Apical vault repair, the cornerstone or pelvic vault reconstruction

Standardized terminology of apical structures in the female pelvis based on a structured medical literature review

The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica-accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.

Uterosacral vault suspension (USLS) at the time of hysterectomy: laparoscopic versus vaginal approach

INTRODUCTION AND HYPOTHESIS

To compare laparoscopic and vaginal approaches to uterosacral ligament vault suspension (USLS) by perioperative data, short-term complications, rates of successful concomitant adnexal surgery and procedural efficacy.

METHODS

Retrospective cohort of USLS procedures performed at the time of hysterectomy at a tertiary care center over a 3-year period. Patient demographics, surgical data, concomitant adnexal procedures and complications were abstracted from a surgical database and compared using parametric or non-parametric tests as appropriate. Validated questionnaires (POPDI-6, UDI-6, PROMIS) were used to collect information on recurrence and long-term complications. Patients were analyzed according to both intention-to-treat analysis based on the intended approach and the completed route of surgery to deal with intraoperative conversions.

RESULTS

Two hundred six patients met the criteria for inclusion; 152 underwent vaginal USLS (V-USLS) and 54 laparoscopic USLS (L-USLS). No statistically significant differences in mean case time, postoperative length of stay or perioperative infection were found. While no ureteric obstructions occurred in the L-USLS group, in the V-USLS group 14 (9%) obstructions occurred (p = 0.023). Postoperative urinary retention was higher with V-USLS (31% vs. 15%, p = 0.024). Rates of successfully completed adnexal surgery differed (56% vs. 98%, p < 0.001) in favor of L-USLS. Patient-reported symptomatic recurrence of prolapse was higher in the V-USLS group (41% vs. 24%, p = 0.046); despite this, re-treatment did not differ between the groups (0% vs. 7%, p = 0.113).

CONCLUSIONS

Perioperative case time and complications did not differ between approaches. However, rates of completed adnexal surgery were significantly higher in the laparoscopic group, which could influence surgical decisions concerning approaches to prolapse surgery.

Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study

PURPOSE

The purpose of the study was to compare the outcome of laparoscopic sacral colpocervicopexy with laparoscopic pectopexy. Our aim was to show that the safety and effectiveness of the new technique is similar to the traditional technique. We expected differences regarding defecation disorders.

PATIENTS AND METHODS

We randomly assigned patients to two treatment groups: 44 in the pectopexy and 41 in the sacropexy group. If necessary, the operative procedures were planned in a so-called multicompartment setting regarding the different pelvic floor disorders. All defects were managed at the same time. Eighty-one patients were examined 12 to 37 months after treatment (mean follow-up 20.67 months).

RESULTS

The long-term follow-up (21.8 months for pectopexy and 19.5 months for sacropexy) showed a clear difference regarding de novo defecation disorders (0% in the pectopexy vs 19.5% in the sacropexy group). The incidence of de novo stress urinary incontinence was 4.8% (pectopexy) vs 4.9% (sacropexy). The incidence of rectoceles (9.5% vs 9.8%) was similar in both groups. No de novo lateral defect cystoceles were found after pectopexy, whereas 12.5% were found after sacropexy. The apical descensus relapse rates, 2.3% for pectopexy vs 9.8% for sacropexy, were not statistically significant. The occurrence of de novo anterior defect cystoceles and rectoceles revealed no significant differences.

CONCLUSION

Laparoscopic pectopexy is a novel method of vaginal prolapse therapy that offers clear practical advantages compared with laparoscopic sacropexy. Because laparoscopic pectopexy does not reduce the pelvic space, it results in a zero percentage of defecation disorders.

Laparoscopic management of genital prolapse

INTRODUCTION

Genital prolapse is one of the most common indications for gynaecological surgery. Surgery is performed traditionally via abdominal, vaginal and laparoscopic approaches.

METHODS

A MEDLINE computer search was performed to explore the recent evidence behind laparoscopic surgery for female pelvic organ prolapse.

RESULTS

Advances in minimal access surgery have led to an increase in adoption of laparoscopic techniques. Current evidence supports the use of laparoscopy for sacrocolpopexy and colposuspension as an alternative to open surgery. However, the introduction of less invasive midurethral sling procedures for stress incontinence has reserved laparoscopic colposuspension for special indications. The scientific evidence regarding uterosacral suspension procedures and paravaginal and vaginal prolapse repairs are sparse.

