estimate the prevalence of symptomatic pelvic organ prolapse (POP) in a Swedish urban female population. The cross-sectional study design included 8,000 randomly selected female residents in Stockholm, 30-79-year old. A postal questionnaire enquired about symptomatic POP, using a validated set of five questions, and about urinary incontinence and demographic data. Of 5,489 women providing adequate information, 454 (8.3%, 95% confidence interval 7.3-9.1%) were classified as having symptomatic POP. The prevalence rose with increasing age but leveled off after age 60. In a logistic regression model that disentangled the independent effects, parity emerged as a considerably stronger risk factor than age. There was a ten-fold gradient in prevalence odds of POP with parity, the steepest slope (four-fold) being between nulliparous and primiparous women. The prevalence of frequent stress urinary incontinence was 8.9% and that of frequent urge incontinence 5.9%. Out of the 454 women with prolapse, 37.4% had either or both types of incontinence.

Laparoscopic uterosacral ligament uterine suspension compared with vaginal hysterectomy with vaginal vault suspension for uterovaginal prolapse.
Diwan A, Rardin CR, Strohsnitter WC, Weld A, Rosenblatt P, Kohli N
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jul 5;.

This study compares the outcomes of laparoscopic uterosacral ligament uterine suspension (LUSUS) to those of vaginal vault suspension with total vaginal hysterectomy (TVH) for the treatment of symptomatic uterovaginal prolapse. We compared the outcomes of 25 LUSUS to those of 25 TVH with vaginal vault suspension among age-matched controls. No significant complications occurred in either group. EBL and hospitalization duration were significantly less in LUSUS patients (72 cc vs. 227 cc, P < .0001 and 1.05 vs. 1.65 days, P = .002). Vault support, as measured by postoperative pelvic organ prolapse quantitation system point D in the LUSUS group and point C in the TVH group, was better for the LUSUS group (D = -9 vs. C = -7.6, P = .002). No LUSUS group patient underwent reoperation for recurrent apical prolapse as compared to three TVH patients. LUSUS is an effective treatment for appropriately selected women with uterovaginal prolapse who desire uterine preservation.

Genital prolapse: a follow-up study assessing subjective and objective results five years or more after surgical intervention.
Moghimi K, Valbo A.
Eur J Obstet Gynecol Reprod Biol 2005 Jun 1;120(2):198-201.
BACKGROUND: With few reports in the field, we wanted to assess the long-term outcome of vaginal repair by objective and subjective measures. METHODS: One hundred and sixty-seven women underwent surgical repair during a five-year period from 1990. Five years or more after surgery, 93 women were interviewed and underwent a physical examination to evaluate the post-operative results. RESULTS: Sixty-eight women (72%) stated that they were satisfied with the operative result. Five women (5.4%) had undergone relapse surgery. The examination revealed relapse in seven women (7.5%). Persistent sensation of vaginal pressure and heaviness was the most frequent symptom among those who were not satisfied with the operative result. The mean age was 67.8 years. The frequency of "de novo" urinary leakage post-operatively does not seem to exceed the expected development of leakage attributable to ageing in the population. CONCLUSIONS: The results in this study reveals that the need for relapse surgery is twice the reported figure when thorough anatomical examination is performed. There is also a discrepancy between the anatomical findings and the subjective symptoms reported by the patient.

Influence of spontaneous and instrumental vaginal delivery on objective measures of pelvic organ support: assessment with the pelvic organ prolapse quantification (POPQ) technique and functional cine magnetic resonance imaging.
Hidar S, Khairi H.
Eur J Obstet Gynecol Reprod Biol 2005 Jun 1;120(2):230.

Repair of prolapse with vaginal sacrocolporectopexy: Technique and results.
Kavallaris A, Kohler C, Diebolder H, Vercellino F, Krause N, Schneider A.
Eur J Obstet Gynecol Reprod Biol 2005 Jun 8;.

OBJECTIVE: Axis and support of the vagina can be restored by sacrocolporectopexy with preservation of coital function. We developed a new technique of transvaginal sacrocolporectopexy for patients with prolapse of uterus and vagina or prolapse of the vaginal vault. STUDY DESIGN: During a 4-year period, 20 patients with vaginal vault prolapse and 83 patients with uterine and vaginal prolapse underwent transvaginal sacrocolporectopexy. Intra- and postoperative complications were recorded. After a mean follow-up period of 24 months (6-48), the result of surgery with respect to prolapse, incontinence, and sexuality was evaluated by patient interviews. RESULTS: No serious perioperative complications occurred with the exception of one patient with bleeding from a presacral vein. Subjectively, 84 patients (82%) were cured of prolapse symptoms. One patient had recurrent grade II vault prolapse and four patients developed a grade II rectocele. Five patients developed urge incontinence grade I. One patient developed fecal incontinence. No patient had coital problems as a sequelae of sacrocolporectopexy. CONCLUSION: Transvaginal sacrocolporectopexy is a safe procedure with a success rate comparable to sacrospinous fixation.

Surgical management of anterior vaginal wall prolapse: an evidencebased literature review.
Maher C, Baessler K. Int Urogynecol
J Pelvic Floor Dysfunct 2005 May 25;.
The aim of this review is to summarize the available literature on surgical management of anterior vaginal wall prolapse. A Medline search from 1966 to 2004 and a hand-search of conference proceedings of the International Continence Society and International Urogynecological Association from 2001 to 2004 were performed. The success rates for the anterior colporrhaphy vary widely between 37 and 100%. Augmentation with absorbable mesh (polyglactin) significantly increases the success rate for anterior vaginal wall prolapse. Abdominal sacrocolpopexy combined with paravaginal repair significantly reduced the risk for further cystocele surgery compared to anterior colporrhaphy and sacrospinous colpopexy. The abdominal and vaginal paravaginal repair have success rates between 76 and 100%, however, no randomized trials have been performed. There is currently no evidence to recommend the routine use of any graft in primary repairs, and possible improved anatomical out-comes have to be tempered against complications including mesh erosions, infections and dyspareunia.

Roles of estrogen receptor, progesterone receptor, p53 and p21 in pathogenesis of pelvic organ prolapse.
Bai SW, Chung DJ, Yoon JM, Shin JS, Kim SK, Park KH. Int Urogynecol
J Pelvic Floor Dysfunct 2005 May 25;.

