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1.  Rectus fascia colpopexy for post-hysterectomy vault prolapse: a valid option 
Objective
Considering the great variety of techniques and disagreement about the ideal route, there is a need for a safe, simple and effective method for the management of apical prolapse.
Material and Methods
Twenty seven cases of post- hysterectomy vault prolapse (twenty four following vaginal and three after total abdominal hysterectomy) were treated surgically by anterior abdominal wall colpopexy with autogenous rectus fascia strips.
Result
Except for minor complaints like- vomiting, fever and urinary retention in 3.7% cases each (n=1), no major complications were encountered. Moreover, no recurrence, on follow-up thus far.
Conclusion
Using autogenous rectus fascia strips in anterior abdominal wall colpopexy is not only a simple, cheap and effective method of treating vault prolapse but is also devoid of any serious complications such as described with other techniques.
doi:10.5152/jtgga.2010.01
PMCID: PMC3939092  PMID: 24591901
Vault Prolapse; rectus fascia; enterocoele
2.  Genital prolapse in women 
BMJ Clinical Evidence  2012;2012:0817.
Introduction
Prolapse of the uterus or vagina is usually the result of loss of pelvic support, and causes mainly non-specific symptoms. It may affect over half of women aged 50 to 59 years, but spontaneous regression may occur. Risks of genital prolapse increase with advancing parity and age, increasing weight of the largest baby delivered, and hysterectomy.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of non-surgical treatments in women with genital prolapse? What are the effects of surgical treatments in women with anterior vaginal wall prolapse? What are the effects of surgical treatments in women with posterior vaginal wall prolapse? What are the effects of surgical treatments in women with upper vaginal wall prolapse? What are the effects of using different surgical materials in women with genital prolapse? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2011 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 15 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: abdominal Burch colposuspension; abdominal sacral colpopexy; abdominal sacrohysteropexy; anterior colporrhaphy with mesh reinforcement; laparoscopic surgery; mesh or synthetic grafts; native (autologous) tissue; open abdominal surgery; pelvic floor muscle exercises; posterior colporrhaphy (with or without mesh reinforcement); posterior intravaginal slingplasty (infracoccygeal sacropexy); sacrospinous colpopexy (vaginal sacral colpopexy); sutures; traditional anterior colporrhaphy; transanal repair; ultralateral anterior colporrhaphy alone or with cadaveric fascia patch; vaginal hysterectomy; vaginal oestrogen; vaginal pessaries; and vaginal sacrospinous colpopexy.
Key Points
Prolapse of the uterus or vagina is usually the result of loss of pelvic support, and causes mainly non-specific symptoms. It may affect over half of women aged 50 to 59 years, but spontaneous regression may occur. Risks of genital prolapse increase with advancing parity and age, increasing weight of the largest baby delivered, and hysterectomy.
We don't know whether pelvic floor muscle exercises or vaginal oestrogen improve symptoms in women with genital prolapse, as we found few studies of adequate quality. The consensus is that vaginal pessaries are effective for relief of symptoms in women waiting for surgery, or in whom surgery is contraindicated, but we don't know this for sure.
In women with anterior vaginal wall prolapse, anterior vaginal wall repair may be more effective than Burch colposuspension at reducing recurrence, and adding mesh reinforcement to anterior colporrhaphy can reduce recurrence. Burch colposuspension may be more effective than anterior vaginal wall repair at reducing stress incontinence.
In women with posterior vaginal wall prolapse, posterior colporrhaphy is more likely to prevent recurrence compared with transanal repair of rectocoele or enterocoele. We don't know whether adding mesh reinforcement improves success rates in women having posterior colporrhaphy.
In women with upper vaginal wall prolapse, abdominal sacral colpopexy reduces the risk of recurrent prolapse, and of postoperative dyspareunia and stress incontinence compared with sacrospinous colpopexy. Posterior intravaginal slingplasty may be as effective as vaginal sacrospinous colpopexy at preventing recurrent prolapse. Vaginal hysterectomy and repair may reduce the need for re-operation and may be more effective at reducing symptoms, compared with abdominal sacrohysteropexy.
We don't know how surgical treatment compares with non-surgical treatment in women with prolapse of the upper, anterior, or posterior vaginal wall.
PMCID: PMC3635656  PMID: 22414610
3.  Genital prolapse in women 
BMJ Clinical Evidence  2009;2009:0817.
Introduction
Prolapse of the uterus or vagina is usually the result of loss of pelvic support, and causes mainly non-specific symptoms. It may affect over half of women aged 50 to 59 years, but spontaneous regression may occur. Risks of genital prolapse increase with advancing parity and age, increasing weight of the largest baby delivered, and hysterectomy.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of non-surgical treatments in women with genital prolapse? What are the effects of surgical treatments in women with anterior vaginal wall prolapse? What are the effects of surgical treatments in women with posterior vaginal wall prolapse? What are the effects of surgical treatments in women with upper vaginal wall prolapse? What are the effects of using different surgical materials in women with genital prolapse? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 14 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: abdominal Burch colposuspension; abdominal sacral colpopexy; abdominal sacrohysteropexy; anterior colporrhaphy with mesh reinforcement; laparoscopic surgery; mesh or synthetic grafts; native (autologous) tissue; open abdominal surgery; pelvic floor muscle exercises; posterior colporrhaphy (with or without mesh reinforcement); posterior intravaginal slingplasty (infracoccygeal sacropexy); sacrospinous colpopexy (vaginal sacral colpopexy); sutures; traditional anterior colporrhaphy; transanal repair; ultralateral anterior colporrhaphy alone or with cadaveric fascia patch; vaginal hysterectomy; vaginal oestrogen; vaginal pessaries; and vaginal sacrospinous colpopexy.
