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Nüssler, Emil
Publications (9 of 9) Show all publications
Nüssler, E. K., Nüssler, E., Eskildsen, J. K. & Löfgren, M. (2019). Decisions to use surgical mesh in operations for pelvic organ prolapse: a question of geography?. International Urogynecology Journal, 30(9), 1533-1539
Open this publication in new window or tab >>Decisions to use surgical mesh in operations for pelvic organ prolapse: a question of geography?
2019 (English)In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 30, no 9, p. 1533-1539Article in journal (Refereed) Published
Abstract [en]

Introduction and hypothesis: Surgical mesh can reinforce damaged biological structures in operations for genital organ prolapse. When a method is new, scientific information is often contradictory. Individual surgeons may accept different observations as useful, resulting in conflicting treatment strategies. Additional scientific information should lead to increasing convergence.

Methods: Based on data from the Swedish National Quality Register of Gynecological Surgery, all patients who underwent their first recurrent anterior compartment prolapse operation between 2006 and 2017 were included (2758 patients). Surgical mesh was used in 56.5%. We analyzed inter-county disparities in and patterns of mesh use over 12 years. To minimize confounding, we selected a group of highly comparable patients where similar decision patterns could be expected.

Results: The use of mesh differed between counties by a factor of 11 (8.6-95.3%). Counties with low use of mesh continued with low use and counties with high use continued with high use.

Conclusions: Decisions regarding how to interpret existing scientific information about mesh implants in the early years of mesh use have led to "communities of practice" highly influenced by geographical factors. For 12 years, these groups have made disparate decisions and upheld them without measurable change toward consensus. The scientific learning process has stopped-despite the abundance of new publications and the steady supply of new types of mesh. Ongoing disparity in surgeons' choices in comparable patients has an adverse effect on clinical care. For the patient, this represents 12 years of a geographical lottery concerning whether mesh is used or not.

Place, publisher, year, edition, pages
Springer London, 2019
Quality control, Surgical decision-making, Surgical mesh, Surgical learning
National Category
Surgery Obstetrics, Gynecology and Reproductive Medicine
urn:nbn:se:umu:diva-163655 (URN)10.1007/s00192-018-3788-y (DOI)000482489100019 ()30343378 (PubMedID)
Available from: 2019-10-31 Created: 2019-10-31 Last updated: 2019-10-31Bibliographically approved
Nüssler, E., Granåsen, G., Nüssler, E. K., Bixo, M. & Löfgren, M. (2019). Repair of recurrent rectocele with posterior colporrhaphy or non-absorbable polypropylene mesh: patient-reported outcomes at 1-year follow-up.. International Urogynecology Journal, 30(10), 1679-1687
Open this publication in new window or tab >>Repair of recurrent rectocele with posterior colporrhaphy or non-absorbable polypropylene mesh: patient-reported outcomes at 1-year follow-up.
Show others...
2019 (English)In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 30, no 10, p. 1679-1687Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare the results of repair of isolated, recurrent, posterior vaginal wall prolapse using standard posterior colporrhaphy versus non-absorbable polypropylene mesh in a routine health care setting.

METHODS: This cohort study was based on prospectively collected data from the Swedish National Register for Gynaecological Surgery. All patients operated for recurrent, posterior vaginal wall prolapse in Sweden between 1 January 2006 and 30 October 2016 were included. A total of 433 women underwent posterior colporrhaphy, and 193 were operated using non-absorbable mesh. Data up to 1 year were collected.

RESULTS: The 1-year patient-reported cure rate was higher for the mesh group compared with the colporrhaphy group, with an odds ratio (OR) of 2.06 [95% confidence interval (CI) 1.03-4.35], corresponding to a number needed to treat of 9.7. Patient satisfaction (OR = 2.38; CI 1.2-4.97) and improvement (OR = 2.13; CI 1.02-3.82) were higher in the mesh group. However, minor surgeon-reported complications were more frequent with mesh (OR = 2.74; CI 1.51-5.01). Patient-reported complications and re-operations within 12 months were comparable in the two groups.

CONCLUSIONS: For patients with isolated rectocele relapse, mesh reinforcement enhances the likelihood of success compared with colporrhaphy at 1-year follow-up. Also, in our study, mesh repair was associated with greater patient satisfaction and improvement of symptoms, but an increase in minor complications. Our study indicates that the benefits of mesh reinforcement may outweigh the risks of this procedure for women with isolated recurrent posterior prolapse.

