Bilateral extraperitoneal uterosacral suspension: a new approach to correct posthysterectomy vaginal vault prolapse

Mid-term efficacy of surgical treatments for post-hysterectomy vaginal vault prolapse: a retrospective study

BACKGROUND

The surgical treatment of post-hysterectomy vaginal vault prolapse (PHVP) has been reported in several clinical studies, but mostly are short-term studies. This study aims to explore the mid-term efficacy of surgical treatments for PHVP.

METHODS

A total of 138 PHVP patients underwent surgery from January 2005 to January 2020 at the Fourth Medical Center of PLA General Hospital, Beijing. The clinical data of 119 patients who completed follow-up were retrospectively analyzed. Both groups of patients are diagnosed Pelvic Organ Prolapse Quantification system (POP-Q) III-IV stage of prolapse, with obvious prolapse-related symptoms and requiring surgical treatment. Among them, pelvic floor reconstruction surgery (RPS) was performed in patients who wanted to retain vaginal function and colpocleisis were used for frail patients who cannot tolerate RPS. We used the POP-Q scores for the objective efficacy evaluation, and use the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20) and Pelvic Floor Impact Questionnaire-7 (PFIQ-7) to evaluate the subjective symptom during follow up. Among them, 61 patients underwent pelvic floor RPS (Group R), and 58 received colpocleisis (Group C).

RESULTS

The surgeries in both groups were successfully completed, the median follow-up time after surgery was 4.3 years (0.25-13 years) and 5.3 years (0.33-15 years), respectively; the overall surgical success rate was 86.9% (53/61) and 100% (58/58), respectively; the subjective satisfaction rate was 90.2% (55/61) and 91.4% (53/58), respectively; and the PFDI-20 and PFIQ-7 scores in both groups were significantly improved compared with the preoperative levels (P<0.05). In Group R, 6 cases (9.8%, 6/61) were dissatisfied after surgery; in Group C, 5 cases (8.6%, 5/58) were dissatisfied after surgery.

CONCLUSIONS

Reconstructive surgery and colpocleisis have a good mid-term effect on PHVP, with good outcome and few complications. The surgeon is expected to ascertain an appropriate surgical procedure based on the characteristics of the patient, the degree and the location of prolapse, in order to achieve the best surgical efficacy and minimize the damage.

Vaginal intraperitoneal versus extraperitoneal uterosacral ligament vault suspensions: a comparison of a standard and novel approach

INTRODUCTION AND HYPOTHESIS

Uterosacral ligament suspension surgery is commonly utilized to correct post-hysterectomy vaginal vault prolapse (VVP). Vaginal intraperitoneal uterosacral vault suspension (IUSVS) is a viable option, but intraperitoneal access can be challenging. An alternative approach is an extraperitoneal uterosacral vault suspension (EUSVS). The aim of our study was to compare surgical outcomes of IUSVS and EUSVS in patients with post-hysterectomy VVP.

METHODS

Retrospective cohort study of women who underwent treatment of post-hysterectomy VVP with an IUSVS and EUSVS from May 2016 to January 2019 at our institution. The primary outcome was surgical success that was assessed by a composite outcome for surgical failure, defined as ANY of the following: (1) apical descent > 1/3 of the TVL or anterior or posterior vaginal wall beyond the hymen, (2) retreatment of prolapse, or (3) bothersome vaginal bulge symptoms with a positive response to either of two questions on the PFDI questionnaire. Secondary outcomes included EBL, operative time, duration of hospitalization, and perioperative complications. Two-sample t-tests and chi-square tests were used for the bivariate analysis.

RESULTS

Eighty patients were included (36 IUSVS and 44 EUSVS) with a mean follow-up of 7 months. For our primary outcome, there was no difference in surgical success (IUSVS group 72.22% vs. EUSVS group 81.82%, p = 0.307). Operative time, duration of hospitalization, and EBL were significantly less in the EUSVS group than in the IUSVS group.

CONCLUSIONS

EUSVS demonstrated similar short-term success compared to IUSVS for post-hysterectomy VVP, with shorter operative time, EBL, and length of stay.