Key Points
Prolapse of the uterus or vagina is usually the result of loss of pelvic support, and causes mainly non-specific symptoms. It may affect over half of women aged 50 to 59 years, but spontaneous regression may occur. Risks of genital prolapse increase with advancing parity and age, increasing weight of the largest baby delivered, and hysterectomy.
We don't know whether pelvic floor muscle exercises or vaginal oestrogen improve symptoms in women with genital prolapse, as we found no studies of adequate quality. The consensus is that vaginal pessaries are effective for relief of symptoms in women waiting for surgery, or in whom surgery is contraindicated, but we don't know this for sure.
In women with anterior vaginal wall prolapse, anterior vaginal wall repair may be more effective than Burch colposuspension, and recurrence can be further reduced by adding mesh reinforcement to anterior colporrhaphy.
In women with posterior vaginal wall prolapse, posterior colporrhaphy is more likely to prevent recurrence than transanal repair of rectocoele or enterocoele. We don't know whether adding mesh reinforcement improves success rates in women having posterior colporrhaphy.
In women with upper vaginal wall prolapse, abdominal sacral colpopexy reduces the risk of recurrent prolapse, dyspareunia, and stress incontinence compared with sacrospinous colpopexy. Posterior intravaginal slingplasty may be as effective as vaginal sacrospinous colpopexy at preventing recurrent prolapse. Vaginal hysterectomy and repair may reduce the need for re-operation and may be more effective at reducing symptoms, compared with abdominal sacrohysteropexy.
We don't know how surgical treatment compares with non-surgical treatment in women with prolapse of the upper, anterior, or posterior vaginal wall.
PMCID: PMC2907774  PMID: 21726473
4.  Sacrospinous ligament suspension with transobturator mesh versus sacral colpopexy for genital prolapse 
Clinics  2016;71(9):487-493.
OBJECTIVE:
To compare the safety and efficacy of abdominal sacral colpopexy and sacrospinous ligament suspension with the use of vaginal mesh for apical prolapse.
METHOD:
This retrospective study was conducted from 2005 to 2012 and included 89 women with apical prolapse who underwent surgery. Assessments included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage. Rates of objective cure and immediate/late complications were compared.
RESULTS:
In total, 41 of the 89 women underwent sacrospinous ligament suspension, and 48 of the women underwent abdominal sacral colpopexy. A total of 40.4% of the women had vault prolapse (p=0.9361). Most of them had no complications (93.2%) (p=0.9418). Approximately 30% of the women had late complications; local pain was the main symptom and was found only in women who underwent the abdominal procedure (25.6%) (p=0.001). Only the women who were submitted to the vaginal procedure had mesh exposure (18.4%). The objective success rate and the rate of anterior vaginal prolapse (p=0.2970) were similar for both techniques.
CONCLUSION:
Sacrospinous ligament suspension was as effective and had a similar objective success rate as abdominal sacral colpopexy for the treatment of apical prolapse. Sacrospinous ligament suspension performed with the use of vaginal mesh in the anterior compartment was effective in preventing anterior vaginal prolapse after surgery.
doi:10.6061/clinics/2016(09)01
PMCID: PMC5004583  PMID: 27652828
Vaginal Prolapse; Surgical Mesh; Pelvic Organ Prolapse; Efficacy; Recurrence
5.  Two parallel, pragmatic, UK multicentre, randomised controlled trials comparing surgical options for upper compartment (vault or uterine) pelvic organ prolapse (the VUE Study): study protocol for a randomised controlled trial 
Trials  2016;17(1):441.
Background
One in three women who have a prolapse operation will go on to have another operation, though not necessarily in the same compartment. Surgery can result in greater impairment of quality of life than the original prolapse itself (such as the development of new-onset urinary incontinence, or prolapse at a different site). Anterior and posterior prolapse surgery is most common (90 % of operations), but around 43 % of women also have a uterine (34 %) or vault (9 %) procedure at the same time. There is not enough evidence from randomised controlled trials (RCTs) to guide management of vault or uterine prolapse. The Vault or Uterine prolapse surgery Evaluation (VUE) study aims to assess the surgical management of upper compartment pelvic organ prolapse (POP) in terms of clinical effectiveness, cost-effectiveness and adverse events.
Methods/design
VUE is two parallel, pragmatic, UK multicentre, RCTs (Uterine Trial and Vault Trial). Eligible for inclusion are women with vault or uterine prolapse: requiring a surgical procedure, suitable for randomisation and willing to be randomised. Randomisation will be computer-allocated separately for each trial, minimised on: requiring concomitant anterior and/or posterior POP surgery or not, concomitant incontinence surgery or not, age (under 60 years or 60 years and older) and surgeon. Participants will be randomly assigned, with equal probability to intervention or control arms in either the Uterine Trial or the Vault Trial. Uterine Trial participants will receive either a vaginal hysterectomy or a uterine preservation procedure. Vault Trial participants will receive either a vaginal sacrospinous fixation or an abdominal sacrocolpopexy. Participants will be followed up by postal questionnaires (6 months post surgery and 12 months post randomisation) and also reviewed in clinic 12 months post surgery. The primary outcome is the participant-reported Pelvic Organ Prolapse Symptom Score (POP-SS) at 12 months post randomisation.
Discussion
Demonstrating the efficacy of vault and uterine prolapse surgeries is relevant not only to patients and clinicians but also to health care providers, both in the UK and globally.
