Does sacrocolpopexy present heterogeneity in its surgical technique? A systematic review

Practice of laparoscopic prolapse surgery in Europe - ESGE Survey

Sacrocolpopexy is considered as the "gold standard" for management of women with apical prolapse. Numerous technical variants are being practiced. The first aim of this survey was to determine the habits of practice of laparoscopic sacrocolpopexy (LSCP) in Europe. The second aim was to determine whether surgeons who perform laparoscopic pelvic organ prolapse (POP) repair are familiar with the practice of alternative techniques and with mesh-less laparoscopic treatment of prolapse. The questionnaire was designed by the Urogynaecology Special Interest Group of the European Society for Gynaecological Endoscopy (ESGE). All ESGE-members were invited by email to respond to this survey consisting of 54 questions divided in different categories. Following review of ESGE member's responses, we have highlighted the great heterogeneity concerning the practice of LSCP and important variability in performance of concomitant surgeries. Alternative techniques are rarely used in practice. Furthermore, the lack of standardisation of the many surgical steps of a laparoscopic sacrocolpopexy is mainly due to the lack of evidence. There is a need for training and teaching in both standard and newer innovative techniques as well as the reporting of medium and long-term outcomes of both standard laparoscopic sacrocolpopexy and any of its alternatives.

Outcomes following sacrocolpopexy using ultralight and lightweight mesh

Introduction and hypothesis

This study reports the long-term anatomic and subjective outcomes following sacrocolpopexy based on mesh weight and provides device-specific data.

Methods

This cohort study compared ultra-lightweight (≤ 20 g/m²) with lightweight mesh (≥ 25 g/m²). The primary outcome was composite failure defined as at least one of ≥ stage 2 apical prolapse, anterior or posterior vaginal wall beyond hymen, complaint of bulge or retreatment. Effect measure estimates were calculated as the incidence rate ratio of composite failure comparing the use of ultra-light with lightweight mesh. Crude and adjusted incidence rate ratios (IRRs) were obtained using uni- and multivariable Poisson regression models.

Results

Of 358 women who met inclusion criteria, 220 (61%) agreed to attend for review; 95 (43%) had ultra-lightweight mesh and 125 (57%) had lightweight mesh including Upsylon^TM. Median follow-up for ultra-light and lightweight mesh was 36 (IQR 22–42) and 63 (IQR 48–87) months, respectively (p < 0.001). Accounting for differences in follow-up time, there was no significant difference in composite failure between ultra-light and lightweight mesh groups (IRR 1.47, 95% CI 0.83–2.52, p = 0.15). This persisted after adjustment for age, body mass index, parity, smoking and presence of advanced prolapse prior to surgery (IRR 1.52, 95% CI 0.94–2.47, p = 0.087). Mesh exposure for both groups was mostly asymptomatic, and the rate was 7% for the ultra-light group and 8% in the lightweight group. Overall, repeat surgery for recurrent apical prolapse and mesh exposure occurred in 4% and 2%, respectively.

Conclusions

Ultra-lightweight mesh appears to have similar incidence rate of failure compared to lightweight mesh. Upsylon^TM mesh has a similar low rate of recurrent apical prolapse and mesh exposure.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-022-05182-w.

Medium term anatomical and functional outcomes following modified laparoscopic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

We evaluated the anatomical and functional outcomes following modified laparoscopic sacrocolpopexy (LSC) utilizing deep dissection of the vaginal walls and distal mesh fixation at the anterior and posterior compartments. We hypothesized that anatomical and functional outcomes improve after this modified LSC technique.

METHODS

This was a retrospective study of all women (n = 240) who underwent LSC for pelvic organ prolapse (POP) from January to December 2017 in a tertiary center. POP-Q staging, validated questionnaires (International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF] and Pelvic Floor Distress Inventory Questionnaire-Short Form), and uroflowmetry were used to evaluate the anatomical and functional outcomes. Statistical analyses were performed using McNemar test and repeated measures analysis of variance with Fisher's least significant difference post hoc (p < 0.05).