Modified Extraperitoneal Uterosacral Ligament Suspension in Preventing Cuff Prolapse Risk after Vaginal Hysterectomy; 4 Clamp Method

Objectives: The extraperitoneal uterosacral ligament suspension (ULS) can be performed during the removal of the uterus in vaginal hysterectomy to prevent cuff prolapse. In this study, we evaluated the modified extraperitoneal ULS technique in terms of preventing cuff prolapse. Methods/Technique: Forty patients with second and third-stage uterine prolapse who were operated were included in the study. During routine vaginal hysterectomy procedure performed on patients, after sacrouterine ligaments which are the first-bites and uteroovarian and round ligaments which are the last-bites have been sutured and knotted, these ligaments were marked with 4-distinct clamps to make the right and left, upper and lower separation. After vaginal cuff was closed the sutures hanged by the clamps were ligated together, and the cuff tissue was stretched to the apical line. Results: According to the POP-Q classification, 22 patients with stage-2 and 18 patients with stage-3 prolapse were operated. During the 2-year follow-up; 4 patients could not be reached and were excluded from follow-up. Five of the remaining 36 patients (13.8%) found to have stage-1 cuff prolapse and 31 (86.1%) of patients had no prolapse. There was no significant decrease in postoperative vaginal length (p [Formula: see text] 0.05). The PISQ-12 sexual function scores was found similar before and after surgery (p [Formula: see text] 0.05). Conclusions: The extraperitoneal ULS is a successful method to prevent cuff prolapse after hysterectomy. Although there are various modified forms of this method, the modified ULS, which we have described as the 4-clamp method, seems to be successful in terms of initial results.

Extraperitoneal uterosacral suspension technique for post hysterectomy apical prolapse in 472 women: results from a longitudinal clinical study

OBJECTIVES

The study aims to evaluate the long-term results of the extraperitoneal uterosacral ligament suspension (bilateral) technique in women with apical prolapse following hysterectomy.

DESIGN

Longitudinal clinical follow up conducted between June 2002 and December 2017.

SETTING

Tertiary urogynaecology centre in Melbourne, Australia.

POPULATION

A total of 472 women with symptomatic vault prolapse who underwent bilateral extraperitoneal uterosacral ligament suspension (EPUSLS). Of these patients, 61% (287/472) had previously had a procedure for pelvic organ prolapse (POP).

METHODS

Follow up using structured, standardised questionnaires and examination by POP-Q and Baden-Walker system pre- and postoperatively.

MAIN OUTCOME MEASURES

Functional and anatomical results and surgical complications.

RESULTS

Mean follow-up duration was approximately 5 years. The objective success rate at vaginal cuff support was 89% (420/472). Only 4% needed revision surgery for vault recurrence. There was improvement in bladder, bowel, and sexual symptoms after the procedure. Mesh exposure rate was 17% (of the 138 having mesh augmentation), with the majority of cases managed conservatively or with minor interventions. The ureteric injury rate was 1% and mainly occurred in patients operated early on in the series. No women had buttock pain.

CONCLUSION

EPUSLS is an effective, suture-based procedure for vault prolapse with few complications even on long-term follow up. This technique avoids the need to open the peritoneum vaginally and has a low risk of ureteric injury and gluteal pain.

TWEETABLE ABSTRACT

Bilateral extraperitoneal USL suspension of vault is effective with low morbidity and a high success rate.

Modified extraperitoneal uterosacral ligament suspension for prevention of vault prolapse after vaginal hysterectomy

INTRODUCTION AND HYPOTHESIS

During vaginal hysterectomy, extraperitoneal uterosacral ligament suspension (ULS) bites can be taken before removing the uterus. We evaluated this modified extraperitoneal ULS for vault prolapse prevention.

METHODS

Study period was 3.5 years. Fifty-one women with third- and fourth-degree prolapse were enrolled. An inverted V incision was made on the anterior vaginal wall and continued as a semicircular incision on the posterior vaginal wall. Lateral vaginal mucosa was pushed up to expose the cardinal-uterosacral ligament complex. The first ULS suture, using polypropylene no. 1, was taken in the upper-most exposed area of the uterosacral ligament. The second suture, using polyglactin no. 1 or 0, was taken 0.5-1 cm below the first suture. During placement of both sutures, traction on the cervix was maintained. The cardinal-uterosacral ligament complex was clamped, dissected, and ligated 1 cm below the second suture. Vaginal hysterectomy was completed. Ends of the ULS suture were fastened to the vault via vesicovaginal and rectovaginal septum using polypropylene within and polyglactin outside vaginal mucosa.

