Pelvic Organ Prolapse Clinical Trial
Official title:
Laparoscopic Lateral Suspension Versus Laparoscopic Sacral Colpopexy for Anterior and Apical Prolapse: an International Multicentric Randomized Trial
The aim of the study will be to compare the SCP and LLS in the management of apical prolapse at 6 weeks, 6 months, 1 year and yearly up to 2 years with the null hypothesis being that no significant differences existed between the two surgical procedures.
Background:
Pelvic Organ Prolapse (POP) is a frequent condition and can substantially affect a woman's
quality of life. It is widely accepted that POP when defined by symptoms has a prevalence of
3-6 % and up to 50 % when based upon vaginal examination. Only 10 to 20 percent of affected
women though seek evaluation for their condition. Although surgery is generally reserved for
patients with bothersome prolapse symptoms at an advanced stage after failure of conservative
treatments, a woman's lifetime risk of surgery for POP is 12-19%. Given the increasing
resources that will be required for POP surgery in the future it is crucial to seek durable,
cost effective interventions with minimal morbidity. Various surgical techniques exist for
the correction of POP for all three compartments and there is an ongoing debate about whether
to favour traditional vaginal techniques or abdominal approaches (either by laparoscopy,
robotically-assisted laparoscopy or laparotomy) using synthetic mesh. Despite the 2011 FDA
warning concerning POP repair with surgical mesh, transabdominal mesh procedures have not
come under severe scrutiny because of more favourable risk-benefit profile. That is why
sacrocolpopexy (SCP) is now considered as gold standard for the correction of apical POP and
can safely and efficiently be performed laparoscopically or with robotic assistance,
subsequently reducing length of hospitalization and recovery time. This technique however
requires dissection at the level of the promontory, which can be challenging, particularly in
obese women and when anatomical variation exists. Serious neurological or ureteral morbidity
as well as life-threatening vascular injury could be the consequence of potential lesions in
the sacral area. Moreover, significant dorso-lumbar pain in up to 50% of patients has been
described following the use of sutures or tackers at the sacrum and most significantly, up to
30% of patients will suffer from de novo constipation due to injury to the hypogastric nerve
during peritoneal dissection. Laparoscopic lateral suspension with mesh (LLS) could represent
an alternative procedure, avoiding dissection at the promontory. Previous studies have shown
that LLS is comparable in terms of subjective and objective outcome and that women are highly
satisfied. Both procedures remain untested against each other under the rigors of a
randomized controlled trial.
Hypothesis and primary objective :
The aim of the study will be to compare the SCP and LLS in the management of apical prolapse
at 6 weeks, 6 months, 1 year and yearly up to 2 years with the null hypothesis being that no
significant differences existed between the two surgical procedures.
Primary and secondary endpoints:
Primary outcome measures will be subjective cure of prolapse ("absence or presence of a bulge
in the vagina"), objective success with anatomic absence of advanced prolapse at POP-Q sites
Ba, C and Bp defined as less than 1 cm individually and as a total.
Secondary outcome measures include all other parameters such as perioperative outcomes,
patient satisfaction, quality of life outcomes, complications, scores on questionnaires and
reoperations.
The study protocol will be submitted to the institutional review boards of every
participating study site and written informed consent will be obtained from all participants
on enrolment.
Project design The investigators will perform an international multicentre single-blind
randomized controlled trial with participating tertiary referral hospital centres in Italy,
France, Germany and Switzerland.
PROJECT POPULATION AND STUDY PROCEDURES:
Project population, inclusion and exclusion criteria From September 2018, consecutive women
referred to one of the participating centers with symptomatic stage 2 or greater apical
prolapse (uterovaginal or vault prolapse) with or without anterior compartment prolapse and
without significant posterior compartment prolapse will be eligible for inclusion. Exclusion
criteria include those younger than 18 years of age, inability to comprehend questionnaires,
to give informed consent or to return for review, unable to undergo general anesthesia, prior
laparoscopic prolapse repair or vaginal mesh prolapse procedure or vaginal length less than 6
cm.
Recruitment, screening and informed consent procedure The investigators aim to end
recruitment in 2020. Patients will be approached and offered participation in our study. From
women who will be accepting to participate, informed consent will be obtained. Before surgery
women will be examined (POP-Q) by consultant and fellows in Urogynaecology, will complete
patient administered validated questionnaires. For Prolapse-related quality of life, the
investigators will use the Pelvic Organ Prolapse quality of life (P-QoL) which was validated
in French, Italian and German. For the assessment of lower urinary tract symptoms, the
investigators will use the International consultation on incontinence questionnaire for
female lower urinary tract symptoms (ICIQ-FLUTS) which was validated in French, Italian and
German. For the assessment of sexual function, the investigators will use either the Female
Sexual Function Index (FSFI) or the IUGA-revised Pelvic Organ Prolapse/Incontinence Sexual
Questionnaire, depending on the availability in the local language of the investigation site.