The aim of this study is to compare the levels of estrogen receptor (ER), progesterone receptor (PR), p53 and p21 between pelvic organ prolapse (POP) and control groups in order to evaluate their roles in pathogenesis of POP, and to find out the relationship among these proteins. Through the year of 2002, uterosacral ligaments were obtained from 20 prolapsus and 24 non-prolapsus hysterectomized uteruses. ER, PR, p53, and p21 proteins were extracted by Western blot analysis and relative levels of proteins were compared by Student t-test and Pearson correlation coefficient. P value <0.05 was considered statistically significant. All patients were postmenopausal and had never taken hormone replacement therapy. ER, PR, p53, and p21 were significantly lower in the study than control group (p<0.0001). Positive correlations were found among all proteins in the prolapse group. Further researches are needed to elucidate the interrelationship among these proteins and their precise roles in pathogenesis of POP.

A 2-year anatomical and functional assessment of transvaginal rectocele repair using a polypropylene mesh.
de Tayrac R, Picone O, Chauveaud-Lambling A, Fernandez H.
Int Urogynecol J Pelvic Floor Dysfunct 2005 May 21;.

This study reports the 2-year results of an original technique for rectocele repair by the vaginal route, using a combined sacrospinous suspension and a polypropylene mesh. Twenty-six women were successively operated between October 2000 and February 2003. Mean age was 63.7 years [range 35-92]. 19 women had had previous pelvic surgery for prolapse and/or urinary incontinence (73.1%), but none had had a previous rectocele repair. Patients underwent physical examination staging of prolapse in the international pelvic organ prolapse staging system. Eleven women had stage 2 posterior vaginal wall prolapse (42.3%), seven had stage 3 (26.9%) and eight had stage 4 (30.8%). The procedure included a bilateral sacrospinous suspension and a polypropylene mesh (GyneMesh, Gynecare, Ethicon France) attached from the sacrospinous ligaments to the perineal body. We did not perform any associated posterior fascial repair, nor myorraphy. Patients were followed up for 10-44 months, with a median follow-up (+/-SD) of 22.7+/-9.2 months. Functional results and sexual function were evaluated using the PFDI, the PFIQ and the PISQ-12 self-questionnaires. Twenty-five women returned for follow-up (96.2%). At follow-up, 24 women were cured (92.3%) and one had asymptomatic stage 2 rectocele. All the patients but one had symptoms and impact on quality of life improved. No postoperative infection of the mesh or rectovaginal fistula was found, but there were three vaginal erosions (12%) and one out of 13 had de novo dyspareunia (7.7%).

Pessary use in advanced pelvic organ prolapse.
Powers K, Lazarou G, Wang A, Lacombe J, Bensinger G, Greston WM, Mikhail MS
Int Urogynecol J Pelvic Floor Dysfunct 2005 May 10;.

The objective of this study was to review our experience with pessary use for advanced pelvic organ prolapse. Charts of patients treated for Stage III and IV prolapse were reviewed. Comparisons were made between patients who tried or refused pessary use. A successful trial of pessary was defined by continued use; a failed trial was defined by a patient's discontinued use. Thirty-two patients tried a pessary; 45 refused. Patients who refused a pessary were younger, had lesser degree of prolapse, and more often had urinary incontinence. Most patients (62.5%) continued pessary use and avoided surgery. Unsuccessful trial of pessary resorting to surgery included four patients (33%) with unwillingness to maintain, three patients (25%) with inability to retain and two patients (17%) with vaginal erosion and/or discharge. Our findings suggest that pessary use is an acceptable first-line option for treatment of advanced pelvic organ prolapse.

Pelvic organ support in pregnancy and postpartum.
O'Boyle AL, O'Boyle JD, Calhoun B, Davis GD. Int Urogynecol
J Pelvic Floor Dysfunct 2005 Jan-Feb;16(1):69-72; discussion 72. Epub 2004 Jul 31.

The purpose of this study was to evaluate pelvic organ support during pregnancy and following delivery. This was a prospective observational study. Pelvic organ prolapse quantification (POPQ) examinations were performed during each trimester of pregnancy and in the postpartum. Statistical comparisons of POPQ stage and of the nine measurements comprising the POPQ between the different time intervals were made using Wilcoxon's signed rank and the paired t-test. Comparison of POPQ stage by mode of delivery was made using Fisher's exact test. One hundred thirty-five nulliparous women underwent 281 pelvic organ support evaluations. During both the third trimester and postpartum, POPQ stage was significantly higher compared to the first trimester (p<0.001). In the postpartum, POPQ stage was significantly higher in women delivered vaginally compared to women delivered by cesarean (p=0.02). In nulliparous pregnant women, POPQ stage appears to increase during pregnancy and does not change significantly following delivery. In the postpartum, POPQ stage may be higher in women delivered vaginally compared to women delivered by cesarean.

Laparoscopic and abdominal sacral colpopexies: a comparative cohort study.
Paraiso MF, Walters MD, Rackley RR, Melek S, Hugney C.
Am J Obstet Gynecol 2005 May;192(5):1752-8.

OBJECTIVE: This study was undertaken to compare laparoscopic and open sacral colpopexies for efficacy and safety. STUDY DESIGN: Charts were reviewed for 56 patients who underwent laparoscopic sacral colpopexy and 61 patients who underwent open sacral colpopexy. Demographic and hospital data, complications, and follow-up visits were reviewed. RESULTS: Mean follow-up was 13.5 +/- 12.1 months and 15.7 +/- 18.1 months in the laparoscopic and open groups, respectively. Mean operating time was significantly greater in the laparoscopic versus open cohort, 269 +/- 65 minutes and 218 +/- 60 minutes, respectively (P < .0001). Estimated blood loss (172 +/- 166 mL vs 234 +/- 149 mL; P = .04) and hospital stay (1.8 +/- 1.0 days vs 4.0 +/- 1.8 days; P < .0001) were significantly less in the laparoscopic group than the open group. Complication and reoperation rates were similar. CONCLUSION: Laparoscopic and open sacral colpopexies have comparable clinical outcomes. Although laparoscopic sacral colpopexy requires longer operating time, hospital stay is significantly decreased.

A prospective randomized trial using solvent dehydrated fascia lata for the prevention of recurrent anterior vaginal wall prolapse.
Gandhi S, Goldberg RP, Kwon C, Koduri S, Beaumont JL, Abramov Y, Sand PK.
Am J Obstet Gynecol 2005;192(5):1649-54.