Trial registration
Current controlled trials ISRCTN86784244 (assigned 19 October 2012), and the first subject was randomly assigned on 1 May 2013 
Electronic supplementary material
The online version of this article (doi:10.1186/s13063-016-1576-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s13063-016-1576-x
PMCID: PMC5016955  PMID: 27609058
Uterine; Vault; Prolapse; Hysterectomy; Suspension; Symptoms; Randomised controlled trial
6.  Transvaginal Sacrospinous Ligament Fixation for Pelvic Organ Prolapse Stage III and Stage IV Uterovaginal and Vault Prolapse 
The result of transvaginal sacrospinous ligament fixation technique, as part of the vaginal repair procedure for massive uterovaginal (Pelvic Organ Prolapse stage III and stage IV and vault prolapse) is evaluated. A total of 32 women were included in the present case series. Marked uterovaginal prolapse was present in 28 women and four had vault prolapse following hysterectomy. Patients with vault prolapse and marked uterovaginal prolapse underwent sacrospinous colpopexy. The mean follow-up period was 2.5 years. Out of the 28 patients with previous marked uterovaginal prolapse, only one had small cystocele 3 years after the surgery. This patient was asymptomatic and did not require repeat surgery. One woman had post-operative urinary tract infection and two had buttock discomfort, one had ischiorectal abscess and two had cuff cellulitis. All complications were dealt with successfully. No other major intra- and post-operative complications occurred. Transvaginal sacrospinous colpopexy can be performed together with vaginal hysterectomy, with marked uterovaginal prolapse and vault prolapse.
PMCID: PMC4300482  PMID: 25648154
Prolapse; Vaginal hysterectomy; Repair
7.  Mesh–free Ventral Rectopexy for Women with Complete Rectal and Uterovaginal Prolapse 
Background:
Mesh rectopexy may be associated with infective complications, erosion into the vagina or rectum, and disintegration or dislodgement. A mesh-free rectopexy will avoid these complications. Objective of the study was to perform mesh-free ventral rectopexy and assess its safety and effectiveness.
Materials and Methods:
Nine women with complete rectal and uterovaginal prolapse were treated with total abdominal hysterectomy, closure of the vaginal vault, extirpation of the pouch of Douglas and suture of anterior rectal wall to the posterior vaginal wall (ventral suture rectopexy). The ventral suture rectopexy was achieved by three pairs of interrupted silk sutures, 2.5 cm above each other, and the first pair very close to the pelvic floor. This composite structure (anterior rectal wall and posterior vaginal wall), sits astride the perineal body. Intussusception and subsequent prolapse of the sutured rectum and vaginal wall is prevented. Vaginal vault prolapse was prevented by the suture of each round ligament of the uterus to the corresponding lateral vaginal fornix. No mesh was used.
Results:
Nine multiparous women aged between 52 and 70 years had the procedure. The mean operative time was 135 minutes (range 110-220). The follow-up period was between 29 months and 7 years. Full continence was restored in all patients within eight weeks of the operation. Bowel habit returned to once daily in four patients and once every other day in the remaining five patients, within thirteen weeks of surgery. One patient had intermittent mucus discharge per rectum for six months. This stopped without a specific treatment. There has been no known recurrence in these nine patients. One patient developed wound infection as a complication. There was no mortality. All the patients are now asymptomatic.
Conclusion:
Ventral suture rectopexy is a safe and effective treatment for complete rectal prolapse in a selected group of patients.
doi:10.4103/2006-8808.110256
PMCID: PMC3673367  PMID: 23741582
Mesh-free; rectal prolapse; uterovaginal prolapse; vaginal vault prolapse; ventral rectopexy
8.  Vaginal Vault Prolapse 
Introduction. Vaginal vault prolapse is a common complication following vaginal hysterectomy with negative impact on women's quality of life due to associated urinary, anorectal and sexual dysfunction. A clear understanding of the supporting mechanism for the uterus and vagina is important in making the right choice of corrective procedure. Management should be individualised, taking into consideration the surgeon's experience, patients age, comorbidities, previous surgery and sex life. Result. Preexisting pelvic floor defect prior to hysterectomy is the single most important risk factor for vault prolapse. Various surgical techniques have been advanced at hysterectomy to prevent vault prolapse. Studies have shown the McCall's culdoplasty under direct visualisation to be superior. Vault prolapse repair rely on either the use of patient's tissue or synthetic materials and can be carried out abdominally or vaginally. Sacrospinous fixation and abdominal sacrocolpopexy are the commonly performed procedures, with literature in favour of abdominal sacrocolpopexy over sacrospinous fixation due to its reported higher success rate of about 90%. Other less commonly performed procedures include uterosacral ligament suspension and illiococcygeal fixation, both of which are equally effective, with the former having a high risk of ureteric injury. Colpoclesis will play a greater role in the future as the aging population increases. Mesh procedures are gaining in popularity, and preliminary data from vaginal mesh procedures is encouraging. Laparoscopic techniques require a high level of skill and experience. There are many controversies on the mechanism of prolapse and management techniques, which we have tried to address in this article. Conclusion. As the aging population increases, the incidence of prolapse will also rise, older techniques using native tissue will continue, while new techniques using the mesh needs to be studied further. The later may well be the way forward in future.
doi:10.1155/2009/275621
PMCID: PMC2778877  PMID: 19936123
9.  Vaginal Treatment of Vaginal Cuff Dehiscence with Visceral Loop Prolapse: A New Challenge in Reparative Vaginal Surgery? 