CONCLUSION

The current evidence supports the outcome of laparoscopic sacrocolpopexy as an alternative to open surgery. Further studies are required on the long-term efficiency in laparoscopic paravaginal repair and vaginal wall prolapse.

Tissue fixation system (TFS) to repair uterovaginal prolapse with uterine preservation: a preliminary report on perioperative complications and safety

OBJECTIVES

To assess the effectiveness, perioperative safety and invasiveness of the Tissue Fixation System (TFS) sling operation when used for repair of uterovaginal prolapse with uterine preservation.

METHODS

Operations using the TFS anchor system were performed on 25 women aged between 44 and 84 years (average 65) for grade 3 or 4 uterine prolapse with or without urinary incontinence. Details of the procedures were as follows: midurethral sling (n=2); posterior sling of the uterosacral ligaments (n=25); U-sling for lateral/central anterior vaginal wall defects (n=24). The defect of the perineal body and rectovaginal fascia were repaired in all cases.

RESULTS

All patients were followed up for a minimum of 3 months. The mean +/- standard deviation of the operating time and loss of blood were 94.2 (+/-19.3) minutes and 98.1 (+/-129.6) mL, respectively. Twelve patients (48%) were discharged on the same day of surgery and 13 patients (52%) on the following day, with a return to normal activities within 1-7 days. There were no intra- or postoperative complications. At the 3-month follow up, cure rates of symptoms due to pelvic laxity were: urinary frequency 85.7% (n=14); nocturia 66.6% (n=12); urgency 93.3% (n=15); and dragging pain 100% (n=6). There was one recurrent uterovaginal prolapse and one recurrent cystocele.

CONCLUSION

The TFS procedure delivers satisfactory results for uterine prolapse repair with uterine preservation. The procedure is useful because of the short duration of the operation, the short term of recovery, its safety profile and minimal invasiveness. There is a significant improvement in the quality of life, especially for older women. However, long-term results are currently unknown.

Minimally invasive treatment of stress urinary incontinence and vaginal prolapse

Stress urinary incontinence and pelvic organ prolapse are prevalent conditions that can have detrimental effects on a woman's quality of life. Surgically, this has often been approached by means of a transvaginal route. With recent advances in laparoscopic and robotic instrumentation and operating systems, there is increasing interest in minimally invasive techniques for correction of pelvic organ prolapse. In this article, the authors briefly describe the laparoscopic and robotic approaches in terms of surgical techniques, operative anatomy, and results published in the literature.

Vaginal vault prolapse: Choice of operation

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

Terminologia Anatomica versus unofficial descriptions and nomenclature of the fasciae and ligaments of the female pelvis: a dissection-based comparative study

OBJECTIVE

The aims of this study were: (1) to define and classify those connective structures of the female pelvis that are of potential clinical interest, (2) to evaluate the adequacy of the Terminologia Anatomica (official nomenclature) and (3) to establish a correspondence between the official nomenclature and the most commonly used terms.

STUDY DESIGN

The results of 30 macroscopic and laparoscopic dissections of fresh cadavers with and without vessel injection of colored latex solutions were compared with the descriptions and definitions in the Terminologia Anatomica and the most frequently cited English and non-English literature from 1890 to 2003.

RESULTS

We identified 3 groups of fasciae, parietal pelvic fascia, visceral pelvic fascia, and extraserosal pelvic fascia, which could be divided into diverse clinically relevant anatomical structures characterized by different locations, spatial orientation, and consistency. These structures differed considerably with regard to number and nomenclature from those described in the Terminologia Anatomica and part of the literature.

CONCLUSION

Our results suggest that the official terminology applied to the connective structures of the female pelvis could be profitably revised and expanded. We offer a complete description of these structures and suggest a classification that may be useful for teaching and clinical purposes.

Surgical techniques for vault prolapse: a review of the literature

We searched MEDLINE for articles indexed between 1972 and 2002 and dealing on operative techniques for vault prolapse. We found 149 articles describing, variously, abdominal sacrocolpopexy with mesh (2008 patients), other transabdominal methods (387 patients), sacrospinous ligament fixation (2390 patients), other transvaginal repairs (1556 patients), laparoscopic procedures (128 patients), intravaginal sling (168 patients) and vaginal obliteration techniques (157 patients). For each of these procedures there is a short presentation of the operative technique and a summary of all published data on concomitant surgery, complications and follow-up results relating to anatomical and functional outcome. Two procedures are more frequently used than the others: abdominal sacrocolpopexy and transvaginal sacrospinous ligament fixation. We were unable to detect any differences in the complication and/or cure rates, but did find a slightly better long-term anatomical outcome after the abdominal technique. Since no standardized outcome measure is available it is difficult to compare the functional results. Only in more recent studies have subjective cure rates (patient satisfaction with the outcome) also been evaluated as well as the objective cure rates determined by the investigators, and the objective and subjective rates are not necessarily the same. The subjective cure rate is probably more strongly influenced by the functional outcome in terms of micturition, defaecation and sexual activity than by the anatomical result.