Colporrhaphy, National register data, Non-absorbable mesh, Patient-reported outcome, Rectocele
National Category
urn:nbn:se:umu:diva-164738 (URN)10.1007/s00192-018-03856-y (DOI)000490733000012 ()30627830 (PubMedID)
Available from: 2019-10-30 Created: 2019-10-30 Last updated: 2019-10-30Bibliographically approved
Nüssler, E. (2019). Vaginal prolapse surgery: an epidemiological perspective : studies of native tissue repair versus implants, surgeons´ practical experiences and five year follow-up in the swedish national quality register for gynecological surgery. (Doctoral dissertation). Umeå: Umeå universitet
Open this publication in new window or tab >>Vaginal prolapse surgery: an epidemiological perspective : studies of native tissue repair versus implants, surgeons´ practical experiences and five year follow-up in the swedish national quality register for gynecological surgery
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Pelvic organ prolapse (POP) is a common condition that impacts on quality of life for many women. The mean age of Swedish women operated for POP is 60 years, and with a life expectancy of approximately 84 years this means that the average patient will live 24 years subsequent to the operation. Therefore, sustainable long-term results of POP surgery are essential. In an effort to improve long-term outcomes of vaginal prolapse surgery, mesh materials have been developed for this purpose. In Sweden, synthetic mesh is used in 7.4% of all primary operations without any coherent consensus about their use. Prolapse surgery is regarded as a routine procedure performed at almost every hospital in Sweden, but a large proportion of the surgeons are inexperienced. In actuality, 73% of them perform the procedure once a month or less frequently. Simultaneously, surgery for POP has been reported to have a highfailure rate internationally. For most surgeons, the operation is a low-frequency procedure, and outcomes have been reported as unsatisfactory. The specific aims of these thesis were to examine:- Mesh-augmented repairs impact on operative results compared to nativetissue repair.- Surgical experience in performing a specific operation and utilize this knowledge in analysing how it may (or may not) affect operative results.- Long-term (5 year) national follow up of POP operations, regarding both the objective epidemiological data and the patient-reported outcomes.

Methods: The studies in this thesis are based on data from the Swedish National Quality Register for Gynaecological Surgery (GynOp), which covers approximately 90% of all gynaecological operations in Sweden. The comparative follow-up of POP surgery using non-absorbable polypropylene mesh versus colporrhaphy using native tissue was analysed in two different cohorts, of women with a primary cystocele and women with a relapse after surgery for a rectocele. Both surgeon reported results and patient-reported outcomes (PROMs) were analysed 1 year post-surgery. Information about surgeons’ experience in performing POP operations was extracted from GynOp over 9 years. Inclusion criteria were otherwise healthy patients who underwent anterior or posterior native tissue repair, or both. The operations were divided into four groups according to the operative experience of the surgeon (measured as average number of operations per active year). Both PROM results and surgeon-reported outcomes after 1 year were investigated. For the long-term follow-up 5 years after any operation for a vaginal prolapse, a new questionnaire to capture PROM data was designed, validated and nationally distributed. Information about re-operations was extracted directly from GynOp.

Results: Mesh-augmented repair of a primary cystocele had a significantly better outcome in terms of absence of symptoms, compared with native tissue repair, OR 1.53(95% CI 1.10-2.13), but also had more complications directly related to the procedure (OR 1.51, RD=6.6%). For recurrent rectocele, mesh was superior to native tissue repair, OR 2.06 (95% CI 1.03-4.35); the number of postoperative complications was equal in the two groups. Among the 1,092 surgeons who were active POP surgeons during the study, 803(73%) participated in POP operations once a month or less frequently in their active years. No differences in patient or surgeon-reported outcomes were seen between the “experience groups”. Kaplan-Meier curves for re-operation after a primary POP operation showed an overall retreatment rate of 11.2% after 5 years. The response rate for the patient questionnaire was 74.9%. Overall, 70% of the patients reported no symptoms, and around 72% and 82% were satisfied with the operative results and felt that their symptoms had improved, respectively.

Discussion: Mesh use was, after 1 year of follow-up, generally characterized by a high cure rate and varying degrees of complications, such as postoperative pain. However, for recurrent rectocele, we found no immediate drawbacks of the method compared with native tissue repair, with the same high cure rate as seen in other compartments. Surgeon experience had no impact on the native tissue operation, and any inconsistency of outcome is more likely inherent in the method than attributable to a surgeon’s lack of experience.The 5-year results indicate that native tissue repair produces much better results, judging from overall Swedish results, than previously thought. This is backed up both by objective data indicating a minimal number of re-operations within 5 years for the most common cases (i.e. primary rectocele and cystocele) and by the outcomes reported by the patients themselves.

Conclusions: Mesh-augmented repair is more effective than native tissue repair forrecurrent rectocele, and without increased risk of complications. Drawbacks of mesh repair vary for other compartments, and for primary operations.- Surgeons’ operative experience in routine POP operations using native tissue has no impact on outcome after 1 year.- Long-term results of POP repair with native tissue are excellent, with a low risk of re-operation and a persistent absence of subjective symptoms.

Abstract [sv]

Bakgrund: Prolaps av bäckenbottens organ, vaginalprolaps (POP) är en vanlig åkomma ochpåverkar livskvaliteten negativt för många kvinnor. Genomsnittsåldern för kvinnor som blir opererade för POP är 60 år och med en medellivslängd på cirka 84 år, betyder detta att den genomsnittliga patienten skall leva 24 år med operationsresultatet. Hållbara resultat av kirugi över lång tid är därför helt essentiell. I ett försök att förbättra långtidsresultaten av vaginalprolapsoperationer, blev nätmaterial (mesh) introducerat. I Sverige blir 7,4 % av alla primäroperationer (första operationen) gjorda med syntetiskt nätmaterial, utan någon samlad konsensus av hur och när näten skall användas. I Sverige anses POP-kirurgi vara rutinoperationer, som utförs på nästan alla sjukhus med en stor andel av operatörer med liten eller ingen rutin av operationen. Sammantaget blir 73 % av operationerna som utförs, gjorda avopertörer som i genomsnitt opererar POP en gång i månaden eller mindre. De flesta kirurger opererar alltså med låg frekvens och resultaten anses vara otillfredsställande. I ett globalt perspektiv, har rapporterats att operation för vaginalprolaps ofta misslyckas. Målen med avhandlingen var att undersöka:- Inflytande på det operativa resultatet när nät används jämfört medoperationer utan nät.- Hur operatörens erfarenhet påverkar operationsresultat.- En nationell långtidsuppföljning (5 år) av prolapsoperationer, avseende både objektiva epidemiologiska data och patientrapporterade utfall.

