Sacrocolpopexy: is there a consistent surgical technique?

Precision in Practice: The Critical Role of Mesh and Procedure Type Specification in Urogynecological Surgeries and Research

Recently, the debate surrounding the use of mesh in urogynecological procedures has intensified, leading to FDA warnings and heightened safety concerns. This clinical opinion emphasizes the vital need to specify mesh types in these procedures, drawing attention to the risk profiles and clinical outcomes associated with various meshes and the procedures that utilize them. A significant issue identified in contemporary literature is the tendency to group diverse mesh types under the same umbrella, disregarding their unique characteristics and applications. We describe the range of mesh types, their application routes, and associated complications, highlighting the risks of this nonspecific approach to patient safety and informed decision making. We critically examine the generalization of mesh terminology in clinical and research dialogues. Concluding with specific recommendations for health care providers and researchers, the paper advocates for a more nuanced understanding and communication in the field, ultimately aiming to improve patient care and safety in urogynecological practice.

A Randomized Clinical Trial Comparing Dubuisson Laparoscopic Lateral Suspension with Laparoscopic Sacropexy for Pelvic Organ Prolapse: Short-Term Results

BACKGROUND

Laparoscopic sacrocolpopexy (LSC) is the gold standard for the treatment of apical prolapse, although dissection of the promontory may be challenging. Laparoscopic lateral suspension (LLS) with mesh is an alternative technique for apical repair with similar anatomical and functional outcomes, according to recent studies. The purpose of this study was to compare these operative techniques.

METHODS

Women with uterine Pelvic Organ Prolapse Quantification (POP-Q) stage 2 were enrolled in this prospective study and were randomly allocated to the LLS or LSC group. At the 12-month follow-up, primary measures included both anatomical and functional outcomes. Perioperative parameters and complications were recorded.

RESULTS

A total of 93 women were randomized, 48 in the LLS group and 45 in the LSC group, with 2 women lost to follow-up in both groups. LSC anatomic success rates were 81.82% for the apical compartment and 95.22% for the anterior compartment. LLS anatomic success rates for the apical and anterior compartments were 90% and 92.30%, respectively. The mean operative time for LLS was 160.3 min, while for LSC it was 168.3 min. The mean blood loss was 100 mL in both procedures. Conversion to laparotomy was necessary in three women. Mesh erosion was not observed in any of the cases. In terms of the complication, Clavien-Dindo grade 1 was observed in two patients in the LLS group and a complication rated grade 3b was observed in one patient in LSC group.

CONCLUSIONS

LLS is a good alternative to LSC, with promising anatomical and quality-of-life results.

Variations in structural support site failure patterns by prolapse size on stress 3D MRI

INTRODUCTION AND HYPOTHESIS

Our objective was to develop a standardized measurement system to evaluate structural support site failures among women with anterior vaginal wall-predominant prolapse according to increasing prolapse size using stress three-dimensional (3D) magnetic resonance imaging (MRI).

METHODS

Ninety-one women with anterior vaginal wall-predominant prolapse and uterus in situ who had undergone research stress 3D MRI were included for analysis. The vaginal wall length and width, apex and paravaginal locations, urogenital hiatus diameter, and prolapse size were measured at maximal Valsalva on MRI. Subject measurements were compared to established measurements in 30 normal controls without prolapse using a standardized z-score measurement system. A z-score greater than 1.28, or the 90th percentile in controls, was considered abnormal. The frequency and severity of structural support site failure was analyzed based on tertiles of prolapse size.

RESULTS

Substantial variability in support site failure pattern and severity was identified, even between women with the same stage and similar size prolapse. Overall, the most common failed support sites were straining hiatal diameter (91%) and paravaginal location (92%), followed by apical location (82%). Impairment severity z-score was highest for hiatal diameter (3.56) and lowest for vaginal width (1.40). An increase in impairment severity z-score was observed with increasing prolapse size among all support sites across all three prolapse size tertiles (p < 0.01 for all).

CONCLUSIONS

We identified substantial variation in support site failure patterns among women with different degrees of anterior vaginal wall prolapse using a novel standardized framework that quantifies the number, severity, and location of structural support site failures.