RESULTS

The anatomical success rate is 96%, with a prolapse recurrence rate of 3.8% at 3-year follow-up. Bulge symptoms and anatomical compartments were significantly improved after LSC. Clinically, there were significant improvements after LSC in voiding dysfunction and bowel symptoms. Also, there was a significant increase in stress urinary incontinence and non-significant decrease in mixed urinary incontinence and urge urinary incontinence. ICIQ-SF and Colorectal-Anal Distress Inventory 8 scores were significantly lower after LSC, signifying improvement in incontinence and bowel symptoms.

CONCLUSION

Our modified LSC technique is safe and effective in restoring level 1 and level 2 supports, without adverse effects on urinary and bowel function. Bladder and bowel symptoms have also been found to keep improving over time.

A biomechanical analysis of different meshes for reconstructions of the pelvic floor in the porcine model

Purpose

Many different surgical approaches have been established for the repair of a pelvic organ prolapse. Especially in laparoscopic surgery, it is important to generate easy surgical techniques with similar stability. This study shall simplify the choice of mesh by evaluating three polypropylene meshes regarding their biomechanical properties.

Methods

Biomechanical testing was performed in the porcine model. The meshes are fixated on porcine fresh cadaver cervices after subtotal hysterectomy. The apical part of the mesh is fixated with parallel screw clamps at the testing frame. Forty-one trials were performed overall, subdivided into four subgroups. The groups differ in mesh type and fixation method. Maximum load, displacement at failure and stiffness parameters were evaluated with an Instron 5565^® test frame.

Results

SERATEX^® E11 PA (E11) showed the highest values for maximum load (199 ± 29N), failure displacement (71 ± 12 mm) and stiffness (3.93 ± 0.59 N/mm). There was no significant difference in all three evaluated parameters between SERATEX^® B3 PA (B3) and SERATEX^® SlimSling^® with bilateral fixation (SSB). SERATEX^® SlimSling^® with unilateral fixation (SSU) had the lowest stiffness (0.91 ± 0.19 N/mm) and maximum load (30 ± 2 N) but no significant difference in displacement at failure.

Conclusion

All meshes achieved a good tensile strength, but the results of maximum load show that the E11 is superior to the other meshes. Through a bilateral fixation of SERATEX^® SlimSling^®, a simple operating method is generated without a loss of stability.

Advanced Cystocele is a Risk Factor for Surgical Failure Following Robotic-Assisted Laparoscopic Sacrocolpopexy

STUDY OBJECTIVE

To assess the outcome of robotic-assisted laparoscopic sacrocolpopexy (RALSCP) and to identify risk factors for surgical failure and long term complications in patients at high risk for surgical failure.

DESIGN

Retrospective cohort study.

SETTING

A university hospital.

PATIENTS

Sixty-seven women with pelvic organ prolapse at high risk for surgical failure.

INTERVENTIONS

RALSCP from November 2012 to July 2020.

MEASUREMENTS AND MAIN RESULTS

Information was collected from the electronic medical records. Pre-operative and post-operative assessment included a urogynecologic history, prolapse staging, cough stress test, and validated quality of life questionnaires. Anatomical success was defined as POP stage less than 2 at last follow-up. Mean follow-up was 24.6 ± 17.9 months. Sixteen women (23.9%) reported bulge symptoms at the latest follow-up; upon POP-Q staging, surgical failure or recurrence was observed in 35 (52.2%) patients. On multiple logistic regression analysis, a pre-operative POP-Q point Ba measurement ≥ 3 cm beyond the hymen was independently related to surgical failure. Late post-operative complications included three (4.5%) cases of post-operative ventral hernia and five (7.5%) cases of mesh erosion, all in patients operated using Ethibond sutures.