Metod: Studierna i denna avhandling är alla baserade på data från Nationella kvalitetsregistret inom gynekologisk kirurgi (GynOp) som täcker drygt 90 % av alla gynekologiska operationer utförda i Sverige. De komparativa analyserna av uppföljning av prolapskirurgi efter antingen operation med icke-resorberbar polypropylenmesh (nät) eller operation utan nät, blev analyserade i två olika kohorter: Kvinnor med primär cystocele (framfall urinblåsan) och kvinnor med återfall av rektocele (framfall ändtarmen). Både läkarrapporterade resultat och patientrapporterade utfall (PROM) blev analyserade efter 1 år. Information avseende kirurgens operativa erfarenhet av prolapsoperationer extraherades från GynOp databasen under en tidsperiod på 9 år. Avseende patienter var inklusionskriterier att de skulle vara i övrigt friska och genomgått antingen främre eller bakre plastik, eller en kombination av enbart de två. Operationerna blev uppdelade i 4 grupper, efter operatörernas praktiska erfarenhet (genomsnittligt antal operationer per aktivt år som operatör). Både PROM och läkarrapporterade resultat efter 1 år blev analyserade. För att undersöka långtidsresultaten efter operation för vaginalprolaps skapades en ny enkät, som efter validering distribuerades nationellt till patienter 5 år efter operationen. Information om reoperationsfrekvenser extraherades direkt frånGynOp.

Resultat: Nätoperationer vid primär cystocele hade signifikant bättre resultat ett år efter operation avseende patientrapporterad frånvaro av prolapssymptom än operation utan nät OR 1.53 (95% CI 1.10-2.13) men det rapporterades också fler komplikationer relaterade till operationen när nät användes (OR 1.51, RD=6.6%). För recidiverande rectocele var nätoperation överlägsen operationer utan nät OR 2.06 (95% CI 1.03-4.35) Mängden av postoperativa komplikationer var här den samma i båda operationsgrupperna. Av de 1092 operatörer som var registrerade som aktiva POP operatörer i studien,var 803 (73 %) aktiva i POP operationer enbart 1 gång per månad eller mindre de år de var aktiva. Det var ingen mätbar skillnad mellan ”erfarenhetsgrupper”avseende patientrapporterade eller läkarraporterade parametrar. Kaplan Meier kurvor (hållbarhetskurvor) för reoperationer efter en primär POP operaton utan nät, visade en återbehandlingsfrekvens på 11,2 % efter 5 år. Svarsfrekvensen på enkäten var 74,9 %. Av de som ej behandlats igen med operation hade 70 % av patienterna inga symptom, och respektive 72 % var nöjda med operationsresultaten och 82 % kände att deras symptom hade minskat.

Diskussion: Användning av nät, med 1 års uppföljning, jämfört med utan nät, karakteriserades av en högre botandegrad, men med fler komplikationer, bland annat postoperativ smärta. Detta undantaget recidiverande rectocele där inga skillnader i komplikationer jämfört med operationer utan nät hittades och med samma höga botandegradsom övriga nätoperationer.viiiOperatörens erfarenhet hade inget inflytande på operationens resultat, och en eventuellt låg botandegrad tycks vara mer sannolikt beroende på metoden, än på operatörens brist på erfarenhet. 5 års resultaten indikerar att operationer utan nät har mycket bättre resultat än hittills känt, baserat på de övergripande svenska resultaten. Detta stöds av både objektiva epidemiologiska data, som indikerar en minimal mängd reoperationer inom 5 år för de vanligaste fallen (såsom primära cysto- och rectocele), och av patientens egna svar på enkäten.

Konklusioner- Nätoperationer är mer effektiva i att bota recidiverande retocele, och har inga mätbara nackdelar avseende komplikationer.- Operatörens manuella erfarenhet med operationer utan nät hade inget inflytande på 1 års resultaten.- Långtidsresultaten efter operation utan nät är bra, med låg risk för reoperation och bestående frånvaro av prolapssymptom efter 5 år.