OBJECTIVE: This study was undertaken to compare outcomes after anterior colporrhaphy with and without a solvent dehydrated cadaveric fascia lata graft. STUDY DESIGN: A total of 162 women were enrolled in a prospective, randomized trial that evaluated the impact of a solvent dehydrated cadaveric fascia lata patch on recurrent anterior vaginal prolapse. Subjects were randomly assigned to standard colporrhaphy with or without a patch. Before and after surgery, subjects were evaluated by both the Baden-Walker and pelvic organ prolapse quantification systems. "Failure" was defined as stage II anterior wall prolapse or worse. RESULTS: Of 154 women randomly assigned (76 patch: 78 no patch), all underwent surgery and 153 (99%) returned for follow-up. Sixteen women (21%) in the patch group and 23 (29%) in the control group experienced recurrent anterior vaginal wall prolapse (P = .229). Only 26% of all recurrences were symptomatic. Concomitant transvaginal Cooper's ligament sling procedures were associated with a dramatic decrease in recurrent prolapse (odds ratio [OR] 0.105 , P < .0001). CONCLUSION: Solvent dehydrated fascia lata as a barrier does not decrease recurrent prolapse after anterior colporrhaphy. Transvaginal bladder neck slings were associated with a significant reduction in the risk of recurrent anterior wall prolapse.

Suture erosion and wound dehiscence with permanent versus absorbable suture in reconstructive posterior vaginal surgery.
Luck AM, Galvin SL, Theofrastous JP.
Am J Obstet Gynecol 2005 May;192(5):1626-9.

OBJECTIVE: This study was undertaken to determine the incidence of wound disruption after reconstructive posterior vaginal surgery with braided permanent versus absorbable suture. STUDY DESIGN: A retrospective cohort study of women undergoing posterior vaginal surgery. Outcomes included suture erosion, wound dehiscence, and additional surgical procedures. RESULTS: Ninety-nine procedures were performed with permanent sutures, followed by 111 with absorbable sutures. There were no differences in demographics or comorbidities between patient groups. Suture erosion/wound dehiscence occurred in 31.3% of the permanent suture group versus 9% of the absorbable suture group (P = .003, odds ratio [OR] = 7.5, 95% CI 2-28). The need for additional surgical intervention was 16.1% among permanent suture group versus no patients with absorbable suture. Performing a concomitant anal sphincteroplasty with permanent sutures significantly increased the incidence of suture erosion (P = .003, OR = 4.7, 95%CI 1.7-13.3). CONCLUSION: Permanent sutures increase the incidence in wound disruption and the need for additional surgical intervention in posterior colporrhaphy and anal sphincteroplasty.

Levator contraction strength and genital hiatus as risk factors for recurrent pelvic organ prolapse.
Vakili B, Zheng YT, Loesch H, Echols KT, Franco N, Chesson RR.
Am J Obstet Gynecol 2005 May;192(5):1592-8.

OBJECTIVE: To correlate levator ani contraction strength and genital hiatus measurements with surgical failure in prolapse. STUDY DESIGN: This retrospective study involved chart review for documentation of levator contraction strength, genital hiatus measurement, and recurrent pelvic floor disorders in women who underwent surgery for prolapse. RESULTS: The recurrent prolapse rate was 34.6%. Median follow-up interval was 5 months. Diminished levator strength was associated with recurrent prolapse (35.8% versus 0%; P = .017). A genital hiatus 5 cm or greater was associated with recurrent prolapse (44.2% vs 27.8%; P = .034). Inability to contract the levator ani was associated with urinary incontinence (35.1% vs 18.8%; P = .023). Increasing levator contraction strength was associated with a decreased reoperation rate for pelvic floor disorders, whereas genital hiatus correlated best with recurrent prolapse. CONCLUSION: Diminished levator ani contraction strength and a widened genital hiatus correlate with an increase in surgical failures in the early postoperative period. These tools are useful for counseling a patient concerning surgery for prolapse.

Abdominal sacral colpopexy with allograft fascia lata: one-year outcomes.
Flynn MK, Webster GD, Amundsen CL.
Am J Obstet Gynecol 2005 May;192(5):1496-500.

OBJECTIVE: The purpose of this study was to assess 1-year outcomes of sacral colpopexy with the use of allograft fascia lata. STUDY DESIGN: Records of all subjects who underwent sacral colpopexy with allograft fascia lata from May 1, 2001, to April 30, 2003, were reviewed. Subjects underwent pre- and postoperative evaluation of prolapse with the pelvic organ prolapse quantification system. The Fisher's exact test was used to analyze the results. RESULTS: Allograft fascia lata was used for 24 colpopexies during this period. No significant intraoperative or postoperative complications or graft erosions occurred. Five subjects were lost to follow-up after 3 months. Analysis was performed on the remaining 19 subjects. Prolapse of stage 2 or more in compartments Aa, Ba, Ap, Bp, and C was preoperatively 50%, 74%, 78%, 84%, and 68% and postoperatively 11%, 16%, 21%, 26%, and 5%, respectively. CONCLUSION: Allograft fascia lata may be a suitable alternative to permanent mesh for sacral colpopexy, but longer-term outcomes and larger studies are needed.

Evaluation of the aged female baboon as a model of pelvic organ prolapse and pelvic reconstructive surgery.
Mattson JA, Kuehl TJ, Yandell PM, Pierce LM, Coates KW.
Am J Obstet Gynecol 2005 May;192(5):1395-8.

OBJECTIVE: This study examines the baboon as an animal model of pelvic organ prolapse (POP) by describing the pelvic floor anatomy and adapting human clinical assessment tools. STUDY DESIGN: The pelvic anatomy of an adult female baboon was observed at necropsy, and comparisons were made to the human and squirrel monkey. The pelvic organ prolapse quantification (POP-Q) system was used to assess vaginal support in 12 living adult baboons, including 6 young, reproductive-age, nulligravid females (4.8 +/- 0.5 years) and 6 older, multiparous females (23.0 +/- 0.5 years). RESULTS: The female baboon pelvic anatomy was found to have similar architecture to the human and squirrel monkey female. Six multiparous females with mean parity of 5 (range 2-8) showed no evidence of POP or differences in POP-Q measurements from 6 nulliparous females. CONCLUSION: The POP-Q system can be used to assess female baboon vaginal support. In a sample of baboons, pelvic support loss consistent with POP was not identified. As the pelvic anatomy is similar to the human female, the baboon may prove useful for evaluating surgical materials and for modeling pelvic floor reconstructive surgeries.

Vaginal Thickness, Cross-Sectional Area, and Perimeter in Women With and Those Without Prolapse.
Hsu Y, Chen L, Delancey JO, Ashton-Miller JA
Obstet Gynecol 2005 May;105(5):1012-1017.