RESULTS

Prolapse stage was 3 in 42 cases and 4 in nine. Duration of operation ranged from 60 to 120 min. Blood loss was 100-300 ml. During follow-up (average 2.3 years) four (8.3%), cases had stage 1 pelvic organ prolapse (POP), three were lost to follow-up, and 44 (91.6%) had no POP.

CONCLUSIONS

Using the cervix as a traction device is a good option when performing extraperitoneal ULS during vaginal hysterectomy to prevent vault prolapse.

Effects of repeated biaxial loads on the creep properties of cardinal ligaments

The cardinal ligament (CL) is one of the major pelvic ligaments providing structural support to the vagina/cervix/uterus complex. This ligament has been studied mainly with regards to its important function in the treatment of different diseases such as surgical repair for pelvic organ prolapse and radical hysterectomy for cervical cancer. However, the mechanical properties of the CL have not been fully determined, despite the important in vivo supportive role of this ligament within the pelvic floor. To advance our limited knowledge about the elastic and viscoelastic properties of the CL, we conducted three consecutive planar equi-biaxial tests on CL specimens isolated from swine. Specifically, the CL specimens were divided into three groups: specimens in group 1 (n = 7) were loaded equi-biaxially to 1 N, specimens in group 2 (n = 8) were loaded equi-biaxially to 2N, and specimens in group 3 (n = 7) were loaded equi-biaxially to 3N. In each group, the equi-biaxial loads of 1N, 2N, or 3N were applied and kept constant for 1200s three times. The two axial loading directions were selected to be the main in-vivo loading direction of the CL and the direction that is perpendicular to it. Using the digital image correlation (DIC) method, the in-plane Lagrangian strains in these two loading directions were measured throughout the tests. The results showed that CL was elastically anisotropic, as statistical differences were found between the mean strains along the two axial loading directions for specimens in group 1, 2, or 3 when the equi-biaxial load reached 1N, 2N, or 3N, respectively. For specimens in group 1 and 2, no statistical differences were detected in the mean normalized strains (or, equivalently, the increase in strain over time) between the two axial loading directions for each creep test. For specimens in group 3, some differences were noted but, by the end of the 3rd creep test, there were no statistical differences in the mean normalized strains between the two axial loading directions. These findings indicated that the increase in strain over time by the end of the 3rd creep test were comparable along these directions. The greatest mean normalized strain (or, equivalently, the largest increase in strain over time) was measured at the end of the 1st creep test (t=1200s), regardless of the equi-biaxial load magnitude or loading direction. Mean normalized strains during the 2nd and 3rd creep tests (t = 100, 600, and 1200s), along each loading direction, were not statistically different. Isochronal data collected at 1N, 2N, or 3N equi-biaxial loads indicated that the CL may be a nonlinear viscoelastic material. Overall, this experimental study offers new knowledge of the mechanical properties of the CL that can guide the development of better treatment methods such as surgical reconstruction for pelvic organ prolapse and radical hysterectomy for cervical cancer.

Technique of extraperitoneal uterosacral ligament suspension for apical suspension

AIM OF THE VIDEO/INTRODUCTION

Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky-Navratil retractor.

METHODS

This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension.

CONCLUSIONS

This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.

Apical prolapse

INTRODUCTION AND HYPOTHESIS

The aim was to review the safety and efficacy of pelvic organ prolapse surgery for vaginal apical prolapse.

METHODS

Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials (RCT) or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.

RESULTS

Abdominal sacral colpopexy (ASC) has a higher success rate than sacrospinous colpopexy with less SUI and postoperative dyspareunia for vault prolapse. ASC had greater morbidity including operating time, inpatient stay, slower return to activities of daily living and higher cost (grade A). ASC has the lowest inpatient costs compared with laparoscopic sacral colpopexy (LSC) and robotic sacral colpopexy (RSC). LSC has lower inpatient costs than RSC (grade B).In single RCTs the RSC had longer operating time than both ASC and LSC (grade B). In small trials objective outcomes appear similar although postoperative pain was greater in RSC. LSC is as effective as ASC with reduced blood loss and admission time (grade C). The data relating to operating time are conflicting. ASC performed with polypropylene mesh has superior outcomes to fascia lata (level I), porcine dermis and small intestine submucosa (level 3; grade B). In a single RCT, LSC had a superior objective and subjective success rate and lower reoperation rate compared with polypropylene transvaginal mesh for vault prolapse (grade B).Level 3 evidence suggests that vaginal uterosacral ligament suspension, McCall culdoplasty, iliococcygeus fixation and colpocleisis are relatively safe and effective interventions (grade C).