Abstract [da]

Baggrund: Prolaps af bækkenbundens organer (POP) er en almindelig lidelse, der stærkt påvirker livskvaliteten for mange kvinder. Den gennemsnitlige svenske kvinde opereret for POP er 60 år ved operationen, og med en forventet gennemsnitlig levealder på 84 år betyder dette, at patienten sandsynligvis vil leve omkring 24 år med operationsresultaterne. Netop derfor er pålidelige, holdbare langtidsresultater af operationen essentielle.I et forsøg på at forbedre især langtidsresultater af POP kirurgi, er net (mesh) materialer blevet introduceret. I Sverige bliver 7,4 % af alle primære operationer opereret med kirurgisk mesh uden nogen øjensynlig konsensus eller ensartethed hvad angår deres optimale brug.I Sverige bliver POP kirurgi ligeledes anset som rutineoperationer udført på stort set ethvert hospital med en stor proportion af uerfarne operatører. I realiteten opererer 73 % af samtlige operatører, der har noget at gøre med POP operationer, mindre end 1 POP-operation om måneden i gennemsnit. POP er i litteraturen desuden rapporteret at være behæftet med en høj rate af mislykkede operationer. Det vil sige, at for de fleste kirurger bliver denne procedure udført med meget lav frekvens, og samtidigt er resultaterne øjensynligt utilfredsstillende. Målene med denne doktorafhandling var at undersøge:- Operationsresultater med mesh sammenlignet med operation uden mesh.- Lægens manuelle erfaring med native POP operationer, og hvordan (eller hvordan ikke) den har indflydelse på resultaterne.- Langtidsresultaterne (5 år) på national basis for POP operationer, både iforhold til de objektive epidemiologiske data og de patientrapporterede udfald.

Metoder: Både de lægerapporterede og de patientrapporterede resultater (PROM) blev analyseret 1 år efter operationen. Information angående lægens erfaring med POP blev taget direkte fra GynOp databasen, og er opsamlet over en periode på 9 år. Inklusionskriterier for patienter var at de skulle være ellers raske, og været opereret med enten kolporrafia anterior eller kolporrafia posterior (eller begge). Operationer blev opdelt i 4 grupper, alt efter den mængde manuel erfaring lægerne havde (målt som gennemsnitligt antal operationer per aktivt år). Både PROM og lægerraporterede parametre blev undersøgt efter 1 år. For at undersøge langtidsresultater 5 år efter operationen, blev et helt nyt spørgeskema designet, valideret, og distribueret nationalt. Information angående reoperationsfrekvens blev taget direkte fra GynOp databasen.

Resultater: Ved primære cystoceler, havde operation med kirurgisk mesh bedre resultater end den native operation hvad angår patienternes prolapssymptomer 1 år efteroperationen OR 1.53 (95% CI 1.10-2.13), men var også behæftet med væsentligt flere operationskomplikationer (OR 1.51, RD=6.6%). For recidiverende rectocele, var mesh også overlegen den native operation OR 2.06 (95% CI 1.03-4.35), men ikke behæftet med flere komplikationer i kølvandet af operationen. Iblandt de 1092 kirurger der var aktive som Pop operatører under studiet, opererede 803 (73 %) mindre end 1 gang om måneden i snit i deres aktive år. Ingen forskel i patient- eller lægerapporterede parametre blev set mellem de forskellige erfaringsgrupper. Den overordnede reoperationsfrekvens vist ved Kaplan Meier kurver efter primære POP operationer var 11,2% efter 5 år. Svarsfrekvensen på spørgeskemaet var 74,9 %. Overordnet efter 5 år, svarede omkring 70 % af alle patienter at de ikke havde prolapssymptomer, samt 72 %angav at være tilfredse med operationsresultatet. Desuden angav 82 % at deres prolapssymptomer var væsentligt forbedrede i forhold til inden operationen.

Diskussion: Resultater af mesh med 1 års follow up sammenlignet med nativoperation, er generelt karakteriseret ved en høj grad af symptomfravær, men varierende grader af ulemper såsom en øget mængde postoperativ smerte. Dog, unikt for recidiverende rektocele ses også denne samme høje grad af symptomfrihed, uden nogen umiddelbare ulemper i forhold til den native operation. Operatørens erfaring har ikke nogen indflydelse på den native operation, og utilfredsstillende resultater er mere sandsynligt iboende metoden end at dette skal henføres til operatørens mangel på erfaring. Resultaterne efter 5 år indikerer, at kolporrafi producerer meget bedre resultater på nationalplan end først antaget. Dette bakkes op af både de rent objektive data der indikerer et minimalt antal re-operationer i løbet af 5 år i de mest almindelige tilfælde (primære, raske, cystocele og rektocele patienter) og af patienternes egne svar ved 5 års followup.

Konklusioner- Mesh-operationer er at foretrække ved recidiverende rektocele, men har en varierende komplikationsprofil ved primære operationer, og operationer i andre compartment.- Operatørens manuelle erfaring med nativ-operationer har ingen indflydelse på det overordnede resultat af operationen efter 1 år.- Langtidsresultater efter nativ-operationer er ganske udmærkede, med en lav risiko for re-operation og et vedholdende fravær af patientrapporterede symptomer.