OBJECTIVE: Use axial magnetic resonance imaging to test the null hypothesis that no difference exists in apparent vaginal thickness between women with and those without prolapse. METHODS: Magnetic resonance imaging studies of 24 patients with prolapse at least 2 cm beyond the introitus were selected from an ongoing study comparing women with prolapse with normal control subjects. The magnetic resonance scans of 24 women with prolapse (cases) and 24 women without prolapse (controls) were selected from those of women of similar age, race, and parity. The magnetic resonance files were imported into an experimental modeling program, and 3-dimensional models of each vagina were created. The minimum transverse plane cross-sectional area, mid-sagittal plane diameter, and transverse plane perimeter of each vaginal model were calculated. RESULTS: Neither the mean age (cases 58.6 years +/- standard deviation [SD] 14.4 versus controls 59.4 years +/- SD 13.2) nor the mean body mass index (cases 24.1 kg/m(2)+/- SD 3.3, controls 25.7 kg/m(2)+/- SD 3.7) differed significantly between groups. Minimum mid-sagittal vaginal diameters did not differ between groups. Patients with prolapse had larger minimum vaginal cross-sectional areas than controls (5.71 cm(2)+/- standard error of the mean [SEM] 0.25 versus 4.76 cm(2)+/- SEM 0.20, respectively; P = .005). The perimeter of the vagina was also larger in the prolapse group (11.10 cm +/- SEM 0.24) compared with controls (9.96 cm +/- SEM 0.22) P = .001. Subgroup analysis of patients with endogenous or exogenous estrogen showed prolapse patients had larger vaginal cross-sectional area (P = .030); in patients without estrogen group differences were not significant (P = .099). CONCLUSION: Vaginal thickness is similar in women with and those without pelvic organ prolapse. The vaginal perimeter and cross-sectional areas are 11% and 20% larger in prolapse patients, respectively. Estrogen status did not affect differences found between groups.

The history and evolution of pessaries for pelvic organ prolapse.
Shah SM, Sultan AH, Thakar R
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 14;.

The use of pessaries for the treatment of genital prolapse dates back prior to the days of Hippocrates and their use has been documented in early Egyptian papyruses. Throughout the centuries remedies such as honey, hot oil, wine and fumes have been used as treatment. Mechanical methods included succussion and leg binding. Pomegranates were also common remedies. In the middle ages, linen and cotton wool soaked in many different potions were used. As new materials were discovered, pessaries evolved and began to resemble those used today. Cork and brass were soon replaced with rubber. Modern day pessaries are made of non-reactive silicone and come in various designs and sizes to suit each individual. Pessaries can be used as an interim measure for women who wish to complete childbearing or women awaiting surgery. It can also be used as a permanent measure for women who are unsuitable for surgery. It remains to be established whether the use of modern pessaries over prolonged periods of time can prevent progression of or even cure, prolapse.

Surgical management of posterior vaginal wall prolapse: an evidence-based literature review.
Maher C, Baessler K
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 19;.

The aim of this review is to summarize the available literature on gynecological management of posterior vaginal wall prolapse. A MEDLINE search and a hand search of conference proceedings of the International Continence Society and International Urogynecological Association was performed. Two randomized trials demonstrated that the transvaginal approach to rectocele is superior to the transanal repair in terms of recurrent prolapse. The traditional posterior colporrhaphy with levator ani plication was largely superceded by fascial repairs with similar anatomic success rates but favorable functional outcome. The midline fascial plication may offer a superior anatomic and functional outcome compared to the discrete site-specific fascial repair. Controlled studies are necessary to evaluate whether a sacrocolpopexy combined with posterior mesh interposition is an effective alternative to the transvaginal repair. There is currently no evidence to recommend the routine use of any graft and complications such as mesh erosion, infection, and rejection have to be considered.

Uterosacral ligament in postmenopausal women with or without pelvic organ prolapse.
Gabriel B, Denschlag D, Gobel H, Fittkow C, Werner M, Gitsch G, Watermann D
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 22;.

The uterosacral ligaments are thought to contribute to pelvic support. The objective of this study was to compare the structural components of these ligaments in women with and without pelvic organ prolapse (POP). We characterized uterosacral ligaments of 25 postmenopausal women with POP and 16 controls histomorphologically and immunohistochemically by quantifying their content of collagen I, III, and smooth muscle using a computerized image analysis. In 84% the uterosacral ligaments were composed of more than 20% of smooth muscle cells. There was no difference in collagen I expression and smooth muscle cell amount between women with POP and those without. In contrast, the collagen III expression was significantly related to the presence of POP (p<0.001) rather than age or parity. Our findings suggest that the higher collagen III expression might be a typical characteristic of POP patients' connective tissue. The considerable amount of smooth muscle cells in uterosacral ligaments may provide pelvic support.

Predictive value of prolapse symptoms: a large database study.
Tan JS, Lukacz ES, Menefee SA, Powell CR, Nager CW
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):203-9. Epub 2004 Oct 23.

We sought to describe the relationship between patient symptoms and pelvic organ prolapse (POP) and report the sensitivity, specificity, and positive and negative predictive value of these POP symptoms. Two urologists and four urogynecologists developed a standardized pelvic floor questionnaire based on face validation for use at three female pelvic floor disorder clinics. Specific questions related to prolapse included questions on urinary splinting, digital assistance for defecation, and a bulge per vagina. Prolapse was assessed with the standardized Pelvic Organ Prolapse Quantitative (POP-Q) terminology. The analysis included 1912 women. Urinary splinting was uncommon (<10%) when Ba <0, but ranged between 23 and 36% for stage III and IV Ba prolapse. Digital assistance was equally common in stage II Bp prolapse (21-38%) and stage III-IV Bp prolapse (26-29%). Only 6-11% of women with stage 0 or I POP reported symptoms of bulge, but with stage II it increased to 77%. Urinary splinting is 97% specific for anterior prolapse. The report of a bulge has an 81% positive predictive value and a 76% negative predictive value. Very few patients without anterior prolapse will report urinary splinting. Digital assistance for fecal evacuation is no more common with massive posterior prolapse than with moderate posterior prolapse. Patient report of a bulge is a valuable screening tool for POP and should prompt a careful exam.

Effectiveness of the McCall culdeplasty in maintaining support after vaginal hysterectomy.
Montella JM, Morrill MY
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):226-9. Epub 2004 Oct 28.