CONCLUSIONS

Anatomical success of RALSCP in POP patients at high risk for surgical failure is worse than previously reported. Advanced pre-operative anterior vaginal wall prolapse is a risk factor for surgical failure. Delayed absorbable sutures for vaginal mesh fixation seem to be safer than multifilament, permanent sutures, in terms of the risk for mesh erosion.

Incidence of Sacral Osteomyelitis and Discitis After Minimally Invasive Sacrocolpopexy

OBJECTIVE

The incidence and associated risk factors for sacral osteomyelitis and sacral discitis after sacrocolpopexy remain unknown. The aim of this study was to determine the incidence of sacral osteomyelitis and discitis after minimally invasive sacrocolpopexy and their association with the method of sacral mesh fixation.

METHODS

This is a retrospective cohort study of consecutive minimally invasive sacrocolpopexies performed by 11 female pelvic medicine and reconstructive surgery board-certified surgeons from January 2009 to August 2019 within a single health system. Sociodemographic, procedure, and clinical variables were abstracted from the electronic health record (EHR). We then performed a confirmatory EHR interrogation, cross-referencing procedural codes for laparoscopic and robot-assisted sacrocolpopexy and diagnostic codes for sacral osteomyelitis and sacral discitis.

RESULTS

The EHR chart review identified 1,189 women who underwent laparoscopic (55.2%) and robot-assisted (44.8%) minimally invasive sacrocolpopexy, all with polypropylene mesh. Median follow-up was 7.7 months (interquartile range, 0-49.8). Titanium helical tacks were used in 52.7% patients, sutures in 41.6%, and both in 5.6%. No cases (0%) of sacral osteomyelitis or discitis were identified by chart review. The system-wide EHR interrogation of procedural and diagnostic codes identified 421 additional procedures for a total of 1,610 minimally invasive sacrocolpopexies. Among these, there were no cases (0%) of osteomyelitis or discitis.

CONCLUSIONS

Sacral osteomyelitis and discitis are rare early outcomes after minimally invasive sacrocolpopexy with an incidence of less than 1/1,000 cases. Given an absence of cases, we were unable to assess for an association between method of sacral attachment and sacral osteomyelitis and sacral discitis.

Exploration of the safe suture area of the presacral space in sacrocolpopexy by 3-dimensional (3D) models reconstructed from CT

INTRODUCTION AND HYPOTHESIS

The objective of this study, a digital in vivo anatomical study based on patient-specific three-dimensional (3D) models reconstructed from computed tomography (CT) scans, was to clarify the anatomy of the presacral space and suggest a safe area for complication-free graft or mesh fixation.

METHODS

We retrospectively studied 182 CT angiography (CTA) datasets from Han Chinese women examined for gynecological diseases from January 2018-June 2020; we used Mimics 21.0 to create 176 3D models of the female presacral space. The distances of pelvic structures from the presacral vessels and ureters were standardized and measured in 3D mode.

RESULTS

The distances from the median sacral artery (MSA) to the bilateral great vessels and bilateral ureters at the sacral promontory (SP) level were similar to the respective distances from the midpoint of the SP (MSP) to those four structures (p > 0.05). At the level of the first transverse line, when the MSA was right of the midline, the MSA was 20.74 ± 3.86 mm from the medial edge of the left first anterior sacral foramen. When the MSA was left of the midline, its average distance from the medial edge of the right first anterior sacral foramen was 20.89 ± 4.92 mm. The SP was 9.71 ± 4.49 mm and 40.39 ± 6.74 mm, respectively, from the first and second sacral transverse veins along the midline.

CONCLUSIONS

To preserve important vasculature, we recommend a 30 × 20-mm (L × W) avascular rectangular-shaped area, 10 mm below the SP and alongside the MSA, for safe graft or mesh attachment during sacrocolpopexy.