Morphology of the suburethral pubocervical fascia in women with stress urinary incontinence: a comparison of histologic and MRI findings

To correlate MRI with histologic findings of the suburethral pubocervical fascia in women with urodynamic stress incontinence. Thirty-one women with urodynamically proven stress urinary incontinence without relevant prolapse underwent preoperative MRI. Tissue specimens obtained from the pubocervical fascia were examined immunohistochemically (types I and III collagen, smooth muscle actin) and the results compared with the MRI findings. MRI demonstrated an intact pubocervical fascia in 61.3% of the cases and a fascial defect in 38.7%. A fascial defect demonstrated by MRI was associated with a decrease in actin (P<0.09) and an increase in collagen III (P<0.01) compared to an intact fascia. In women with stress urinary incontinence, smooth muscle actin in the pubocervical fascia is decreased, changed in structure, and replaced by type III collagen. MRI allows evaluation of the pubocervical fascia and its morphologic changes.

Laparoscopic and abdominal sacral colpopexies: a comparative cohort study

OBJECTIVE

This study was undertaken to compare laparoscopic and open sacral colpopexies for efficacy and safety.

STUDY DESIGN

Charts were reviewed for 56 patients who underwent laparoscopic sacral colpopexy and 61 patients who underwent open sacral colpopexy. Demographic and hospital data, complications, and follow-up visits were reviewed.

RESULTS

Mean follow-up was 13.5 +/- 12.1 months and 15.7 +/- 18.1 months in the laparoscopic and open groups, respectively. Mean operating time was significantly greater in the laparoscopic versus open cohort, 269 +/- 65 minutes and 218 +/- 60 minutes, respectively (P < .0001). Estimated blood loss (172 +/- 166 mL vs 234 +/- 149 mL; P = .04) and hospital stay (1.8 +/- 1.0 days vs 4.0 +/- 1.8 days; P < .0001) were significantly less in the laparoscopic group than the open group. Complication and reoperation rates were similar.

CONCLUSION

Laparoscopic and open sacral colpopexies have comparable clinical outcomes. Although laparoscopic sacral colpopexy requires longer operating time, hospital stay is significantly decreased.

[Prolapse surgery]

Operative cystocele/rectocele management and prolapse surgery have become increasingly important domains of urogynecologic surgery. The risk of prolapse surgery in women lies at around 11% today and one-third of these are reoperations. There are currently three competing operative procedures: (1) the transvaginal approach with a vaginae fixatio sacrospinalis vaginalis or sacrotuberalis, (2) transabdominal pelvic sacrocolpopexy, and (3) transabdominal laparoscopic sacrocolpopexy.We compared efficacy, reoperation rates, and complication rates in abdominal sacrocolpopexy to those found with the transvaginal or laparoscopic surgical approaches, by reviewing the literature of the last 10 years, including 1995, in an online search. Analysis of the accumulated data made it clear, moreover, that randomized, prospective studies on the three different operative procedures are missing; these are mandatory, however, to enable exact and objective assessment of efficacy, long-term results, and complication rates.

Uterine preservation during surgery for uterovaginal prolapse: a review

The traditional surgical treatment for uterovaginal prolapse has been vaginal hysterectomy. For many reasons, women may request uterine preservation at the time of prolapse surgery. The purpose of this paper is to review the medical literature pertaining to the role of uterine preservation during reconstructive surgery for uterovaginal prolapse. A MEDLINE search of literature in the English language (1966 to current) was carried out using the keywords 'hysterectomy', 'hysteropexy', 'uterine preservation', 'uterine suspension' and 'uterovaginal prolapse.' Fourteen articles primarily addressing the surgical repair of uterovaginal prolapse with uterine preservation were included in this review. Papers primarily addressing other forms of pelvic organ prolapse, incontinence or obliterative procedures were excluded. Existing procedures and their clinical outcomes were reviewed. The current literature suggests that uterine preservation during surgery for uterovaginal prolapse may be an option in appropriately selected women who desire it; prospective, randomized trials are needed to corroborate this.