CONCLUSION

Sacral colpopexy is an effective procedure for vault prolapse and further data are required on the route of performance and efficacy of this surgery for uterine prolapse. Polypropylene mesh is the preferred graft at ASC. Vaginal procedures for vault prolapse are well described and are suitable alternatives for those not suitable for sacral colpopexy.

Where to for pelvic organ prolapse treatment after the FDA pronouncements? A systematic review of the recent literature

INTRODUCTION

With the publication of the updated US Food and Drug Administration (FDA) communication in 2011 on the use of transvaginal placement of mesh for pelvic organ prolapse (POP) it is appropriate to now review recent studies of good quality on POP to assess the safety and effectiveness of treatment options and determine their place in management.

METHODS

A systematic search for studies on the conservative and surgical management of POP published in the English literature between January 2002 and October 2012 was performed. Studies included were review articles, randomized controlled trials, prospective and relevant retrospective studies as well as conference abstracts. Selected articles were appraised by the authors regarding clinical relevance.

RESULTS

Prospective comparative studies show that vaginal pessaries constitute an effective and safe treatment for POP and should be offered as first treatment of choice in women with symptomatic POP. However, a pessary will have to be used for the patient's lifetime. Abdominal sacral colpopexy is effective in treating apical prolapse with an acceptable benefit-risk ratio. This procedure should be balanced against the low but non-negligible risk of serious complications. The results of native tissue vaginal POP repair are better than previously thought with high patient satisfaction and acceptable reoperation rates. The insertion of mesh at the time of anterior vaginal wall repair reduces the awareness of prolapse as well as the risk of recurrent anterior prolapse. There is no difference in anatomic and subjective outcome when native tissue vaginal repairs are compared with multicompartment vaginal mesh. Mesh exposure is still a significant problem requiring surgical excision in approximately ≥ 10 % of cases. The ideal mesh has not yet been found necessitating more basic research into mesh properties and host response. Several studies indicate that greater surgical experience is correlated with fewer mesh complications. In women with uterovaginal prolapse uterine preservation is a feasible option which women should be offered. Randomized studies with long-term follow-up are advisable to establish the place of uterine preservation in POP surgery.

CONCLUSION

Over the last decade treatment of POP has been dominated by the use of mesh. Conservative treatment is the first option in women with POP. Surgical repair with or without mesh generally results in good short-term objective and functional outcomes. However, basic research into mesh properties with host response and comparative studies with long-term follow-up are urgently needed.

An effective and safe innovation for the management of vault prolapse

Objective

Considering the great variety of techniques and disagreement about the ideal route, there is a need for a simple, safe and effective method for the management of vault prolapse.

Study Design

51 cases of post- hysterectomy vault prolapse: 45 following vaginal and 6 after total abdominal hysterectomy were treated surgically by anterior abdominal wall colpopexy with autogenous rectus fascia strips.

Results

Except for minor complaints like vomiting, fever and urinary retention in 3.92% cases each (n = 2 each), no major complications were encountered. Moreover, no recurrence, thus far, on follow-up.

Conclusion

Using autogenous rectus fascia strips in anterior abdominal wall colpopexy is not only simple, cheap and effective method of treating apical prolapse but is also devoid of any serious complications as described with other techniques.

Midline uterosacral plication anterior colporrhaphy combo (MUSPACC): preliminary surgical report

INTRODUCTION AND HYPOTHESIS

the objective of this study is to examine the surgical safety and early efficacy of the midline uterosacral (ligament) plication anterior colporrhaphy (MUSPACC) procedure.

METHODS

a retrospective review of the perioperative data of 41 women who had undergone an MUSPACC procedure without any other vaginal vault supportive procedure was performed.

RESULTS

the MUSPACC procedure can be performed comfortably through a single midline anterior vaginal wall incision, providing concomitant levels 1 and 2 support at anterior colporrhaphy. The procedure is safe and relatively quick (median 23 min) with consistent access to the intermediate section of the uterosacral ligament. Blood loss is generally minimal to small. Dissection is relatively limited. The ureters (2 cm or more lateral) are not deemed to be at risk. Short-term anatomical results are promising. There was no significant change in vaginal length.