The FSFI is available in French and Italian and the PISQ-IR in French and German. For the
assessment of bowel dysfunction, the Wexner score will be used. All patients will undergo
multichannel urodynamics including at least a free-flow study, cystometry with bladder
filling to maximum of 500 mL, a stress-test in a sitting and standing position with and
without prolapse reduction and a pressure-flow. Prolapse will be reduced using sponge-holding
forceps at the apex. Women without symptoms of urinary stress incontinence (USI) and with
positive stress test with or without prolapse reduction will be considered as having occult
stress urinary in- continence (SUI). Those who will be eligible and agree to participation
will complete written consent forms and will be enrolled. After completion of study consent,
allocation to the SCP group or the LLS group will be done by computer generated randomization
by the study statistician. The prolapse repair (SCP or LLS) will be performed either with
traditional laparoscopy or with robotic assisted laparoscopy.
Clinical assessment and data collection:
Preoperative parameters will be defined as follows: Body Mass Index, Parity, Vaginal
deliveries, sexual activity, dyspareunia, hormonal status, previous operations including POP
surgery, hysterectomy, stress urinary incontinence, lower urinary tract symptoms such as
urgency, increased daytime frequency and nycturia. Perioperative parameters will be defined
as follows: operating time from knife to skin to cessation of cystoscopy. Intra- operative
blood loss will be defined in milliliters by the anesthetist. All patients will have the
indwelling catheter removed on day 1 and will complete a 24-hour trial of void. Patients will
be discharged after a successful trial of void or successful teaching of clean intermittent
self-catheterization (CISC) and not requiring analgetic injection in the last 12 hours.
Catheters days will be defined as days indwelling catheter or CISC was used. Admission days
will equal number of nights in hospital at midnight. Pain score at 1 month will be recorded
on a visual analogue scale of 0-10 (0 no pain; 10 worst pain).
Postoperative follow-up visits will be planned at 6 weeks, 6 months, 1 year and then yearly
up to 2 years.
The 6-week examination and review will be performed by the surgeon with all study data and
future visits completed by blinded co-authors (Different surgeon or Urogynaecology fellows)
who will be unaware of group allocation. Return to activities of daily living will be defined
as days to return to driving, preparing meals, and shopping.
Women with problems will be referred by the reviewers to our clinics for management.
Self-assessed patient satisfaction (circle a score that describes your satisfaction with
surgery) will be completed on a visual analogue scale (VAS) of 0-10 with 0 being lowest as
previously described and using the Patient Global Impression of Improvement (PGI-I).
At every subsequent follow-up visit, patients will be interviewed about prolapse symptoms,
asked to fill-out the previously mentioned questionnaires, the VAS, the PGI-I and the
following parameters will be assessed: sexual activity, dyspareunia, hormonal status,
operations for SUI, recurrent or de novo SUI, lower urinary tract symptoms such as urgency,
increased daytime frequency and nocturia. The investigators will also report complication
rates using the Clavien Dindo scale.
The investigators will follow the recommendations of the International Urogynaecology
Association (IUGA) for reporting outcome of surgical procedures for pelvic organ prolapse and
mesh-related complications will be classified using the joint International Urogynaecology
Association/International Continence Society (IUGA/ICS) complication classification
calculator.
STATISTICS AND METHODOLOGY:
Power calculation:
Given a 76% 2-year objective success rate for SP and 89% with LS, the sample size required to
detect a 30% difference in success rates with a power of 80% and alpha .05 was 47 per group.
To allow for drop of 15% and to ensure an adequately powered study 110 will be recruited. The
study will be registered at the clinical trials registry www.clinicaltrials.gov after the
enrollment of patients had commenced.
Methodology:
Frequency and percentages will be used to describe categorical variables, Fisher's exact test
will be used to compare treatment groups, and logistic regression to estimate odds ratios
(ORs) and associated 95% confidence intervals (95% CIs). Matched analyses for pre- and
post-consistency will use McNemar test. Means and standard deviations (SDs) will be used to
describe approximately normally distributed continuous data. Analysis of covariance (ANCOVA)
will be used to compare treatment groups at 1-year post intervention adjusting for
pre-intervention values and to estimate mean differences between treatment groups (95% CI).
Medians and range (minimum, maximum values) will be used to describe non-normally distributed
continuous data, Wilcoxon rank sum test will be used to compare treatment groups and Student
t test to estimate mean differences (95% CI). Paired t tests will be used for differences
between pre- and post-measurements. All analyses will be undertaken using SPSS version 24.0;
and 0.05 defined statistical significance for all tests. Data will be analyzed on an
intention- to-treat basis.
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