Vaginal cuff dehiscence is a rare, but potentially morbid, complication of total hysterectomy and refers to separation of the vaginal cuff closure. The term vaginal cuff dehiscence is frequently interchanged with the terms of cuff separation or cuff rupture. All denote the separation of a vaginal incision that was previously closed at time of total hysterectomy. After dehiscence of the vaginal cuff, abdominal or pelvic contents may prolapse through the vaginal opening. Bowel evisceration, outside the vulvar introitus, can lead to serious sequelae, including peritonitis, bowel injury and necrosis, or sepsis. Therefore, although prompt surgical and medical intervention is required to replace prolapsed structures, the main problem remains the reconstruction of vaginal vault. In case of recent hysterectomy, vaginal reparation only requires the approximation of vaginal walls, including their fascia, while if dehiscence occurs after a long time from hysterectomy, the adequate suspension of the vaginal vault has to be taken into consideration. In this report we describe the case of a postmenopausal patient, undergoing surgical emergency because of the evisceration of an intestinal loop through a dehiscence of vaginal vault, after numerous reconstructive vaginal surgeries for vaginal prolapse. This paper analyzes clinical circumstances, risk factors, comorbidity, and clinical and surgical management of this complication.
doi:10.1155/2014/257398
PMCID: PMC4265380  PMID: 25525534
10.  Trans-vaginal total pelvic floor repair using customized prolene mesh: A safe and cost-effective approach for high-grade pelvic organ prolapse 
Aims:
To assess safety, efficacy, and cost-effectiveness of trans-vaginal total pelvic floor repair with customized prolene mesh in patients with high-grade pelvic organ prolapse.
Materials and Methods:
A total of 32 patients, who underwent trans-vaginal total pelvic floor repair using a customized prolene mesh from January 2007 to June 2010 for grade III and IV pelvic organ prolapse, were analyzed retrospectively. Prolapse was graded using Pelvic Organ Prolapse Quantification system of International Continence Society. Patients were evaluated for symptoms associated with prolapse pre- and postoperatively.
Results:
Of the 32 patients, 18 were grade IV uterine prolapse, 10 were grade III uterine prolapse, and 4 were grade IV vault prolapse. Twenty-eight patients underwent vaginal hysterectomy at the time of repair. All the patients had associated anterior and posterior prolapse of varying degree. Follow-up ranged from 6 to 42 months. All patients had symptomatic relief after surgery. There were no intraoperative rectal or bladder injuries. Early complications were perineal pain (30), de novo urgency (4), vaginal discharge (3), vaginal wall hematoma (2), and failure to void (2). Two patients had vaginal erosion of mesh.
Conclusions:
Trans-vaginal total pelvic floor repair using a customized prolene mesh is safe and effective treatment for comprehensive repair of high-grade pelvic organ prolapse. The use of this custom-made prolene mesh makes the procedure very cost-effective and affordable. The reduction in cost is about 25-30 times with the use of this mesh when compared with commercially available variety.
doi:10.4103/0970-1591.94949
PMCID: PMC3339780  PMID: 22557712
Customized prolene mesh; prolapse; trans vaginal tape
11.  Risk of Mesh Erosion With Sacral Colpopexy and Concurrent Hysterectomy 
Obstetrics and gynecology  2003;102(2):306-310.
OBJECTIVE
To examine short- and long-term mesh-related complications in women undergoing abdominal sacral colpopexy with concurrent hysterectomy, compared with women with a prior hysterectomy undergoing sacral colpopexy alone.
METHODS
Patient characteristics, hospital complications, postoperative clinical course, and long-term graft-related complications were reviewed for all women with genital prolapse who underwent abdominal sacral colopexy between 1996 and 1998. Women with concurrent hysterectomy were compared with women with vaginal prolapse after a prior hysterectomy.
RESULTS
One hundred twenty-four patients, 60 with concurrent hysterectomy and 64 with prior hysterectomy, were observed postoperatively for a median of 35.5 (0–74) months. Demographics of the two groups were similar, with a mean age of 65.1 ± 9.4 years and a mean body mass index of 25.8 ± 4.2 kg/m2. Eighty percent of colpopexies used prolene sythetic mesh and 20% allograft material. Initial operative and hospital complications were rare in both groups and included a blood transfusion of 2 U, a ureteral transection, a wound infection, heart block, and an arrhythmia. Delayed graft complications included one mesh erosion in a patient with a prior hysterectomy that was managed by office resection (0.8%).
CONCLUSION
Concurrent hysterectomy with abdominal sacral colopopexy has a low incidence of mesh complications and can be used as a first-line treatment for genital prolapse.
doi:10.1016/S0029-7844(03)00515-5
PMCID: PMC1364470  PMID: 12907104
12.  Treatment of uterine prolapse stage 2 or higher: a randomized multicenter trial comparing sacrospinous fixation with vaginal hysterectomy (SAVE U trial) 
BMC Women's Health  2011;11:4.
Background
Pelvic organ prolapse is a common health problem, affecting up to 40% of parous women over 50 years old, with significant negative influence on quality of life. Vaginal hysterectomy is currently the leading treatment method for patients with symptomatic uterine prolapse. Several studies have shown that sacrospinous fixation in case of uterine prolapse is a safe and effective alternative to vaginal hysterectomy. However, no large randomized trials with long-term follow-up have been performed to compare efficacy and quality of life between both techniques.
The SAVE U trial is designed to compare sacrospinous fixation with vaginal hysterectomy in the treatment of uterine prolapse stage 2 or higher in terms of prolapse recurrence, quality of life, complications, hospital stay, post-operative recovery and sexual functioning.
