Vaginally assisted laparoscopic sacrocolpopexy for the treatment of complete uterovaginal prolapse

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.

Severe pelvic organ prolapse. Is there a long-term cure?

INTRODUCTION AND HYPOTHESIS

Vaginally assisted laparoscopic sacrocolpopexy (VALS) is a combined vaginal and laparoscopic surgical approach that has been described for the treatment of women with a uterus who suffer from severe multicompartmental pelvic organ prolapse (POP). The aim of this study is to evaluate the long-term anatomical and functional outcomes and report the long-term mesh-related complications.

METHODS

This was a single-center prospective study of women with advanced POP who underwent VALS with at least 3 years of follow-up. The primary outcome was "composite surgical success" defined as: (1) no descent of the vaginal apex (point C) more than one-third into the vaginal canal and no anterior or posterior vaginal wall beyond the hymen (Ba and Bp < 0) (anatomical success), (2) no vaginal bulge symptoms and (3) no re-treatment for prolapse recurrence.

RESULTS

The median follow-up was 7 years (range 3-10 years) with a composite surgical success rate of 95.7% (90/94). Failures (4.3%) included one (1.1%) case of anatomical recurrence (Bp: +1), one woman (1.1%) reporting vaginal bulge symptoms and two women (2.1%) who underwent a posterior colporrhaphy 6 and 12 months after primary surgery (reoperation rate: 2.1%). Two of 94 patients (2.1%) had been treated for mesh extrusion of the vaginal cuff prior to the follow-up visit.

CONCLUSIONS

The combined VALS technique can be considered a safe and effective procedure for the treatment of severe POP allowing a long-term anatomical restoration of all compartments with excellent functional outcomes.

Cuff Closure by Vaginal Route in TLH: Case Series and Review of Literature

Total Laparoscopic Hysterectomy (TLH) represents one of the most performed gynaecological procedures nowadays. The closure of the vaginal cuff is the most diffucult part of TLH because of the difficulty of laparoscopic suturing techniques. Our aim was to evaluate the efficacy and safety of vaginal cuff closure by vaginal route on patients submitted to TLH. During the period between January 2013 to December 2015 total number of 64 laparoscopic hysterectomy were performed in our clinic. TLH and vaginal vault closure was performed as described by Ghezzi for all patients. The length of cuff closure time and the frequency of vaginal cuff-related complications were measured. Mean age was 48.1 (38-71) years, mean parity was 2.6 (1-9). Most ranked indications for hysterectomy were abnormal uterine bleeding and symptomatic leiomyoma. Average cuff closure time was 6 (2-17) minute. In average 24 (2-36) month follow-up there were no vaginal vault dehiscence. Transvaginal vaginal cuff closure seems to be safe, easy and effective for total vaginal hysterectomy. Using vaginal route can significantly reduce the length of closure time. This technique has comparable complication rates with endoscopic suturing techniques.