The aim of this study was to evaluate the effectiveness of a McCall culdeplasty in maintaining support of the post-hysterectomy vaginal cuff in women undergoing surgery for uterine prolapse. A retrospective chart review was performed on all patients who had a vaginal hysterectomy and McCall culdeplasty for uterine prolapse without prolapse of the posterior vaginal fornix. Patients were examined pre- and postoperatively using the International Continence Society (ICS) staging system. Data were analyzed using repeated measures analysis of variance (ANOVA) for correlation between preoperative point D and the two postoperative point C measurements. Of the 43 patients studied, 39 (90%) had stage 0 prolapse and 3 (7%) had stage I prolapse of the vaginal cuff 1 year postoperatively. In patients who have hysterectomies for uterine prolapse with good support of the posterior vaginal fornix, the McCall culdeplasty is a highly successful procedure in maintaining proper anatomic support of the vaginal cuff.

Surgical reinforcement of support for the vagina in pelvic organ prolapse: concurrent iliococcygeus fascia colpopexy (Inmon technique).
Koyama M, Yoshida S, Koyama S, Ogita K, Kimura T, Shimoya K, Murata Y, Nagata I
Int Urogynecol J Pelvic Floor Dysfunct 2005 May-Jun;16(3):197-202. Epub 2004 Oct 23.

To reinforce the support of the vagina, concurrent use of iliococcygeus fascia colpopexy with the McCall culdeplasty was scheduled for primary uterine prolapse. Forty-five women with primary uterine prolapse without stress urinary incontinence were treated by McCall culdeplasty alone or McCall culdeplasty plus iliococcygeus fascia colpopexy for suspension of the upper portion of the vagina. Recurrence of vaginal support defects were carefully followed for 15-50 months. Additional iliococcygeus fascia colpopexy did not change with the axis of the vagina obtained by McCall culdeplasty, although it prolonged total operation time by 32 min and increased blood loss by 94 ml. Two cases (8.3%) had postoperative vaginal defects in the group undergoing combined procedures and seven recurrent cases (33.3%) were observed in the group undergoing McCall culdeplasty alone. The durability of the combined procedures was superior to that of the modified McCall culdeplasty alone by Kaplan-Meier analysis. These results suggest that iliococcygeus fascia colpopexy is reasonably safe and strengthens not only the attachment of the upper part of the vagina but also that of the anterolateral vaginal wall.

P-QOL: a validated questionnaire to assess the symptoms and quality of life of women with urogenital prolapse.
Digesu GA, Khullar V, Cardozo L, Robinson D, Salvatore S
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jun;16(3):176-181. Epub 2004 Oct 21.

To develop a simple, valid, reliable questionnaire to assess the severity of symptoms and their impact on the quality of life in women with urogenital prolapse. Women recruited from gynaecology outpatient clinics were asked to complete a prolapse quality of life questionnaire (P-QOL) before their hospital visit. At the time of the visit, they were examined supine using the International Continence Society (ICS) prolapse score (POP-Q). A second P-QOL was posted and completed by patients 2 weeks later. The validity was assessed by measuring levels of missing data, comparing symptom scores between affected and asymptomatic women and comparing symptom scores with objective prolapse stages. The internal reliability was assessed by measuring the Cronbach alpha coefficient; 155 symptomatic and 80 asymptomatic women were studied. Severity according to P-QOL strongly correlated with the vaginal examination findings (p<0.01, rho>0.5). The total scores for each P-QOL domain were significantly different between symptomatic and asymptomatic women (p<0.001). All items achieved a Cronbach alpha greater than 0.80 showing good inter-rater reliability. The test-retest reliability confirmed a highly significant correlation between the total scores for each domain. A P-QOL questionnaire for English-speaking patients has been developed which is reliable and valid.

Epidemiology of prolapse and incontinence questionnaire: validation of a new epidemiologic survey.
Lukacz ES, Lawrence JM, Buckwalter JG, Burchette RJ, Nager CW, Luber KM
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 26;.

The epidemiology of prolapse and incontinence questionnaire (EPIQ) was developed to screen for female pelvic floor disorders (PFD). Content and face validity, reliability, internal consistency and criterion validity of the EPIQ to detect the presence of pelvic organ prolapse (POP), stress urinary incontinence (SUI), overactive bladder (OAB) and anal incontinence (AI) is presented. Cronbach's alpha; Spearman's, kappa, intraclass correlations, factor analysis and Chi-Squared tests were used for analysis. Questions related to PFD proved internally consistent (alpha = 0.91) and reproducible (correlations >0.70) for all but three items on the EPIQ. Positive and negative predictive values of the EPIQ to detect PFD were: POP = 76% and 97%, SUI = 88% and 87%, OAB = 77% and 90% and AI = 61% and 91% respectively. EPIQ is a psychometrically validated screening instrument that may identify women at high risk of having pelvic floor disorders in large undiagnosed populations.

Does pelvic organ prolapse quantification exam predict urethral mobility in stages 0 and I prolapse?
Noblett K, Lane FL, Driskill CS
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 26;.

Objective: To determine if women with anterior support stages 0 or I by pelvic organ prolapse quantification (POP-Q) system require Q-tip testing to assess urethral mobility. Methods: A prospective study of 134 women presenting for urogynecologic evaluation were examined and assigned stages of anterior wall support according to the POP-Q system. A Q-tip test was performed and urethral hypermobility was defined as a straining angle >/=30 degrees . The Spearman correlation coefficient was used to assess degree of correlation between POP-Q point Aa position and Q-tip values. Results: The correlation coefficient between point Aa position and Q-tip angle was r=0.787 (P<0.001). Urethral hypermobility was noted in 91% of stage I and 100% of stage II-IV patients. The positive predictive value of Q-tip angle >/=30 degrees in stage I-IV prolapse was 99%. Conclusion: The POP-Q system is highly predictive of straining urethral angle in all stages of prolapse.

JAMA patient page. Uterine prolapse.
Ringold S, Lynm C, Glass RM
JAMA 2005 Apr 27;293(16):2054.

An 80-year-old woman with vaginal prolapse.
Cundiff GW
JAMA 2005 Apr 27;293(16):2018-27.

Sacral colpopexy using mersilene mesh in the treatment of vaginal vault prolapse.
Limb J, Wood K, Weinberger M, Miyazaki F, Aboseif S
World J Urol 2005 Feb;23(1):55-60. Epub 2004 Nov 11.