Robotically assisted laparoscopic lateral suspension: a step-by-step approach aiming to standardize a novel procedure

INTRODUCTION AND HYPOTHESIS

The aim of this video is to show a step-by-step approach to robotically assisted laparoscopic lateral suspension for pelvic organ prolapse aiming to standardize this procedure.

METHODS

This video shows a robotically assisted laparoscopic approach to a POP-Q stage 3 prolapse with a combined anterior and apical defect. First, the trocars are positioned, with one 8-mm trocar, two lateral trocars 5 cm above the anterior-superior iliac spine, and a 10-mm assistant trocar either paraumbilically or suprapubically. Second, the uterovesical pouch is dissected up to 2 cm above the level of the bladder neck. The mesh is then fixed to the vesicovaginal fascia and to the isthmus uteri. Next, a laparoscopic forceps is inserted retroperitoneally through the lateral trocars and the lateral arms of the mesh are pulled retroperitoneally. The peritoneum of the uterovesical fold is sutured, including round ligament plication. Finally, the lateral arms of the peritoneum are fixed to the peritoneum of the abdominal wall.

CONCLUSIONS

Robotically assisted laparoscopic lateral suspension is a safe alternative to laparoscopic and robotically assisted laparoscopic sacropexy and very well suited for uterine-preserving POP surgery. This video contributes to the standardization of this procedure, and we believe our video to be useful in helping urogynecologists to perform this innovative procedure.

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.

Technical features, perioperative and anatomical outcomes of a standardized suturing pattern for robotic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Several technical alternatives to repair mesh using laparoscopic sacrocolpopexy exist. We aim to describe the outcomes and surgical technique of robotic-assisted colpo-/cervicosacropexy using a standardized suturing scheme to repair the mesh.

METHODS

We retrospectively reported data of 60 consecutive cases of robotic-assisted colpo-/cervicosacropexy for advanced multicompartmental prolapse using a standardized suturing design. We placed three non-absorbable stitches on the cervix or three absorbable stitches on the apex of the vaginal vault, six long-term absorbable stitches on the anterior vaginal wall deep to the basis of the vesical trigone, six similar posterior stitches with the deeper row of sutures down to the levator ani plane and three non-absorbable stitches on the sacral promontory as the cranial support for Y-shaped polypropylene mesh.

RESULTS

Median operative time was 188 ± 43 min. All the procedures were successfully performed using a Da Vinci Si platform in a three-arm configuration, and no conversion to open or traditional laparoscopic surgery was needed. The length of hospital stay was 1.2 ± 1.7 days, and no readmission within 30 postoperative days was reported. At a follow-up of 12 and 24 months, no case of extrusion or exposure of the mesh occurred, and the retreatment rate was 6.7%.

CONCLUSIONS

Our suturing technique is safe and effective, with negligible risk of complications and good medium-term results. It is plausible that robotic systems may facilitate precise, accurate and reproducible placement of the stitches, thereby favoring wider diffusion of minimally invasive treatment of advanced prolapse.

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.

Laparoscopic minimally invasive sacrocolpopexy or hysteropexy and transobturator tape combined with native tissue repair of the vaginal compartments in patients with advanced pelvic organ prolapse and incontinence

INTRODUCTION AND HYPOTHESIS

The aim of the study was to evaluate hysterectomized and non-hysterectomized patients with prolapse and incontinence. Laparoscopic sacrohysteropexy (LSHP) and minimally invasive sacrocolpopexy (LMSCP) were done in combination with transobturator tape (TOT) and native tissue repair of the anterior and posterior vaginal compartments in patients with pelvic organ prolapse (POP) and occult, stress, or urinary incontinence (SUI). The hypothesis is that both methods are successful.

METHODS

A total of 81 patients with POP were evaluated: 44 had vaginal vault prolapse (POPQ points Ba, C, and Bp were 1.2, 2.6, and 0.4, respectively) and 37 had uterine prolapse (POPQ points Ba, C, and Bp were 1.8, 1.7, and 1.3, respectively). LMSCP (which means less dissection of the vagina in its upper third and avoiding possible collision with the ureters anteriorly or the rectum posteriorly) was performed in patients with vault prolapse, whereas patients with uterine prolapse underwent LSHP. Transobturator tape (TOT) was placed in all patients to treat symptomatic and occult urinary incontinence. Systematic anterior and posterior colporrhaphy was performed in both groups.