CONCLUSIONS

the MUSPACC procedure is safe, relatively quick, and free of significant bleeding. It provides concomitant levels 1 and 2 vaginal support.

Surgical anatomy of the uterosacral ligament

INTRODUCTION AND HYPOTHESIS

This study aims to elucidate and expand current knowledge of the uterosacral ligament (USL) from a surgical viewpoint.

METHODS

Studies were performed on 12 unembalmed cadaveric pelves and five formalin-fixed pelves.

RESULTS

The USL, 12-14-cm long, can be subdivided into three sections: (1) distal (2-3 cm), intermediate (5 cm), and proximal (5-6 cm). The thick (5-20 mm) distal section, attached to cervix and upper vagina, is confluent laterally with the cardinal ligament. The proximal section is diffuse in attachment and generally thinner. The relatively unattached intermediate section is wide, and thick, well defined when placed under tension, more than 2 cm from the ureter and suitable for surgical use. The strength of the USL is perhaps derived not only from the ligament itself, but also from the addition of extraperitoneal connective tissue.

CONCLUSIONS

The USL can be subdivided into three sections according to thickness and attachments with the intermediate section suitable for surgical use, particularly for vaginal vault support.

[How to manage multicompartment pelvic organe prolapse?]

Repair of pelvic organ prolapse by vaginal route may use native tissues or meshes, which have been in extensive use over the last decades. Traditional surgery, and particularly sacrospinous fixation, has been proven to be effective with long term follow-up with well-known specific risks that could be avoided by skilled surgeons on condition that he observes basic vaginal surgery rules. This surgery is still recommended as first choice in patients over 70 years old with high-grade prolapse. Nevertheless recurrence rate after high-grade cystocele repair using native tissues as been reported between 30 and 50% depending on the technique used. Mesh repair and particularly the use of mesh kits is a valid option in case of prolapse with cystocele behind the hymen, specifically in case of paravaginal defect. Meshes use is licit in patients with prolapse recurrence as well. In contrast, spread use of transvaginal meshes in young patients with grade 3 or 4 prolapse whom tissues have a poor quality, has to be considered very carefully because of the lack of knowledge about long term results and sexual outcome.

The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication

INTRODUCTION AND HYPOTHESIS

The objective of this study is to evaluate cervical amputation with uterosacral ligament plication (modified Manchester) and compare it to vaginal hysterectomy with high uterosacral ligament plication procedure with special regard to the middle compartment.

METHODS

Consecutive women with pelvic organ prolapse who underwent either vaginal hysterectomy or a modified Manchester procedure were included. Assessments were made preoperatively and at 1-year follow-up, including physical examination with pelvic organ prolapse quantification standardised questionnaires (incontinence impact questionnaire, urogenital distress inventory, and defaecatory distress inventory).

RESULTS

Between 2002 and 2007, 156 patients were included. Ninety-eight patients returned for a 1-year follow-up. In the modified Manchester group, we found no middle compartment recurrence versus two (4%) in the vaginal hysterectomy group. Anterior and posterior compartment prolapse recurrences (stage >or=2) were similar (approximately 50%). Considering operating time and blood loss, modified Manchester was more favourable. There was no difference in the pre- and postoperative subjective scores. The overall functional outcome was acceptable.

CONCLUSIONS

We found an excellent performance of both procedures regarding middle compartment recurrences.

Uterosacral ligament vaginal vault suspension: anatomy, outcome and surgical considerations

PURPOSE OF REVIEW

With aging populations, primary pelvic organ and recurrent pelvic organ prolapse have become a large-scale public health concern. Surgical options for patients include both abdominal and vaginal approaches, each with its own safety and efficacy profiles. This review summarizes the most recent anatomic, surgical and outcome data for uterosacral ligament vault suspension. It offers data on methods to avoid complications and difficult surgical scenarios.

RECENT FINDINGS

Uterosacral ligament suspension allows reattachment of the vaginal vault high within the pelvis. New modifications in technique including the extraperitoneal and laparoscopic approaches allow surgeons more freedom when planning surgery. Five-year data on the durability of the procedure make it a viable surgical option.

SUMMARY

As a technique widely used by many pelvic reconstructive surgeons, uterosacral ligament vault suspension provides a safe, anatomically correct and durable approach to uterine and vault prolapse. It requires advanced surgical training and an intimate understanding of pelvic anatomy to avoid and identify ureteral injury.