The Austrian Sacrocolpopexy Registry: Surgical Techniques, Perioperative Safety, and Complications

STUDY OBJECTIVE

Sacrocolpopexy (SCP) has become the standard procedure to correct uterovaginal prolapse in women, but techniques and approaches are not standardized. We report the results of the Austrian Sacrocolpopexy Registry, which aimed to collect data on surgical techniques and perioperative outcomes.

DESIGN

The Austrian Urogynecology Working Group initiated a registry to assess surgical variability and perioperative safety of SCP. The study was performed at 14 centers (13 in Austria,1 in Switzerland). Institutional review board approvals were obtained.

PATIENTS

Consecutive patients with symptomatic pelvic organ prolapse (POP).

INTERVENTIONS

SCP in the course of routine POP treatment.

MEASUREMENTS AND MAIN RESULTS

Preoperative assessment included demographic data, clinical data on bladder, and bowel functions and POP-Q status. Surgical data included surgical approach (open, laparoscopic, robotic), type of mesh, depth of dissection, nerve sparing techniques, suture materials, uterus or cervix-sparing techniques, peritoneal closure, and concomitant surgeries. A total of 401 patients were recruited into the study. The mean age was 57 years (range: 26-84) and mean body mass index was 34. A total of 137 (34%) patients had undergone previous surgery for prolapse and in 264 cases SCP was the primary procedure. A total of 170 (42%) patients had undergone previous hysterectomy; For patients with uterus, SCP was performed with subtotal (n = 148) or total (n = 3) hysterectomy. A total of 285 (71%) SCPs were done laparoscopically, 102 (25%) robotically and 10 (3%) per laparotomy. The conversion rate from laparoscopy to abdominal surgery was 4.5%. Various meshes and suture materials were used and fixation techniques also varied widely. Four patients underwent reoperation within 30 days (2 trocar herniations, and 1 bowel obstruction, 1 compartment syndrome). One patient died of aortic dissection 7 days after SCP.

CONCLUSIONS

Most SCPs in this registry were performed laparoscopically, but there was considerable variation in surgical techniques. Perioperative morbidity appears modest.

Comparison of absorbable and permanent sutures for laparoscopic sacrocervicopexy: A randomized controlled trial

INTRODUCTION

Pelvic organ prolapse is a common cause of morbidity and decreased quality of life among women and is treatable by laparoscopic sacrocolpopexy. Recent data suggest that absorbable sutures are a feasible and appealing option for mesh attachment given a potential decreased risk of complications related to mesh erosion. The aim of the present study was to demonstrate the non-inferiority of absorbable sutures to permanent sutures for laparoscopic sacrocervicopexy.

MATERIAL AND METHODS

We performed a randomized, single-blinded, non-inferiority trial comparing late-absorbable sutures (group A) to non-absorbable sutures (group B) for anterior and posterior vaginal mesh fixation during laparoscopic sacrocervicopexy at a single center in Italy. The primary outcome was prolapse correction at 12 months after surgery, defined as the absence of a pelvic organ prolapse leading edge reaching or extending below the level of the hymen and the absence of bulge symptoms. Secondary outcomes included intraoperative parameters, postoperative characteristics, and long-term morbidity. Statistical analyses were performed using STATA version 16.

RESULTS

A total of 150 patients with pelvic organ prolapse were prospectively randomized 1:1 into two groups (A or B). Baseline characteristics and intraoperative parameters including blood loss, operation time, and intraoperative complications were comparable between groups. The success rate was 100% in both groups and no differences in prolapse correction were observed. The rates of de novo urinary incontinence and persistent urinary incontinence were also similar between groups. The rate of mesh erosion at 12 months was 0% in group A and 4% in group B (P = .24).

CONCLUSIONS

Late absorbable sutures are non-inferior to non-absorbable sutures for laparoscopic sacrocervicopexy in terms of procedural success. Moreover we did not see any differences in terms of operative parameters, or intraoperative and postoperative characteristics, although the study was not powered to these outcomes.