Abstract [de]

Hintergrund: Prolaps der weiblichen Beckenorgane (POP) ist eine häufige Erkrankung, die sich auf die Lebensqualität vieler Frauen auswirkt. In Schweden ist das Durchschnittsalter der für POP operierten Frauen 60 Jahre. Bei einer Lebenserwartung von etwa 84 Jahren bedeutet dies, dass eined urchschnittliche Patientin weitere 24 Jahre nach der Operation lebt. Verlässliche Langzeitergebnisse nach POP-Chirurgie sind daher unentbehrlich. In dem Bestreben, die langfristigen Ergebnisse nach einer Operation für Vaginalprolaps zu verbessern, wurden Netzmaterialien zum Einsatz gebracht. In Schweden wird synthetisches Netz bei 7,4 % aller Primäroperationen verwendet, ohne dass ein kohärenter Konsens über deren Verwendung besteht. In Schweden wird die POP-Operation als Routineoperation angesehen, die in fast allen Krankenhäusern durchgeführt wird. Ein großer Teil der Chirurgen ist unerfahren, 73 % führen den Eingriff einmal im Monat oder weniger durch. Gleichzeitig weisen POP-Operationen in globaler Sicht eine hohe Ausfallrate auf. Das Ziel dieser Arbeit ist es zu untersuchen:- Einfluss von netzverstärkten Operationen auf die operativen Ergebnisse im Vergleich zu Plastiken mit nativem Gewebe.- Hat chirurgische Erfahrung mit POP-Operationen Bedeutung für dieoperativen Ergebnisse von Nativoperationen (und in welchem Ausmaß)?- Langfristige (5-jährige) nationale Verlaufskontrolle von native POP Operationen, sowohl in Bezug auf objektive epidemiologische Daten als auch auf die von Patienten gemeldeten Ergebnisse.

Methoden: Alle verwendeten Daten wurden aus der Datenbank des Nationalen Qualitätsregisters für gynäkologische Chirurgie (GynOp) extrahiert. In Bezug auf die Erfahrungen der Chirurgen mit POP-Operationen wurden überneun Jahre kontinuierlich und prospektiv gesammelte GynOp Daten verwendet. Sowohl die vom Chirurgen als auch die vom Patienten berichteten Ergebnisse(PROM) wurden nach einem Jahr analysiert. Einschlusskriterien waren ansonsten gesunde Patienten, bei denen eine Reparatur des anterioren oder posterioren Kompartment (oder beides) mitnativem Gewebe durchgeführt wurde. 

Die Operationen wurden je nach manueller Erfahrung des Chirurgen in vier Gruppen eingeteilt (durchschnittliche Anzahl Operationen pro aktives Jahr).Für das Langzeit-Follow-up fünf Jahre nach einer Vorfalloperation wurde ein neuer Fragebogen zur Erfassung von PROM-Daten entworfen, validiert und national angewendet. Informationen zu Reoperationen wurden direkt aus GynOp extrahiert.

Ergebnisse: Die netzverstärkte Operationen einer primären Zystozele zeigten ein signifikant besseres Ergebnis in Bezug auf das Fehlen von Prolaps Symptomen im Vergleich zur Operation mit nativen Gewebe, OR 1,53 (95% CI 1,10-2,13), aber auch eine erhöhte Anzahl Komplikationen, die in direktem Zusammenhang mit der Operation standen (OR 1,51; RD = 6,6 %). Bei rezidivierenden Rektozelen war das Netz der Operation mit nativem Gewebe klar überlegen OR 2.06 (95% CI 1.03-4.35). Die Anzahl der postoperativen Komplikationen war in beiden Gruppen gleich. Unter den 1 092 Chirurgen, die während der Studie operativ aktiv waren, nahmen 803 Chirurgen (73 %) in ihren aktiven Jahren einmal im Monat oder weniger an einer POP-Operation teil. Es wurden keine Unterschiede in den von Patienten oder Chirurgen berichteten Ergebnissen zwischen den „Erfahrungsgruppen“ festgestellt. Nach fünf Jahren zeigte eine Kaplan-Meier-Kurve eine chirurgische Reoperationsrate von 11,2 %. Die Rücklaufquote des Patientenfragebogens betrug 74,9 %. Insgesamt gaben 70 % der Patienten keine Symptome an. 72 % und 82 %waren mit den operativen Ergebnissen zufrieden und fühlten, dass sich ihre Symptome besserten.

Diskussion: Die Netzanwendung ist nach einjähriger Nachsorge im Allgemeinen durch eine hohe Heilungsrate und unterschiedlich schwere Komplikationen sowiepostoperative Schmerzen gekennzeichnet. Bei rezidivierenden Rektozelen wurden jedoch keine unmittelbaren Nachteile der Netzanwendung im Vergleich zur nativen Gewebereparatur festgestellt. Gleichzeitig sieht man signifikant verbesserte Heilungsraten wie in anderen Kompartments. Die Erfahrung des Chirurgen hat keinen Einfluss auf die Ergebnisse bei einer Operation mit nativem Gewebe. Inkonsistente Ergebnisse sind wahrscheinlicher Methode bedingt als dass dies auf mangelnde Erfahrung des Chirurgen zurückzuführen währe.

Die Fünfjahresergebnisse deuten darauf hin, dass für primäre Rekto- und Zystozelen die Operation mit nativem Gewebe viel bessere Ergebnisse erbringt als bisher angenommen. Dies wird sowohl durch eine minimale Anzahl von Reoperationen innerhalb von fünf Jahren untermauert als auch durch die von den Patienten selbst berichteten Ergebnisse.