RESULTS

Both groups showed anatomic (p < 0.0001) and symptomatic improvement (p < 0.001-p < 0.05). Voiding was significantly improved after surgery without postoperative incontinence (p < 0.001). There was no significant difference between groups regarding duration of surgery (p = 0.06), hospital stay (p = 0.13), blood loss (0.83), Clavien-Dindo grade 3 (p = 0.87), and Clavien-Dindo grade 1-2 (p = 0.92) complications.

CONCLUSION

Minimally invasive LSCP or LSHP combined with TOT and native tissue repair of the anterior and posterior vaginal compartment is a successful treatment for POP.

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.

Vaginal cuff perforation during robotic-assisted mesh recto-sacrocolpopexy

INTRODUCTION

We report on the management of intraoperative vaginal cuff perforation during robotic-assisted mesh recto-sacrocolpopexy for vaginal vault prolapse with defecatory dysfunction.

CASE PRESENTATION

A 75-year-old woman with vaginal bulge and constipation was to undergo a joint robotic mesh recto-sacrocolpopexy. Intraoperatively, mesh was secured to the left posterior vaginal wall following dissection. Prior to contralateral suture placement, the vaginal cuff split open and exposed an end-to-end anastomotic sizer previously inserted in the vagina. Due to subsequent mesh erosion risk, we proceeded with vaginotomy closure with running and interrupted absorbable sutures, removal of mesh, direct suture rectopexy to the promontory, and enterocele defect correction by reapproximating the right and left wings of the peritoneum flaps over the rectum with running sutures. Patient reported satisfactory outcomes after 2 years.

CONCLUSION

We reviewed our experience with vaginal cuff perforation during robotic-assisted mesh recto-sacrocolpopexy prompting enterocele repair and rectopexy without mesh.

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.

Robot-assisted surgery for the management of apical prolapse: a bi-centre prospective cohort study

OBJECTIVE

Robot-assisted surgery is a recognised treatment for pelvic-organ prolapse. Many of the surgical subgroup outcomes for apical prolapse are reported together, leading to a paucity of homogenous data.

DESIGN

Prospective observational cohort study (NCT01598467, clinicaltrials.gov) assessing outcomes for homogeneous subgroups of robot-assisted apical prolapse surgery.

SETTING

Two European tertiary referral hospitals.

POPULATION

Consecutive patients undergoing robot-assisted sacrocolpopexy (RASC) and supracervical hysterectomy with sacrocervicopexy (RSHS).

METHODS

Anatomical cure (simplified Pelvic Organ Prolapse Quantification, sPOPQ, stage 1), subjective cure (symptoms of bulge), and quality of life (Pelvic Floor Impact Questionnaire, PFIQ-7).

MAIN OUTCOME MEASURES

Primary outcome: anatomical and subjective cure.

SECONDARY OUTCOMES

surgical safety and intraoperative variables.

RESULTS

A total of 305 patients were included (RASC n = 188; RSHS n = 117). Twelve months follow-up was available for 144 (RASC 76.6%) and 109 (RSHS 93.2%) women. Anatomical success of the apical compartment occurred for 91% (RASC) and in 99% (RSHS) of the women. In all compartments, the success percentages were 67 and 65%, respectively. Most recurrences were in the anterior compartment [15.7% RASC (symptomatic 12.1%); 22.9% RSHS (symptomatic 4.8%)]. Symptoms of bulge improved from 97.4 to 17.4% (P < 0.0005). PFIQ-7 scores improved from 76.7 ± 62.3 to 13.5 ± 31.1 (P < 0.0005). The duration of surgery increased significantly for RSHS [183.1 ± 38.2 versus 145.3 ± 29.8 (P < 0.0005)]. Intraoperative complications and conversion rates were low (RASC, 5.3 and 4.3%; RSHS, 0.0 and 0.0%). Four severe postoperative complications occurred after RASC (2.1%) and one occurred after RSHS (1.6%).