National survey of surgical practices: Sacropexy in France in 2019

INTRODUCTION AND HYPOTHESIS

Sacropexy is a reference surgical treatment for pelvic organ prolapse in women. The great variability in surgical techniques for this procedure is a source of bias that complicates analysis of the results of trials assessing it. Using the French guidelines issued in 2016 by the SCGP, AFU, SIFUD-PP, and CNGOF as a reference, we sought to inventory the surgical practices of the surgeons who perform these procedures.

METHODS

In November 2018, a questionnaire about the technical aspects of this procedure was distributed by email to the French physicians performing it. It was distributed to members of several professional societies (CNGOF, SCGP, and SIFUD) and to gynecologists practicing in clinics owned by the ELSAN group.

RESULTS

Of the 273 responders, 92% reported that they perform most operations laparoscopically. Overall, 83% of gynecologic surgeons used polypropylene prostheses (mesh); 38% routinely placed a posterior mesh, while the rest did so only in cases of clinical rectocele with anorectal symptoms. A concomitant hysterectomy was performed by 51% of respondents when the uterus was bulky and/or associated with substantial uterine prolapse. Finally, half the surgeons suggested the placement of a suburethral sling for women with stress urinary incontinence.

CONCLUSIONS

Although practices are largely consistent with the most recent guidelines, surgical techniques vary widely between surgeons, both in France and internationally.

Robotic-assisted repair of pelvic organ prolapse: a scoping review of the literature

The purpose of this article is to perform a scoping review of the medical literature regarding the efficacy, safety, and cost of robotic-assisted procedures for repair of pelvic organ prolapse in females. Sacrocolpopexy is the “gold standard” repair for apical prolapse for those who desire to maintain their sexual function, and minimally-invasive approaches offer similar efficacy with fewer risks than open techniques. The introduction of robotic technology has significantly impacted the field, converting what would have been a large number of open abdominal sacrocolpopexy (ASC) procedures to a minimally-invasive approach in the United States. Newer techniques such as nerve-sparing dissection at the sacral promontory, use of the iliopectineal ligaments and natural orifice vaginal sacrocolpopexy may improve patient outcomes. Prolapse recurrence is consistently noted in at least 10% of patients regardless of route of mesh placement. Ancillary factors including pre-operative prolapse stage, retention of the cervix, type of mesh implant, and genital hiatus (GH) size all adversely affect surgical efficacy, while trainees do not. Minimally-invasive apical repair procedures are suited to early recovery after surgery protocols but may not be appropriate for all patients. Studies evaluating longer-term outcomes of robotic sacrocolpopexies are needed to understand the relative risk/benefit ratio of this technique. With several emerging robotic platforms with improved features and a focus on decreasing costs, the future of robotics seems bright.

Laparoscopic management of pelvic organ prolapse recurrence after open sacrocervicopexy

In this narrated video we present a case of pelvic organ prolapse (POP) recurrence 12 years after sacrocervicopexy, outline our management and suggest an optimal laparoscopic surgical technique that may reduce the risk of future recurrence. A 71-year-old patient, who had undergone an open sub-total hysterectomy with sacrocervicopexy 12 years previously, complained of a bulging sensation in her vagina, of 12 months' duration. On physical examination, a Pelvic Organ Prolapse Quantification (POP-Q) stage III prolapse was diagnosed, with marked apical, anterior and posterior compartment prolapse. On laparoscopy we identified the old mesh attached to the promontory and to the vaginal apex, without any fixation of the vaginal walls. Complete mesh excision was performed, followed by vaginal dissection to facilitate implantation of two new meshes and performing a new sacrocolpopexy. No postoperative complications occurred. Over 6 weeks of post-operative follow-up, there was no pelvic pain, dysuria or dyschezia. A good anatomical result was noted without any prolapse. Laparoscopy appears to be an effective approach to complete mesh excision. For the treatment of prolapse recurrence, complete excision of the old mesh with new pelvic mesh-augmented reconstruction is recommended. Thorough dissection of the vesico-vaginal and recto-vaginal spaces followed by mesh fixation to the relevant vaginal walls may reduce recurrence.