Laparoscopic pelvic floor repair

Articles on laparoscopic approach to pelvic floor reconstruction continue to proliferate throughout the worldwide literature. Although procedures like laparoscopic Burch seem to be fading fast, other procedures like the laparoscopic paravaginal repair and sacral colpopexy seem to be more common and visible in the literature. This article reviews the pertinent anatomy, surgical procedures, and literature concerning the laparoscopic approach to pelvic floor reconstruction.

Laparoscopic Treatment of Pelvic Floor Defects in Women of Reproductive Age

STUDY OBJECTIVE

To evaluate the efficacy of conservative laparoscopic treatment of genital prolapse in women of reproductive age.

DESIGN

Retrospective analysis (Canadian Task Force classification II-2).

SETTING

University hospital, Center of Reconstrutive Pelivc Endosurgery, Reproductive Medical Unit, S. Orsola Hospital, Bologna, Italy.

PATIENTS

Fifteen women of reproductive age with genital prolapse. Interventions. Conservative laparoscopic surgical correction of genital prolapse. Apical prolapse was corrected by sacral colpohysteropexy. Burch colposuspension was always included to treat evident or latent stress urinary incontinence. Anterior compartment defects were treated by laparoscopic paravaginal repair and by the interposition of an intervesicouterine prosthesis. Posterior compartment defects were corrected by a prosthetic reconstruction of the rectovaginal support structure.

MEASUREMENTS AND MAIN RESULTS

All patients underwent surgery between January 1998 and December 2000. They were prospectively evaluated for a minimum of 24 months of follow-up. No woman underwent additional surgery during the follow-up period. All women had resolution of the apical prolapse. In one woman, anterior compartment correction (i.e., correction of the anterior part of endopelvic fascia, including correction of bladder and anterior vaginal wall prolapse) was reported. No woman underwent additional prolapse surgery during the follow-up period. Three women became pregnant after surgery: one had an abortion at 8 weeks' gestation; the other two completed term pregnancies and delivered by cesarean section.

CONCLUSION

Laparoscopic therapy of genital prolapse is a desirable procedure in patients of reproductive age because it respects the anatomic structures and maintains the function of the organs. Furthermore, laparoscopic treatment is feasible and well-tolerated and produces good results.

Rectocele: pathogenesis and surgical management

BACKGROUND

Rectocele is a common finding in patients with intractable evacuatory disorders. Although much rectocele surgery is conducted by gynecologists en passant with other forms of vaginal surgery, many reports lack appreciation of the importance of coincident anorectal symptoms, and do not report functional and clinical outcome data. The pathogenesis of rectocele is still controversial, as is the embryological and anatomical importance of the rectovaginal septum as well as recognizable defects in its integrity and its relevance in formal repair when rectocele is operated upon as the principal condition in patients with intractable evacuatory difficulty.

DISCUSSION

The investigation and surgical management of rectocele is controversial given the relatively small numbers of operated patients in any single specialist unit and the relative lack of prospective data concerning functional outcome in operated cases. The imaging of rectocele patients is currently in a state of change, and the newer diagnostic modalities including dynamic magnetic resonance imaging frequently display a multiplicity of pelvic floor disorders. When surgery is indicated, coloproctologists most commonly utilize an endorectal defect-specific repair, but there are few controlled randomized data regarding outcome and response criteria of specific symptoms with particular surgical approaches. A Medline-based literature search was conducted for this review to assess the clinical results of defect-specific rectocele repairs using the endorectal, transvaginal, transperineal, or combined approaches. Only the studies are included that report both pre- and postoperative symptoms including constipation, evacuatory difficulty, pelvic pain, the impression of a pelvic mass, fecal incontinence, dyspareunia or the need for assisted digitation to aid defecation.

CONCLUSION

The history of rectocele repair, its clinical and diagnostic features and the advantages, disadvantages and indications for the different surgical techniques are presented in this review. Suggested diagnostic and surgical therapeutic algorithms for management have been included. It is recommended that a multicenter controlled randomized trial comparing surgical approaches for symptomatic evacuatory dysfunction where rectocele is the principal abnormality should be conducted.

Laparoscopic repair of vaginal vault prolapse

PURPOSE OF REVIEW

Currently, the two laparoscopic techniques available and described in the literature for the treatment of vaginal vault prolapse are uterosacral ligament vault suspension and sacrocolpopexy. These two techniques are opposing each other fundamentally. While the first is reconstructive, the second is essentially palliative.