We report the efficacy and safety of abdominal sacral colpopexy using Mersilene mesh to treat vaginal vault prolapse. A total of 61 patients underwent sacral colpopexy to treat vaginal vault prolapse of whom 58 were available for evaluation. The procedure utilizes an abdominal approach to expose the vaginal vault and the anterior surface of the first and second sacral vertebrae. A Mersilene mesh is fastened to the anterior and posterior vaginal walls then anchored to the sacrum without tension. Hysterectomy and posterior colporrhaphy were performed as indicated. Concomitant anti-incontinence surgery was performed in 52 patients: 41 underwent Burch colposuspension, and 11 had pubovaginal sling placement. To assess long-term subjective and clinical efficacy, patients completed a questionnaire and underwent pelvic examination at least 1 year following surgery. The resolution of symptoms, objective restoration of normal pelvic support, and urinary continence defined surgical success. Median patient age at operation was 62 years. Previous operations included 29 hysterectomy procedures, five failed sacrospinous fixation, and 12 failed anti-incontinence procedures. The total complication rate was 15%. With a median follow-up of 26 months, complete correction of vaginal prolapse was found in 91% of patients. Vaginal symptoms were relieved in 90% of patients and 88% of patients had resolution of their urinary incontinence. Ninety percent of patients were satisfied with the surgery and would recommend it to others. Sacral colpopexy using Mersilene mesh relieves vaginal vault symptoms, restores vaginal function, and provides durable pelvic support.

Cadaveric prolapse repair with sling: intermediate outcomes with 6 months to 5 years of followup.
Frederick RW, Leach GE
J Urol 2005 Apr;173(4):1229-33.

PURPOSE: We present the prospective, intermediate-term results for cadaveric prolapse repair with sling as combined treatment of stress urinary incontinence and cystocele. MATERIALS AND METHODS: A total of 251 of 295 (85%) patients undergoing cadaveric prolapse repair with sling (CaPS) had at least 6 months of questionnaire and pelvic examination followup. All patients had objectively demonstrated stress urinary incontinence and grade 2 to 4 cystocele before surgery. Followup outcome measures included a validated subjective continence and patient satisfaction questionnaire, SEAPI (stress incontinence, emptying, anatomy, protection, inhibition) scores, pelvic examination for prolapse recurrence and complications, and quality of life scores. RESULTS: The overall patient reported subjective incontinence cured/dry rate (no incontinence episodes of any type) was 114 of 251 (45%), the cured/improved rate (50% improvement or greater) was 192 of 251 (76%) and the failed rate (less than 50% improvement) was 59 of 251 (24%). When considering stress urinary incontinence the cured/dry rate was 141 of 251 (56%), cured/improved rate was 207 of 251 (82%) and failed rate was 44 of 251 (17.5%), with 17 of the 44 (39%) cases having mixed urinary incontinence. Of the 59 failures 33 (56%) occurred after 12 months of followup. Of 153 patients 13 (8.5%) experienced de novo urge incontinence. The symptomatic cystocele recurrence rate was 18 of 251 (7%). There were statistically significant improvements in SEAPI and prolapse quality of life scores. Of 251 patients 200 (80%) were at least 50% satisfied and of 251 193 (77%) stated they would undergo the CaPS procedure again. CONCLUSIONS: With a maximum followup of 5 years in patients undergoing CaPS, we have seen excellent, durable cystocele repair results. While our subjective continence rates have decreased with an increasing number of late failures, we continue to observe significant improvement in SEAPI scores and quality of life with good patient satisfaction and low morbidity.

A new device for bone anchor fixation in laparoscopic sacrocolpopexy: The Franciscan laparoscopic bone anchor inserter.
van der Weiden RM, Withagen MI, Bergkamp AB, Mannaerts GH
Surg Endosc 2005 Mar 11;.

BACKGROUND: A laparoscopic modification of the sacrocolpopexy procedure with mesh and bone anchor fixation with the Franciscan laparoscopic bone anchor inserter was developed. METHODS: We developed a laparoscopic bone anchor inserter for the placement of a titanium bone anchor in sacral segment 3 as fixation for the mesh in laparoscopic sacrocolpopexy procedures performed in women with posthysterectomy vault prolapse. RESULTS: Surgery successfully corrected vaginal vault prolapse. Laparoscopic bone anchor insertion with this new and simple device took 2 minutes and provided a firm anchor for mesh fixation. MRI demonstrated an anatomically preferable vaginal axis toward the hollow of the sacrum. CONCLUSION: Application of the newly developed Franciscan laparoscopic bone anchor inserter in laparoscopic sacrocolpopexy is an easy and safe procedure that provides firm fixation and excellent anatomical results.

Recurrent pelvic organ prolapse in a woman with bladder exstrophy: a case report of surgical management and review of the literature.
Muir TW, Aspera AM, Rackley RR, Walters MD
Int Urogynecol J Pelvic Floor Dysfunct 2004 Nov-Dec;15(6):436-8. Epub 2004 Aug 17.

Management of gynecologic issues in women with bladder exstrophy is challenging. Congenital pelvic organ prolapse and prolapse-associated pregnancy and delivery are common. The management of prolapse is complicated by the anatomic changes involving the bony pelvis, connective tissue support, pelvic floor, and the length and axis of the vagina. A case of recurrent pelvic organ prolapse successfully managed with a sacral colpopexy and a review of the literature are presented.

Anatomical outcome and quality of life following posterior vaginal wall prolapse repair using collagen xenograft.
Altman D, Lopez A, Gustafsson C, Falconer C, Nordenstam J, Zetterstrom J
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 5;.

The aim of this study was to evaluate quality of life, sexual function, and anatomical outcome after posterior vaginal wall prolapse repair using a collagen xenograft. Thirty-three patients were evaluated preoperatively and at 6 and 12 months follow-up (FU). Quality of life and sexual function were assessed using a self-reported questionnaire. Prolapse staging was performed using the pelvic organ prolapse quantification system (POPQ). Preoperatively 3 patients had stage I, 26 patients stage II, and 4 patients stage III prolapse of the posterior vaginal wall. Prolapse of the posterior vaginal wall >/= stage II was observed in 7 patients (21%) at the 6-month FU and in 13 patients (39%) at the 12-month FU. Mean point Bp was reduced from -1.1 preoperatively to -2.5 at 6 months FU (p<0.01) and -1.8 at 12 months FU (p<0.01). Previous abdominal surgery was associated with a less favorable anatomical outcome (odds ratio: 2.0, 95% confidence interval: 1.5-3.8). There were no significant changes in sexual function or dyspareunia during the 1-year FU. Preoperatively 76% of the patients reported a negative impact on quality of life as a result of genital prolapse. There was a significant improvement in several variables associated with quality of life at 6 and 12 months FU. Posterior vaginal wall prolapse repair using a collagen xenograft was associated with an unsatisfying anatomical outcome at 1-year FU although several quality of life-associated variables affecting psychosocial function were improved. Improvement was not restricted to postoperative restoration of vaginal topography, and previous surgery had a negative effect on anatomical outcome.