Methods/design
The SAVE U trial is a randomized controlled multi-center non-inferiority trial. The study compares sacrospinous fixation with vaginal hysterectomy in women with uterine prolapse stage 2 or higher. The primary outcome measure is recurrence of uterine prolapse defined as: uterine descent stage 2 or more assessed by pelvic organ prolapse quantification examination and prolapse complaints and/or redo surgery at 12 months follow-up. Secondary outcomes are subjective improvement in quality of life measured by generic (Short Form 36 and Euroqol 5D) and disease-specific (Urogenital Distress Inventory, Defecatory Distress Inventory and Incontinence Impact Questionnaire) quality of life instruments, complications following surgery, hospital stay, post-operative recovery and sexual functioning (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire). Analysis will be performed according to the intention to treat principle. Based on comparable recurrence rates of 3% and considering an upper-limit of 7% to be non-inferior (beta 0.2 and one sided alpha 0.025), 104 patients are needed per group.
Discussion
The SAVE U trial is a randomized multicenter trial that will provide evidence whether the efficacy of sacrospinous fixation is similar to vaginal hysterectomy in women with uterine prolapse stage 2 or higher.
Trial registration
Netherlands Trial Register (NTR): NTR1866
doi:10.1186/1472-6874-11-4
PMCID: PMC3045971  PMID: 21324143
13.  Mesh complications in female pelvic floor reconstructive surgery and their management: A systematic review 
We reviewed the incidence, predisposing factors, presentation and management of complications related to the use of synthetic mesh in the management of stress urinary incontinence and pelvic organ prolapse repair. Immediate complications, such as bleeding, hematoma, injury to adjacent organs during placement of mesh and complication of voiding dysfunction are not discussed in this review, since they are primarily related to technique. A PubMed search of related articles published in English was done from April 2008 to March 2011. Key words used were urinary incontinence, mesh, complications, midurethral sling, anterior prolapse, anterior vaginal repair, pelvic organ prolapse, transvaginal mesh, vault prolapse, midurethral slings, female stress urinary incontinence, mesh erosion, vaginal mesh complications, and posterior vaginal wall prolapse. Since there were very few articles dealing with the management of mesh-related complications in the period covered in the search we extended the search from January 2005 onwards. Articles were selected to fit the scope of the topic. In addition, landmark publications and Manufacturer and User Facility Device Experience (MAUDE) data (FDA website) were included on the present topic. A total of 170 articles were identified. The use of synthetic mesh in sub-urethral sling procedures is now considered the standard for the surgical management of stress urinary incontinence. Synthetic mesh is being increasingly used in the management of pelvic organ prolapse. While the incidence of extrusion and erosion with mid-urethral sling is low, the extrusion rate in prolapse repair is somewhat higher and the use in posterior compartment remains controversial. When used through the abdominal approach the extrusion and erosion rates are lower. The management of mesh complication is an individualized approach. The choice of the technique should be based on the type of mesh complication, location of the extrusion and/or erosion, its magnitude, severity and potential recurrence of pelvic floor defect.
doi:10.4103/0970-1591.98453
PMCID: PMC3424888  PMID: 22919127
Anterior vaginal repair; mesh complications; mid-urethral sling; pelvic organ prolapse; stress urinary incontinence
14.  Fallopian Tube Prolapse after Hysterectomy: A Systematic Review 
PLoS ONE  2013;8(10):e76543.
Background
Prolapse of the fallopian tube into the vaginal vault is a rarely reported complication that may occur after hysterectomy. Clinicians can miss the diagnosis of this disregarded complication when dealing with post-hysterectomy vaginal bleeding.
Objectives
We performed a systematic review in order to describe the clinical presentation, therapeutic management and outcome of fallopian tube prolapse occurring after hysterectomy.
Search Strategy
A systematic search of MEDLINE and EMBASE references from January 1980 to December 2010 was performed. We included articles that reported cases of fallopian tube prolapse after hysterectomy. Data from eligible studies were independently extracted onto standardized forms by two reviewers.
Results
Twenty-eight articles including 51 cases of fallopian tube prolapse after hysterectomy were included in this systematic review. Clinical presentations included abdominal pain, dyspareunia, post- coital bleeding, and/or vaginal discharge. Two cases were asymptomatic and diagnosed at routine checkup. The surgical management reported comprised partial or total salpingectomy, with vaginal repair in some cases combined with oophorectomy using different approaches (vaginal approach, combined vaginal-laparoscopic approach, laparoscopic approach, or laparotomy). Six patients were initially treated by silver nitrate application without success.
Conclusions
This systematic review provided a precise summary of the clinical characteristics and treatment of patients presenting with fallopian tube prolapse following hysterectomy published in the past 30 years. We anticipate that these results will help inform current investigations and treatment.
doi:10.1371/journal.pone.0076543
PMCID: PMC3792027  PMID: 24116117
15.  A systematic arrangement of laparoscopic total abdominal hysterectomy: a new technique. 
This sequential, prospective, observational clinical trial evaluated a systematic arrangement of laparoscopic total abdominal hysterectomy and prophylactic, retroperitoneal posterior culdoplasty with vaginal vault suspension surgical techniques by suturing method. The uterus was extirpated laparoscopically in 25 consecutive patients using an extra- and intra-corporeal two-turn flat square knot method. Upon completion of uterine excision, a new prophylactic laparoscopic technique of retroperitoneal posterior culdoplasty and vaginal vault suspension were initiated to prevent pelvic relaxation. Retroperitoneal culdoplasty was performed using the anterior rectal fascia, the posterior uterovaginal fascia, and the deep layer retroperitoneal of the uterosacral ligaments. Vaginal vault suspension was performed using posteriorly the deep layer of the uterosacral ligaments; from a lateroposterior aspect, the vaginal vault was suspended to the cardinal ligaments bilaterally, and anteriorly, the vesicouterine fascia provided support for the vaginal apex. A systematic arrangement of surgical steps was evaluated. All predetermined samples of laparoscopic total abdominal hysterectomy with posterior retroperitoneal culdoplasty and vaginal vault suspension were accomplished in a prearranged systematic order. Neither technical failure nor conversion to laparotomy or transvaginal approach was encountered. This technique expedites uterine extirpation and prophylactic pelvic reconstruction with a low complication rate, can be executed with no transvaginal approach, and eliminates the morbidity and mortality associated with laparotomy itself.