RECENT FINDINGS

In both methods the surgeon starts with the identification and dissection of the pubocervical and rectovaginal fascia. In the first technique however, the new vaginal vault, made by re approximation of the two fasciae, is attached to the uterosacral complex, while in the second one, each fascia is suspended from the sacral promontorium, using a mesh. In review of the existing literature, it seems that the palliative surgical approach is more successful in the long term, giving a cure rate of approximately 92%, probably as it involves using mesh instead of the native tissue.

SUMMARY

In this article we discuss the laparoscopic techniques available currently, analyse their results, discuss their differences and compare them with other non-laparoscopic techniques. Finally, we discuss the different options described, and offer some guidelines for the future of laparoscopic treatment of pelvic prolapse.

Laparoscopic surgery for pelvic support defects

Reconstructive pelvic surgery for the treatment of vaginal prolapse continues to evolve as surgeons continue their quest for definitive surgical cure. Though there are three primary routes of access to reconstructive pelvic surgery (abdominal, vaginal and laparoscopic) it is the laparoscopic approach that appears to be the least utilized. This is in part due to the great degree of technical difficulty associated with laparoscopic suturing. This paper reviews the general principles and functional anatomy associated with normal vaginal support as well as the laparoscopic surgical approach to pelvic floor support defects.

Surgical management of the apical vaginal defect

PURPOSE OF REVIEW

To review the etiology, presentation, imaging techniques and current surgical management of the apical vaginal defect.

RECENT FINDINGS

Urologists are increasingly managing urinary incontinence and prolapse of the anterior and posterior compartment but most refer the management of the apical defect to gynecologists. A variety of abdominal and vaginal repairs are commonly utilized to repair the apical defect, often based on the surgeon's preference. Of the abdominal repairs, abdominal sacral colpopexy with mesh remains the gold standard. Laparoscopic techniques, although feasible, have not gained widespread acceptance. Of the vaginal restorative procedures there are proponents for uterosacral ligament vault suspension, iliococcygeus and sacrospinous ligament fixation. The uterosacral ligament vault suspension is the most anatomic of the repairs and hence least likely to create a predisposition to future anterior or posterior vaginal wall defects or compromise vaginal function. In rare instances where restorative procedures are discouraged and sexual function is no longer desired, obliterative procedures, which are better tolerated, may be more appropriate.

SUMMARY

The best approach for restoration of vaginal apical support remains controversial with abdominal and vaginal routes commonly utilized. A single approach or procedure based on the surgeon's preference is not always optimal. Procedure selection should be individualized based on the patient's age, comorbidities, prior surgical history and level of physical and sexual activity. The transvaginal uterosacral ligament vaginal vault suspension is increasingly our procedure of choice for management of the apical defect due to its versatility, reduced postoperative morbidity and excellent short-term results.

Enterocele repair and vaginal vault suspension

A paradigm shift has occurred in the approach to enterocele repair and vaginal vault suspension. This change in our approach is based on anatomic dissections that demonstrate that the loss of the upper suspensory fibers of the paracolpium and parametrium lead to uterine prolapse and vaginal prolapse after hysterectomy. In addition, the separation of the pubocervical from the rectovaginal fascia results in apical enterocele where the peritoneum is in contact with the vaginal mucosa. These fascial defects are hernias, and appropriate herniorraphy techniques will correct these defects and result in successful reconstruction of the vaginal tube and its reattachment to the suspensory cardinal uterosacral complex.

Laparoscopic management of pelvic organ prolapse

Until recently, most major gynecologic surgery was performed either vaginally or by laparotomy. In the last decade, surgeons have explored laparoscopic access for many gynecologic surgical disorders. Pelvic reconstructive surgery can be performed laparoscopically but demands a high skill level especially in suturing. Initial reports for laparoscopic bladder neck suspension for genuine stress urinary incontinence are encouraging but lack long term follow-up. The literature contains only a few case studies addressing pelvic support procedures. In this review we present our methods for laparoscopic management of different types of pelvic floor support defects. We view laparoscopy as a method of access rather than a procedure. We present laparoscopic techniques that do not modify the surgical procedures that have been validated by conventional surgery.

Laparoscopy or open Burch colposuspension?

The laparotomy Burch has long been considered the gold standard for the repair of genuine stress incontinence. With the advent of laparoscopic Burch, many have argued that possibly this should be the new gold standard. However, when many laparoscopic bladder series were examined, there was some question of whether these should be considered Burch procedures and there is still a lack of long-term laparoscopic data.