Posterior sling (infracoccygeal sacropexy): An alternative procedure for vaginal vault prolapse.
Sivaslioglu AA, Gelisen O, Dolen I, Dede H, Dilbaz S, Haberal A
Aust N Z J Obstet Gynaecol 2005 Apr;45(2):159-60.

Abstract This study of 30 patients evaluated the effectiveness and safety of the posterior sling (infracoccygeal sacropexy) in the surgical treatment of vaginal vault prolapse. The patients were reevaluated 3 months, 6 months and yearly postoperatively. Coexisting preoperative symptoms of pelvic pain, urgency, nocturia and 'obstructed' micturition feeling were followed-up. There was remarkable improvement in vault prolapse and in coexisting symptoms.
Is the pelvic organ prolapse quantification system (POPQ) being used? A survey of members of the International Continence Society (ICS) and the American Urogynecologic Society (AUGS).
Auwad W, Freeman RM, Swift S
Int Urogynecol J Pelvic Floor Dysfunct 2004 Sep-Oct;15(5):324-7. Epub 2004 May 18.
The authors performed a web-based questionnaire survey of 667 members of the ICS and AUGS to determine the current use of the pelvic organ prolapse quantification (POPQ) system by members of the professional societies which have advocated its use. Three hundred and eighty (57%) gynecologists responded. This international survey shows that only 40.2% of ICS and AUGS members who responded routinely use the POPQ system in their clinical practice and provides information on the most common reasons for not using it. The results highlight some of the concerns regarding the complex nature of the system and its acceptance and use by specialists worldwide. It also suggests the need for a simplified version of the classification system that is user-friendly and can be adopted by all practitioners.

Patient satisfaction and changes in prolapse and urinary symptoms in women who were fitted successfully with a pessary for pelvic organ prolapse.
Albertsen PC
J Urol 2005 Mar;173(3):942-3.

Surgery for pelvic organ prolapse in women of 80 years of age and older.
Schweitzer KJ, Vierhout ME, Milani AL
Acta Obstet Gynecol Scand 2005 Mar;84(3):286-9.

Background. To investigate the long-term results of women over 80 years of age following surgery for pelvic organ prolapse. Design. Retrospective, descriptive study. Methods. We reviewed all records of women of 80 years and older operated for pelvic organ prolapse; all patients alive were contacted through a postal questionnaire. Results. A total of 2058 operations for pelvic organ prolapse were performed in the study period. One hundred and twenty-eight patients were 80 years and older with the mean age of 83 years (range 80-92 years). In three cases, serious complications occurred, and one of them died shortly after the operation. Follow-up was done with a postal questionnaire. Eighty-eight percent of patients who were alive at the time of data analysis returned the questionnaire. The mean duration of follow-up was 28 months (range 1-80 months). There were no patients who reported a relapse of prolapse. Urinary incontinence, urge, stress, or mixed incontinence, was present in almost half of the cases. The time to full recovery after the operation was experienced to be less than 3 months for 48%. General satisfaction with the procedure was high with 88% being (very) satisfied. Conclusion. The operative correction of a pelvic organ prolapse in a group of women 80 years and older is a successful operation, with an acceptable morbidity and a high satisfaction of the patients.

Pelvic Organ Support Study (POSST): The distribution, clinical definition, and epidemiologic condition of pelvic organ support defects.
Swift S, Woodman P, O'boyle A, Kahn M, Valley M, Bland D, Wang W, Schaffer J
Am J Obstet Gynecol 2005 Mar;192(3):795-806.

Objective The purpose of this study was to describe the distribution of pelvic organ support in a gynecologic clinic population to define the clinical disease state of pelvic organ prolapse and to analyze its epidemiologic condition. Study design This was a multicenter observational study. Subjects who were seen at outpatient gynecology clinics who required an annual gynecologic examination underwent a pelvic organ prolapse quantification examination and completed a prolapse symptom questionnaire. Receiver operator characteristic curves were used to define pelvic organ prolapse with the use of symptoms and pelvic organ prolapse quantification examination measures. Standard age-adjusted univariate and multivariate logistic regression analysis were used to evaluate various relationships. Results The population consisted of 1004 women who were aged 18 to 83 years. The prevalence of pelvic organ prolapse quantification stages was 24% (stage 0), 38% (stage 1), 35% (stage 2), and 2% (stage 3). The definition of pelvic organ prolapse that was determined by the receiver operator characteristic curve was the leading edge of their vaginal wall that was -0.5 cm above the hymenal remnants. Multivariate analysis revealed age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus as risk factors for pelvic organ prolapse, as defined in this population. Conclusion The results from this population suggest that there is a bell-shaped distribution of pelvic organ support in a gynecologic clinic population. Advancing age, Hispanic race, increasing body mass index, and the increasing weight of the vaginally delivered fetus have the strongest correlations with prolapse.

Controversies and uncertainties: Abdominal versus vaginal surgery for pelvic organ prolapse.
Brubaker L
Am J Obstet Gynecol 2005 Mar;192(3):690-3.

Reconstructive pelvic surgery is a common phenomenon in American women. The efficacy and durability of current procedures are often extrapolated from clinical case series and may be fraught with bias. Although the route of reconstructive pelvic surgery is debated with little evidence to support expert opinion, several recent clinical trials have provided a modest amount of data that can assist surgeons in counseling women who are facing prolapse repairs. An individual woman's tolerance for certain symptoms and risks can be matched with the scientifically based evidence for certain procedures. It is clear that the route of surgery must vary with individual surgeons and individual patients. The challenge is to test current surgical habits using modern clinical trials to obtain the necessary information to optimize each and every woman's restorative surgery.

Randomized study on surgical treatment for vaginal prolapse.
Thompson PK
Am J Obstet Gynecol 2005 Feb;192(2):658.

The expression and function of the endothelin system in contractile properties of vaginal myofibroblasts of women with uterovaginal prolapse.
Poncet S, Meyer S, Richard C, Aubert JD, Juillerat-Jeanneret L
Am J Obstet Gynecol 2005 Feb;192(2):426-32.

Objective The endothelin-1 system regulates (myo)fibroblast contraction in wound healing. Our aim was to determine endothelin-1 system expression and function in contractile properties of vaginal myofibroblasts of women with uterovaginal prolapse. Study design Cultures of alpha-smooth muscle actin-positive myofibroblasts that were established at the time of repair surgery for prolapse (n = 30; mean age, 56 +/- 14 years) were analyzed and compared for their expression of the endothelin-1 system and contractile properties to myofibroblasts from primiparous women. Results Myofibroblasts expressed the complete endothelin system but did not secrete endothelin-1. Endothelin-1 binding was mediated exclusively by the endothelin B-receptor. In 3-dimensional collagen gels, spontaneous contraction of myofibroblasts from estrogen-treated women with prolapse was statistically significantly lower than from young primiparous women. Exogenous addition of endothelin-1 decreased the spontaneous contraction of myofibroblasts. Conclusion Genital myofibroblasts of women with uterovaginal prolapse are poorly contractile, and endothelin-1 further decreases vaginal myofibroblast contraction, which is opposite to observations in skin myofibroblasts.