PMCID: PMC2608474  PMID: 10643213
16.  Assessment of the durability of robot-assisted laparoscopic sacrocolpopexy for treatment of vaginal vault prolapse 
Journal of Robotic Surgery  2007;1(2):163-168.
Transabdominal sacrocolpopexy has been shown, in multiple long-term studies of its success and durability, to be the definitive treatment option for post-hysterectomy vaginal vault prolapse. It is, however, associated with greater morbidity than vaginal repair. We describe a minimally invasive technique for vaginal vault prolapse repair and present our experience with a minimum of one-year follow-up. The surgical technique involves five laparoscopic ports—three for the da Vinci robot and two for the assistant. After appropriate dissection a polypropylene mesh is attached to the sacral promontory and to the vaginal apex by use of Gore-Tex sutures. The mesh material is then covered by the peritoneum. Patient analysis focused on complications, urinary continence, patient satisfaction, and morbidity, with a minimum of 12 months follow-up. Forty-two patients with post-hysterectomy vaginal vault prolapse underwent robot-assisted laparoscopic sacrocolpopexy at our institute and 35 have a minimum of 12 months follow-up, with a mean follow-up of 36 months (range 12–48) in the group. Mean age was 67 (47–83) years and mean operating time was 3.1 (2.15–4.75) h for the entire cohort. All but one patient were discharged home on postoperative day one; one patient left on postoperative day two. One developed recurrent grade three rectocele, one had recurrent vault prolapse, and two suffered from vaginal extrusion of mesh. All patients were satisfied with their outcome. The robot-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the reduced morbidity of laparoscopy. We observed reduced hospital stay, low occurrence of complications, and high patient satisfaction, with a minimum of 1-year follow-up. Most importantly, the long-term results of the robotic repair are similar to those of open repair, but with significantly less morbidity.
doi:10.1007/s11701-007-0028-8
PMCID: PMC4247457  PMID: 25484955
Robotics; Laparoscopy; Sacrocolpopexy; Vaginal vault prolapse
17.  Reaching the unreached: Mobile surgical camps in a remote village of Himachal Pradesh 
Journal of Mid-Life Health  2014;5(3):139-142.
Aims:
The aim was to study the epidemiological factors responsible for pelvic organ prolapse (POP) in poor women of the remote village Shillai, do their POP quantification staging, to study the variety of surgeries conducted in mobile surgical camps in this area.
Materials and Methods:
Retrospective analysis of surgeries conducted in five mobile surgical camps in Shillai, Himachal Pradesh from 2009 to 2013, under “Project Prolapse”.
Results:
A total number of surgeries conducted in five camps from 2009 to 2013 were 490 including 192 gynecological surgeries. Eighty-two percent of gynecological surgery was conducted for POP. Poor nutritional status (mean weight 41.1 kg), multiparty (mean 3.5), early marriage (mean age 18.2 years), unassisted home deliveries (100%), premature bearing down (23.8%), early postpartum resumption of strenuous activity (54.7%) and smoking (33%) contribute to the high incidence of POP. Anterior compartment prolapse was seen in 99% of patients undergoing surgery while posterior compartment prolapse was seen in 4% of patients. Vaginal hysterectomy with anterior repair with culdoplasty was the most common procedure performed (73.4%), and vault suspension was done in 3.6% subjects. The complication rate was negligible.
Conclusion:
Uterovaginal prolapse is not only socially embarrassing and disabling; its surgical treatment is complex and costly too. The free mobile surgical camps under Project Prolapse in Shillai, Himachal Pradesh has provided relief to old neglected, disabled women suffering from prolapse in this remote village. Parallel counseling of women and dais for safe hospital delivery and training subordinates in prolapse surgery may help in addressing the problem of POP in this area in the long run.
doi:10.4103/0976-7800.141215
PMCID: PMC4195187  PMID: 25317000
Menopausal problems; multiparty; pelvic organ prolapse; uterovaginal prolapse
18.  A rare case of vaginal vault evisceration and its management 
A 66 year old woman presented to A&E with per vagina bleeding and a mass protruding from the vagina. The patient was examined under anaesthesia, which revealed vaginal prolapse with evisceration of approximately 20-30 cm of bowel. The patient had received an abdominal hysterectomy 30 years ago for menorrhagia. In the last decade, the patient had experienced other recurrent episodes of prolapse (cystocoele and retrocoele). Vaginal vault evisceration is a recognised rare complication of hysterectomy and is a gynaecological emergency. This patient’s condition was rapidly recognised and surgically managed. The repair was achieved in two surgeries. Initially, the small bowel was re-inserted into the peritoneal cavity through the vaginal wall defect and the vaginal defect repaired. After sufficient time for healing, a sacrocolpopexy was performed to repair the prolapse.
doi:10.1093/jscr/2012.5.6
PMCID: PMC3649544  PMID: 24960134
19.  Prolapse of fallopian tube through abdominal wound after caesarean section mimicking scar endometriosis: a case report 
Introduction
Prolapse of the fallopian tube after hysterectomy is a rare but known complication. Cases of prolapse of the fallopian tube through the vaginal vault have been reported after abdominal, vaginal or laparoscopic hysterectomies. This is the first case report to the best of our knowledge on the prolapse of a fallopian tube through an abdominal wound after caesarean section.