Laparoscopic sacrocolpopexy: A comprehensive literature review on current practice

Sacrocolpopexy is considered the preferred treatment for vaginal vault. However, numerous technical variants are being practiced. We aimed to summarize the recent literature in relation to technical aspects of laparoscopic sacrocolpopexy (LSC). We focused on surgical technique, mesh type, concomitant surgeries, and training aspects. We performed 2 independent literature searches in Medline, Scopus, the Cochrane library, and Embase electronic databases including the keywords: 'sacrocolpopexy', 'sacral colpopexy' and 'promontofixation'. Full text English-language studies of human patients, who underwent LSC, published from January 1, 2008 to February 26, 2019, were included. Levels of evidence using the modified Oxford grading system were assessed in order to establish a report of the available literature of highest level of evidence. Initially, 953 articles were identified. After excluding duplicates and abstracts screening, 35 articles were included. Vaginal fixation of the mesh can be performed with barbed or non-barbed (level 1), absorbable or non-absorbable sutures (level 2). Fixation of the mesh to the promontory can be performed with non-absorbable sutures or non-absorbable tackers (level 2). The current literature supports using type 1 mesh (level 2). Ventral mesh rectopexy can safely be performed with LSC while concurrent posterior repair has no additional benefit (level 2). There is no consensus regarding the preferred type of hysterectomy or the benefit of an additional anti urinary incontinence procedure. A structured learning program, as well as the number of procedures needed in order to be qualified for performing LSC is yet to be established. There are numerous variants for performing LSC. For many of its technical aspects there is little consensus.

Medium-term outcome of laparoscopic sacrocolpopexy using polivinylidene fluoride as compared to a hybrid polyglecaprone and polypropylene mesh: A matched control study

AIM

To compare 2-year outcomes of laparoscopic sacrocolpopexy (LSCP) either with polyvinylidene fluoride (PVDF) or hybrid polypropylene containing a resorbable polyglecaprone (PP+ PG) mesh.

MATERIALS AND METHODS

Retrospective audit on 105 consecutive patients undergoing LSCP a with PVDF-mesh (DynaMesh, FEG Textiltechniken), matched by prolapse stage and cervicopexy or vault suspension to 105 controls undergoing LSCP with a hybrid PP + PG-mesh (Ultrapro, Ethicon). Patients are part of an ongoing prospective study. The primary outcome measure was the Patient Global Impression of Change score (PGIC), the coprimary variable was failure rate at the vault (≤1 cm). Other outcomes were intraoperative and postoperative complications within 3 months categorized by the Clavien-Dindo classification, reinterventions, graft-related complications (GRCs) and functional outcomes. All assessments were performed by an independent assessor. Data are reported as median (interquartile range) number and percent as appropriate, the Mann-Whitney U, χ² , or Fisher exact were used for comparison.

RESULTS

Patient satisfaction in the PVDF group, as measured with the PGIC, was high (90.9% PGIC, ≥4) as well as was the anatomical success (97.3%) at a follow-up of 26 months. These outcomes were comparable to those of PP + PG-patients (84.8% PGIC, ≥4; 94.9% anatomical success). There were five patients (2.4%) with Dindo-III or higher complications and three patients had GRCs (1.5%), without differences between mesh type. Level-II posterior defects (Bp ≥ -1) were less likely in PVDF patients (34.1% vs 50% for PP + PG-patients; P = .003). Women in the PVDF group also were less bothered by prolapse (7.5% vs 26.4%; P = .001), yet they complained more of constipation (15.0% vs 9.0%; P = .01).

CONCLUSION

There were no differences in patient satisfaction and anatomical outcomes after LSCP either with PVDF or PP + PG mesh.