Schlussfolgerungen- Bei rezidivierenden Rektozelen ist eine netzverstärkte Operation signifikant haltbarer als eine Operation mit nativem Gewebe, mit vergleichbaren Komplikationsprofil. Die Vor- und Nachteile sind für die anderen Fällen variierend.- Die operative Erfahrung eines Chirurgen (Anzahl POP Operationen mitnativem Gewebe) hat keinen Einfluss auf das 1-Jahres Ergebnis von Operationen mit nativem Gewebe.- Die Langzeitergebnisse nach POP Operationen mit nativem Gewebe sind ausgezeichnet, mit einem geringen Risiko für eine Reoperation und einem anhaltenden Fehlen subjektiver Prolaps Symptomen.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2019. p. 79
Umeå University medical dissertations, ISSN 0346-6612 ; 2051
pelvic organ prolapse, Kaplan-Meier curves, long-term follow-up, quality register, questionnaire, patient reported outcome, cystocele, rectocele, colporrhaphy, non-absorbable mesh, surgical experience
National Category
Medical and Health Sciences
Research subject
health services research; Obstetrics and Gynaecology
urn:nbn:se:umu:diva-164725 (URN)978-91-7855-113-2 (ISBN)
Public defence
2019-11-22, Hörsal A, Unod T9, Daniel Naezéns väg, 907 37 Umeå, Sverige, Umeå, 13:00 (Swedish)
Available from: 2019-11-01 Created: 2019-10-29 Last updated: 2019-10-31Bibliographically approved
Bohlin, K. S., Ankardal, M., Nüssler, E., Lindkvist, H. & Milsom, I. (2018). Factors influencing the outcome of surgery for pelvic organ prolapse. International Urogynecology Journal, 29(1), 81-89
Open this publication in new window or tab >>Factors influencing the outcome of surgery for pelvic organ prolapse
Show others...
2018 (English)In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 29, no 1, p. 81-89Article in journal (Refereed) Published
Abstract [en]

Pelvic organ prolapse (POP) surgery is a common gynecological procedure. Our aim was to assess the influence of obesity and other risk factors on the outcome of anterior and posterior colporrhaphy with and without mesh. Data were retrieved from the Swedish National Register for Gynecological Surgery on 18,554 women undergoing primary and repeat POP surgery without concomitant urinary incontinence (UI) surgery between 2006 and 2015. Multivariate logistic regression analyses were used to identify independent risk factors for a sensation of a vaginal bulge, de novo UI, and residual UI 1 year after surgery. The overall subjective cure rate 1 year after surgery was 80% (with mesh 86.4% vs 77.3% without mesh, p < 0.001). The complication rate was low, but was more frequent in repeat surgery that were mainly mesh related. The use of mesh was also associated with more frequent de novo UI, but patient satisfaction and cure rates were higher compared with surgery without mesh. Preoperative sensation of a vaginal bulge, severe postoperative complications, anterior colporrhaphy, prior hysterectomy, postoperative infections, local anesthesia, and body mass index (BMI) 30 were risk factors for sensation of a vaginal bulge 1 year postsurgery. Obesity had no effect on complication rates but was associated increased urinary incontinence (UI) after primary surgery. Obesity had no influence on cure or voiding status in women undergoing repeat surgery. Obesity had an impact on the sensation of a vaginal bulge and the presence of UI after primary surgery but not on complications.

Place, publisher, year, edition, pages
Springer London, 2018
Body mass index, Mesh, Obesity, Pelvic organ prolapse, Postoperative complications, Urinary continence
National Category
Obstetrics, Gynecology and Reproductive Medicine
urn:nbn:se:umu:diva-144089 (URN)10.1007/s00192-017-3446-9 (DOI)000419451200011 ()28894904 (PubMedID)
Available from: 2018-01-29 Created: 2018-01-29 Last updated: 2018-06-09Bibliographically approved
Nüssler, E., Eskildsen, J. K., Nüssler, E. K., Bixo, M. & Löfgren, M. (2018). Impact of surgeon experience on routine prolapse operations. International Urogynecology Journal, 29(2), 297-306
Open this publication in new window or tab >>Impact of surgeon experience on routine prolapse operations
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2018 (English)In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 29, no 2, p. 297-306Article in journal (Refereed) Published
Abstract [en]

Introduction and hypothesis: Surgical work encompasses important aspects of personal and manual skills. In major surgery, there is a positive correlation between surgical experience and results. For pelvic organ prolapse (POP), this relationship has to our knowledge never been examined. In any clinical practice, there is always a certain proportion of inexperienced surgeons. In Sweden, most prolapse surgeons have little experience in performing prolapse operations, 74% conducting the procedure once a month or less. Simultaneously, surgery for POP globally has failure rates of 25-30%. In other words, for most surgeons, the operation is a low-frequency procedure, and outcomes are unsatisfactory. The aim of this study was to clarify the acceptability of having a high proportion of low-volume surgeons in the management of POP.

Methods: A group of 14,676 exclusively primary anterior or posterior repair patients was assessed. Data were analyzed by logistic regression and as a group analysis.