Laparoscopic sacral colpopexy approach for genito-urinary prolapse: experience with 363 cases.
Rozet F, Mandron E, Arroyo C, Andrews H, Cathelineau X, Mombet A, Cathala N, Vallancien G
Eur Urol 2005 Feb;47(2):230-6.

OBJECTIVE: To evaluate the surgical outcome, complications and benefits of laparoscopic double promonto-fixation for patients with pelvic prolapse. METHODS: Women with genito-urinary prolapse underwent a transperitoneal placement of a 100% polyester mesh on the anterior vaginal wall and a posterior mesh on the levator ani muscle. Both of these were anchored to the sacral promontory. A TVT was placed simultaneously in patients who had concurrent stress urinary incontinence. RESULTS: A total of 363 patients were operated upon between 1996 and 2002. Their mean age was 63 (range 35-78), average follow-up was 14.6 months, the mean operating time was 97minutes. There were 8 conversions due to anesthetic or surgical difficulties. Follow up was done by a postal questionnaire and physical examination at 6 months and then yearly. 96% were satisfied with the results of their operation and no patients complained of sexual dysfunction. There was a 4% recurrence rate of prolapse, 3 vaginal erosions, 2 urinary retentions that required TVT section, 1 bowel incarcerations, 1 spondylitis and 2 mesh infection. CONCLUSIONS: Laparoscopic promonto-fixation is feasible and highly effective technique that offers good long-term results with complication rates similar to open surgery, with the added benefits of minimally invasive surgery.

Infected abdominal sacrocolpopexies: diagnosis and treatment.
Mattox TF, Stanford EJ, Varner E
Int Urogynecol J Pelvic Floor Dysfunct 2004 Sep-Oct;15(5):319-23. Epub 2004 May 14.

The abdominal sacrocolpopexy is an excellent procedure to surgically treat vaginal vault prolapse. A synthetic graft is often used to support the vaginal apex, but has the potential to become infected or erode, requiring its removal or revision. The purpose of this paper is to report our experience in the management of patients with infected synthetic grafts after abdominal sacrocolpopexy. A review of the patient databases from three specialty gynecology centers was performed from March 1996 to June 2002. Only patients with an infected graft after an abdominal sacrocolpopexy were included in the study; patients with either suture or graft erosion responding to conservative treatment were excluded. Twenty-two women, ages 37-73 years, developed infection of the synthetic graft after an abdominal sacrocolpopexy (1-60 months after their initial surgery, mean 8.8 months). The infected materials included polytetrafluoroethylene (PTFE, Goretex, n =15) and polypropylene (n=7). Nine of the 15 PTFE meshes and four of the seven polypropylene meshes were placed at the time of a contaminated case (abdominal hysterectomy [n=12], colon resection [n=1]). Eighteen (82%) of the infected grafts involved braided permanent suture to attach the graft to the vaginal wall, monofilament/non-braided permanent suture was used in three patients, and suture type could not be determined in one. All graft removals were attempted vaginally, and this was successful in 16 cases (73%). Two patients experienced significant bleeding: the first patient required an emergency laparotomy and the second patient's bleeding was controlled with packing. A rectovaginal fistula occurred 3 weeks postoperatively in one patient. Synthetic graft infection should be considered as the differential diagnosis in a patient who has undergone an abdominal sacrocolpopexy. Transvaginal removal is preferred, but is fraught with potentially serious complications. The use of braided permanent sutures to affix the graft to the vagina may be associated with mesh infections.

Translevator posterior intravaginal slingplasty: anatomical landmarks and safety margins.
Smajda S, Vanormelingen L, Vandewalle G, Ombelet W, Jonge ED, Hinoul P
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 27;.

The posterior intravaginal sling is a new tension-free needle suspension technique. It is used for the treatment of middle compartment (vaginal vault or uterine) prolapse. The Prolene sling suspends the vagina at the upper border of level II support as described by DeLancey (Am J Obstet Gynecol 166:1717, 1992). Human cadaveric dissections were undertaken to explore the pertinent anatomy that is involved when using this blind needle technique. Pre-dissected cadaveric material was used to obtain didactic illustrations of the anatomy of the procedure. Description of the surgical technique using anatomical landmarks and relative distances of the needle to these landmarks will improve the surgeon's visual understanding of the procedure. The measurements obtained demonstrate that the needle stays at a minimal distance of 4 cm away from the major (pudendal) vessels that could potentially cause life-threatening haemorrhage.

Prolapse of neovagina created with labia minora: a case report.
Coulon C, Orazi G, Nayama M, Cosson M
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 13;.

Prolapse of a neovagina created in patients with congenital vaginal aplasia is rare. A 55-year-old woman with a neovagina was referred for management of complete prolapse and stress urinary incontinence. At the age of 19 she had undergone surgery for creation of a neovagina using the labia minora. She accepted vaginal surgical treatment to correct her prolapse. A posterior intravaginal slingplasty was successfully performed, associated with tension-free vaginal tape through the obturator foramens. There is no other case of prolapse of a labia minora neovagina described in the literature. The common procedures were not adapted in this case. Indeed, the vaginal tissues were extremely fragile, making the dissection more difficult. The vaginal approach sounded interesting to us to correct this prolapse.

Surgical outcome of abdominal sacrocolpopexy with synthetic mesh versus abdominal sacrocolpopexy with cadaveric fascia lata.
Gregory WT, Otto LN, Bergstrom JO, Clark AL
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan 12;.

Nineteen women who had an abdominal sacrocolpopexy (ASC) with synthetic mesh and 18 women who had an ASC with freeze-dried, irradiated cadaveric fascia lata returned for blinded pelvic organ prolapse quantification (POPQ) examinations. The mean relative vaginal descent (delta) from perfect total vaginal length in the mesh group was 1.1 (0.3) cm, and the delta in the fascia group was 2.8 (0.8) cm (p=0.02, Mann-Whitney U). The proportion of women with "optimal" surgical outcome in the mesh group was 89% and 61% in the fascia group (p=0.06, Fischer's exact test). This study suggests that cadaveric fascia lata may not be a good choice for ASC.

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