Case presentation
We report a case of the prolapse of the fimbrial end of a fallopian tube through an abdominal scar after caesarean section mimicking scar endometriosis. A 24-year-old primipara South Asian woman of Punjabi ethnicity presented to our institute with a fleshy mass protruding through her abdominal scar and bleeding from the mass during menstruation for the past 5 months. She underwent a caesarean section 6 months earlier for breech presentation. Her history revealed she had wound dehiscence on the sixth postoperative day. The major portion of her wound healed in 1 month leaving a 2 cm area in the middle of her vertical scar. An abdominal examination revealed a 2×2 cm fleshy mass protruding through the middle part of her infraumbilical abdominal scar. At the time of the surgery we found that the fimbrial end of her left fallopian tube was protruding through her abdominal scar.
Conclusion
Awareness of this complication may prevent improper management of wound dehiscence and such complication causing prolonged agony to the patient.
doi:10.1186/s13256-015-0769-3
PMCID: PMC4682246  PMID: 26674349
Fallopian tube; Prolapse; Scar endometriosis
20.  Robotic Sacrocolpopexy: An Observational Experience at Mayoclinic, USA 
Although there are many studies the ongoing debate on the management of posthysterectomy vault prolapse whether it should be abdominal, vaginal, or laparoscopic still continues. However there is no clear consensus. Though the incidence of vaginal vault prolapse is said to range from 0.2 to 45%, the choice of the optimal treatment depends on the surgeon's experience, suitability for surgery, age, symptoms, quality of life impairment, and prolapse grade. Abdominal sacrocopopexy (ASCP) with mesh interposition is the traditional surgical procedure for treating pelvic organ prolapse and has been shown to have one of the highest long-term success rates for vaginal vault prolapse. The laparoscopic approach offers reduced morbidity, shorter hospitalization, and decreased post operative pain. The disadvantages of the laparoscopic approach include longer operating time and need for advanced laparoscopic surgical skills including suturing. Robot-assisted laparoscopic procedure allows the performance of complex laparoscopic maneuvers with less difficulty, and thereby simplifies the complex procedure. The aim is to describe and demonstrate the use and benefit of robot-assisted laparoscopic sacrocolpopexy in the treatment of posthysterectomy vaginal vault prolapse in obese patients along with mid-urethral sling application.
doi:10.4103/0974-1216.85285
PMCID: PMC3304284  PMID: 22442537
Mid-urethral sling; obese women; robotic sacrocolpopexy
21.  Laparoscopic Supracervical Hysterectomy With Transcervical Morcellation and Sacrocervicopexy: Initial Experience With a Novel Surgical Approach to Uterovaginal Prolapse 
The objective of this retrospective study was to evaluate the feasibility, safety, and efficacy of a new laparoscopic technique for the treatment of uterovaginal prolapse using a transcervical access port to minimize the laparoscopic incision. From February 2008 through August 2010, symptomatic pelvic organ prolapse in 43 patients was evaluated and surgically treated using this novel procedure. Preoperative assessment included pelvic examination, the pelvic organ prolapse quantification scoring system (POP-Q), and complex urodynamic testing with prolapse reduction to evaluate for symptomatic or occult stress urinary incontinence. The surgical procedure consisted of laparoscopic supracervical hysterectomy with transcervical morcellation and laparoscopic sacrocervicopexy with anterior and posterior mesh extension. Concomitant procedures were performed as indicated. All procedures were completed laparoscopically using only 5-mm abdominal port sites, with no intraoperative complications. Patients were followed up postoperatively for pelvic examination and POP-Q at 6 weeks, 6 months, and 12 months. The median (interquartile range) preoperative POP-Q values for point Aa was 0 (−1.0 to 1.0), and for point C was −1.0 (−3.0 to 2.0). Postoperatively, median points Aa and C were significantly improved at 6 weeks, 6 months, and 12 months (all p < .001). One patient was found to have a mesh/suture exposure from the sacrocervicopexy, which was managed conservatively without surgery. We conclude that laparoscopic supracervical hysterectomy with transcervical morcellation and laparoscopic sacrocervicopexy is a safe and feasible surgical approach to treatment of uterovaginal prolapse, with excellent anatomic results at 6 weeks, 6 months, and 12 months. Potential advantages of the procedure include minimizing laparoscopic port site size, decreasing the rate of mesh exposure compared with other published data, and reducing the rate of postoperative cyclic bleeding in premenopausal women by removing the cervical core. Longer follow-up is needed to determine the durability and potential long-term sequelae of the procedure.
doi:10.1016/j.jmig.2012.06.009
PMCID: PMC3693750  PMID: 23084680
Laparoscopic sacrocervicopexy; Laparoscopic supracervical hysterectomy; Pelvic organ prolapse; POP-Q; Transcervical morcellation
22.  Laparoscopic management of fallopian tube prolapse masquerading as adenocarcinoma of the vagina in a hysterectomized woman 
BMC Women's Health  2002;2:2.
Background
Fallopian tube prolapse as a complication of abdominal hysterectomy is a rare occurrence. A case with fallopian tube prolapse was managed by a combined vaginal and laparoscopic approach and description of the operative technique is presented.
Case presentation
A 39-year-old woman with vaginal prolapse of the fallopian tube after total abdominal hysterectomy presented with an incorrect diagnosis of adenocarcinoma of the vaginal apex. The prolapsed tube and cystic ovary were removed by vaginal and laparoscopic approach. The postoperative course went well.