Results: Experienced surgeons had shorter operation times and hospital stays. Surgical experience did not affect surgical or patient-reported complication rates, organ damage, reoperation, rehospitalization, or patient satisfaction, nor did it improve patient-reported failure rates 1 year after surgery. Assistant experience, similarly, had no effect on the outcome of the operation.

Conclusions: A management model for isolated anterior or posterior POP surgery that includes a high proportion of low-volume surgeons does not have a negative impact on the quality or outcome of anterior or posterior colporrhaphy. Consequently, the high recurrence rate was not due to insufficient experience of the surgeons performing the operation.

Place, publisher, year, edition, pages
Springer, 2018
pelvic organ prolapse, national register data, patient-reported outcome, surgical outcome, quality control, learning curve
National Category
urn:nbn:se:umu:diva-144825 (URN)10.1007/s00192-017-3353-0 (DOI)000423154300017 ()28577172 (PubMedID)

Errata: Nüssler, E., Eskildsen J. K., Nüssler, E. K., Bixo, M., Löfgren, M. Impact of surgeon experience on routine prolapse operations. International Urogynecology Journal 2018;29:2. DOI: 10.1007/s00192-017-3525-y

Available from: 2018-03-05 Created: 2018-03-05 Last updated: 2019-10-30Bibliographically approved
Campbell, J., Pedroletti, C., Ekhed, L., Nüssler, E. & Strandell, A. (2018). Patient-reported outcomes after sacrospinous fixation of vault prolapse with a suturing device: a retrospective national cohort study. International Urogynecology Journal, 29(6), 821-829
Open this publication in new window or tab >>Patient-reported outcomes after sacrospinous fixation of vault prolapse with a suturing device: a retrospective national cohort study
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2018 (English)In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 29, no 6, p. 821-829Article in journal (Refereed) Published
Abstract [en]

Introduction and hypothesis: Innovations in suturing devices have facilitated sacrospinous ligament fixation (SSF) for the correction of vaginal vault prolapse. It is uncertain if outcomes using suturing devices differ from those using a traditional suturing technique. We hypothesize that no difference exists in the efficacy and safety 1 year after SSF for vault prolapse performed with suturing devices or using a traditional technique. The objective was to compare SSF using a suturing device with traditional SSF for the treatment of vault prolapse, regarding symptoms of prolapse recurrence, patient satisfaction, incidence of re-operation, and complications 1 year postoperatively.

Methods: We carried out a retrospective cohort study using register-based national data from 2006 to 2013. The Swedish Quality Register of Gynecological Surgery includes assessments pre-operatively, at hospital admittance, surgery, discharge, and questionnaires at 8 weeks and 1 year after surgery. Demographic variables and surgical methods were included in multivariate logistic regression analyses.

Results: In the suturing device group (SDG, n = 353), 71.5% were asymptomatic of recurrence after 1 year compared with 78.7% in the traditional SSF group (TSG, n = 195); risk difference - 7.3% (95%CI -15.2%; 0.7%). Adjusted odds ratio (aOR) for being asymptomatic 1 year postoperatively was 0.56 (95%CI 0.31; 1.02, p = 0.057). Patient satisfaction was similar in SDG and TSG (78.1% vs 78.4%). Reoperation occurred in 7.4% in the SDG compared with 3.6% in the TSG, risk difference 3.8% (95%CI 0.0%; 7.5%), aOR 3.55 (95%CI 1.10; 11.44, p = 0.03).

Conclusions: Patient satisfaction was similar 1 year after SSF, despite symptoms of recurrence being more likely and reoperation more common after using a suturing device compared with a traditional technique. The methods did not differ with regard to surgical complications.

Place, publisher, year, edition, pages
Springer, 2018
patient-reported outcome, sacrospinous ligament fixation, suturing device, vault prolapse
National Category
Obstetrics, Gynecology and Reproductive Medicine
urn:nbn:se:umu:diva-148015 (URN)10.1007/s00192-017-3491-4 (DOI)000431930700007 ()28988359 (PubMedID)
Available from: 2018-05-30 Created: 2018-05-30 Last updated: 2018-06-09Bibliographically approved
Madsen, L. D., Nüssler, E., Kesmodel, U. S., Greisen, S., Bek, K. M. & Glavind-Kristensen, M. (2017). Native-tissue repair of isolated primary rectocele compared with nonabsorbable mesh: patient-reported outcomes. International Urogynecology Journal, 28(1), 49-57
Open this publication in new window or tab >>Native-tissue repair of isolated primary rectocele compared with nonabsorbable mesh: patient-reported outcomes
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2017 (English)In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 28, no 1, p. 49-57Article in journal (Refereed) Published
Abstract [en]

We evaluated patient-reported outcomes and complications after treatment of isolated primary rectocele in routine health-care settings using native-tissue repair or nonabsorbable mesh. We used prospective data from the Swedish National Register for Gynaecological Surgery and included 3988 women with a primary operation for rectocele between 2006 and 2014: 3908 women had native-tissue repair, 80 were operated with nonabsorbable mesh. No concurrent operations were performed. Pre- and perioperative data were collected from doctors and patients. Patient-reported outcomes were evaluated 2 and 12 months after the operation. Only validated questionnaires were used. One year after native-tissue repair, 77.8 % (76.4-79.6) felt they were cured, which was defined as never or hardly ever feeling genital protrusion; 74.0 % (72.2-75.7) were very satisfied or satisfied, and 84 % (82.8-85.9) reported improvement of symptoms. After mesh repair, 89.8 % (77.8-96.6) felt cured, 69.2 % (54.9-81.3) were very satisfied or satisfied, and 86.0 % (72.1-94.7) felt improvement. No significant differences were found between groups. Organ damage was found in 16 (0.4 %) patients in the native-tissue repair group compared with one (1.3 %) patient in the mesh group [odds ratio (OR) 3.08; 95 % confidence interval (CI) 0.07-20.30]. The rate of de novo dyspareunia after native-tissue repair was 33.1 % (30.4-35.8), comparable with that after mesh repair. The reoperation rate was 1.1 % (0.8-1.5) in both groups. Most patients were cured and satisfied after native-tissue repair of the posterior vaginal wall, and the patient-reported outcomes were comparable with results after mesh repair. The risk of serious complications and reoperation were comparable between groups.

Colporrhaphy, National register data, Non absorbable mesh, Patient-reported outcome, Rectocele
National Category
Obstetrics, Gynecology and Reproductive Medicine
urn:nbn:se:umu:diva-131088 (URN)10.1007/s00192-016-3072-y (DOI)000391360900006 ()
Available from: 2017-06-13 Created: 2017-06-13 Last updated: 2018-06-09Bibliographically approved
Haya, N., Baessler, K., Christmann-Schmid, C., de Tayrac, R., Dietz, V., Guldberg, R., . . . Maher, C. F. (2015). Prolapse and continence surgery in countries of the Organization for Economic Cooperation and Development in 2012. American Journal of Obstetrics and Gynecology, 212(6), Article ID 755.e1.
Open this publication in new window or tab >>Prolapse and continence surgery in countries of the Organization for Economic Cooperation and Development in 2012
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2015 (English)In: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, Vol. 212, no 6, article id 755.e1Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The purpose of this study was to report the rates and types of pelvic organ prolapse (POP) and female continence surgery performed in member countries of the Organization for Economic Co-operation and Development (OECD) in 2012. STUDY DESIGN: The published health outcome data sources of the 34 OECD countries were contacted for data on POP and female continence interventions from 2010-2012. In nonresponding countries, data were sought from national or insurer databases. Extracted data were entered into an age-specific International Classification of Disease, edition 10 (ICD-10)-compliant Excel spreadsheet by 2 authors independently in English-speaking countries and a single author in non-English-speaking countries. Data were collated centrally and discrepancies were resolved by mutual agreement. RESULTS: We report on 684,250 POP and 410,352 continence procedures that were performed in 15 OECD countries in 2012. POP procedures (median rate, 1.38/1000 women; range, 0.51-2.55 prolapse procedures/1000 women) were performed 1.8 times more frequently than continence procedures (median rate, 0.75/1000 women; range, 0.46-1.65 continence procedures/1000 women). Repairs of the anterior vaginal compartment represented 54% of POP procedures; posterior repairs represented 43% of the procedures, and apical compartment repairs represented 20% of POP procedures. Median rate of graft usage was 15.7% of anterior vaginal repairs (range, 3.3-25.6%) and 8.5% (range, 3.2-17%) of posterior vaginal repairs. Apical compartment repairs were repaired vaginally at a median rate of 70% (range, 35-95%). Sacral colpopexy represented a median rate of 17% (range, 5-65%) of apical repairs; 61% of sacral colpopexies were performed minimally invasively. Between 2010 and 2012, there was a 3.7% median reduction in transvaginal grafts, a 4.0% reduction in midurethral slings, and a 25% increase in sacral colpopexies that were performed per 1000 women. Midurethral slings represented 82% of female continence surgeries. CONCLUSION: The 5-fold variation in the rate of prolapse interventions within OECD countries needs further evaluation. The significant heterogeneity (> 10 times) in the rates at which individual POP procedures are performed indicates a lack of uniformity in the delivery of care to women with POP and demands the development of uniform guidelines for the surgical management of prolapse. In contrast, the midurethral slings were the standard female continence surgery performed throughout OECD countries in 2012.

Place, publisher, year, edition, pages
Elsevier, 2015
continence surgery, graft, Organization for Economic Cooperation and Development, prolapse rgery
National Category
Obstetrics, Gynecology and Reproductive Medicine
urn:nbn:se:umu:diva-105242 (URN)10.1016/j.ajog.2015.02.017 (DOI)000355262000012 ()25724403 (PubMedID)
Available from: 2015-06-24 Created: 2015-06-22 Last updated: 2018-06-07Bibliographically approved
Nüssler, E., Granåsen, G., Bixo, M. & Löfgren, M.Five-year follow-up after surgery for pelvic organ prolapse using national quality register data and patient-reported outcome.
Open this publication in new window or tab >>Five-year follow-up after surgery for pelvic organ prolapse using national quality register data and patient-reported outcome
(English)Manuscript (preprint) (Other academic)
urn:nbn:se:umu:diva-164739 (URN)
Available from: 2019-10-30 Created: 2019-10-30 Last updated: 2019-10-30

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