Conclusions
Early or late fallopian tube prolapse can occur after total abdominal hysterectomy and vaginal hysterectomy. Symptoms consist of persistent blood loss or leukorrhea, dyspareunia and chronic pelvic pain. Vaginal removal of prolapsed tube with laparoscopic surgery may be a suitable treatment. The abdominal or vaginal approach used in surgical correction of prolapsed tubes must be decided in each case according to the patient's individual characteristics.
doi:10.1186/1472-6874-2-2
PMCID: PMC65047  PMID: 11818035
23.  Early results of a novel technique for anterior vaginal wall prolapse repair: anterior vaginal wall darn 
BMC Urology  2014;14:51.
Background
The aim of this study was to describe the results of a 1-year patient follow-up after anterior vaginal wall darn, a novel technique for the repair of anterior vaginal wall prolapse.
Methods
Fifty-five patients with anterior vaginal wall prolapse underwent anterior vaginal wall darn. The anterior vaginal wall was detached using sharp and blunt dissection via an incision beginning 1 cm proximal to the external meatus and extending to the vaginal apex. The space between the tissues that attach the lateral vaginal walls to the arcus tendineus fasciae pelvis was then darned. Cough Stress Test, Pelvic Organ Prolapse Quantification, seven-item Incontinence Impact Questionnaire, and six-item Urogenital Distress Inventory scores were performed 1-year postoperatively to evaluate recovery.
Results
One-year postoperatively, all patients were satisfied with the results of the procedure. No patient had vaginal mucosal erosion or any other complication.
Conclusions
One-year postoperative findings for patients in this series indicate that patients with stage II–III anterior vaginal wall prolapse were successfully treated with the anterior vaginal wall darn technique.
doi:10.1186/1471-2490-14-51
PMCID: PMC4105512  PMID: 24973955
Anterior vaginal wall prolapse; Darn; Pelvic organ prolapse; Stress urinary incontinence; Surgical technique
24.  Changes in Prolapse Surgery Trends Relative to FDA Notifications Regarding Vaginal Mesh 
Introduction and Hypothesis
In 2008 and 2011, the FDA released notifications regarding vaginal mesh. In describing prolapse surgery trends over time, we predicted vaginal mesh use would decrease and native-tissue repairs would increase.
Methods
Operative reports were reviewed for all prolapse repairs from 2008–2011 at our large regional hospital system. The number of each type of prolapse repair was determined per quarter year and expressed as a percentage of all repairs. Surgical trends were examined focusing on changes with respect to the release of 2 FDA notifications. We used linear regression to analyze surgical trends and Chi-square for demographic comparisons.
Results
1211 women underwent 1385 prolapse procedures. Mean age was 64+12 and 70% had stage III prolapse. Vaginal mesh procedures declined over time (p=0.001), comprising 27% of repairs in early 2008, 15% at the 1st FDA notification, 5% by the 2nd FDA notification, and 2% at the end of 2011. The percentage of native-tissue anterior/posterior repairs (p<0.001) and apical suspensions (p=0.007) increased, while colpocleisis remained constant (p=0.475). Despite an overall decrease in open sacral colpopexies (p<0.001), an initial increase was seen around the 1st FDA notification. We adopted laparoscopic/robotic techniques around this time, and the percentage of minimally invasive sacral colpopexies steadily increased thereafter (p<0.001). All sacral colpopexies combined as a group declined over time (p=0.011).
Conclusions
Surgical treatment of prolapse continues to evolve. Over a 4-year period encompassing 2 FDA notifications regarding vaginal mesh and the introduction of laparoscopic/robotic techniques, we performed fewer vaginal mesh procedures and more native-tissue repairs and minimally invasive sacral colpopexies.
doi:10.1007/s00192-013-2231-7
PMCID: PMC4049448  PMID: 24081497
FDA Public Health Notification; FDA Safety Communication; Pelvic organ prolapse; Prolapse repair; Prolapse surgery trends; Surgical trends; Vaginal mesh
25.  Laparoscopic Sacrocolpopexy, Hysterectomy, and Burch Colposuspension: Feasibility and Short-Term Complications of 77 Procedures 
Objective:
To report our first cases of laparoscopic sacropexy and assess the feasibility and short-term complications.
Methods:
We retrospectively studied 77 laparoscopic sacral colpopexies performed from June 1996 to May 1998. Suspension was reinforced with 2 strips of synthetic mesh. Five patients had previously undergone hysterectomy, and 4 others had experienced failure of surgery for prolapse of the uterus.
Results:
Laparoscopy was performed in 83 women with symptomatic prolapse of the uterus. Six cases required conversion to laparotomy because of technical difficulties. All of the remaining 77 patients underwent laparoscopic sacropexy that included anterior and posterior mesh reinforcement. Subtotal laparoscopic hysterectomy was performed in 60 cases, laparoscopic Burch colposuspension in 74, and levator myorrhaphy via a vaginal approach in 55. Operative time decreased from 292 to 180 minutes as experience was gained. The main operative complications were 1 rectal and 2 bladder injuries. Three patients required reoperations for hematoma or hemorrhage. One patient complained of chronic inflammation of the cervix, and another experienced rejection of the posterior mesh 6 months after the operation. Mean follow-up was 343 days. Three other patients required reoperation, 1 for a third-degree cystocele and 2 for recurrent stress incontinence.
Conclusion:
Laparoscopic sacrocolpopexy is feasible. Operative time and postoperative complications are related to the surgeon's experience but remain comparable to those noted in laparotomy. Long-term assessment is required to confirm the results of this procedure.
PMCID: PMC3043409  PMID: 12113413
Laparoscopy; Sacrocolpopexy; Mersilene mesh; Burch colposuspension

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