CONCLUSIONS

This is the largest reported prospective cohort study on robot-assisted apical prolapse surgery. Both procedures are safe, with durable results.

TWEETABLE ABSTRACT

European bi-centre trial concludes that robot-assisted surgery is a viable approach to managing apical prolapse.

Complications after minimally invasive sacrocolpopexy with and without concomitant incontinence surgery: A National Surgical Quality Improvement Program (NSQIP) database study

AIMS

To compare surgical complications for patients having minimally invasive sacrocolpopexy (MISCP) with concomitant incontinence procedure, to those having MISCP alone.

METHODS

Patients undergoing MISCP with and without a concomitant incontinence procedure between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. The main outcome of interest was a composite of surgical site infection, bleeding requiring blood transfusion, return to the operating room within 30 days, and surgical stay >48 h. Log-binomial regression was used to identify independent risk factors for the outcome and to generate adjusted effect measures for variables of interest.

RESULTS

Seven thousand ninety-seven women met the inclusion criteria, of which 2433 (34%) underwent a concomitant incontinence procedure. Patients having incontinence procedures were slightly older (59 ± 11 vs 58 ± 12, P < 0.0001) and had longer total operating time (225 IQR 170-267 vs 184 IQR 120-232 min, P < 0.0001). Pre-operative steroid use, wound class III/IV (vs I/II), and longer operative time were independent predictors of the composite outcome. After adjusting for baseline patient characteristics and co-morbidities, no association was observed between concomitant incontinence procedure and the composite outcome (adjusted RR 0.87, 95%CI 0.65-1.18) but there was an increased likelihood of urinary tract infection (adjusted RR 2.47 95%CI 1.89-3.27).

CONCLUSIONS

Despite being associated with a longer operative time, performing an incontinence procedure at the time of MSCIP was not associated with an increased risk of clinically important surgical complications other than urinary tract infection.

Sacrocolpopexy With Concomitant Total vs Supracervical Hysterectomy: Functional Support Comparisons in Cadavers

OBJECTIVE

This study aimed to compare the ability of abdominal sacrocolpopexy (ASC) with concomitant total vs supracervical hysterectomy to resist downward traction as a measure of functional anatomic support in human cadavers.

METHODS

Supracervical hysterectomy was performed on unembalmed cadaver specimens, followed by ASC attaching polypropylene mesh to the posterior cervix/vagina only and then the anterior and posterior cervix/vagina. Using a metal bolt placed through the cervix tied to a filament passing through a fixed pulley system, successive weights of 0.5 to 3.0 kg were added to provide increasing loads on the apex (cervix), and the distances traversed by the apex were recorded. The same process was then repeated in each specimen after removal of the cervix (with vaginal cuff closure). One-way and repeated-measures analysis of measure was used for between-group and within-group comparisons, respectively, with P ≤ 0.05 considered statistically significant.

RESULTS

Eight cadavers were examined. At lower weight loads, pulling distances in the 4 groups examined were similar and were not significantly different with the presence or absence of the cervix. At weight loads of 2.5 kg or greater, we noted a trend of increased pulling distances when posterior mesh only was used vs when anterior/posterior mesh was placed, although this difference was not significant. Interestingly, there was tearing of the vaginal wall or partial separation of mesh/sutures attachments to the vagina noted in 3 specimens.

CONCLUSIONS

This study showed no differences in the ability of the cervix (after supracervical hysterectomy) compared with the vaginal cuff (after total hysterectomy) to resist downward traction of successive weights after ASC. Clinical trials are necessary to correlate these findings with prolapse recurrence rates and patient satisfaction following these procedures.

[CLINICAL OUTCOMES OF LAPAROSCOPIC SACROCOLPOPEXY FOR PELVIC ORGAN PROLAPSE: A RETROSPECTIVE ANALYSIS OF 500 CASES FROM A SINGLE INSTITUTION]

(Objectives) Laparoscopic sacrocolpopexy (LSC) is becoming a more popular alternative for pelvic organ prolapse (POP) repair in Japan in the recent years. This study aimed to evaluate the safety and efficacy of LSC. (Patients and methods) This is a retrospective study on all the LSC cases that were performed in Urogynecology center, Kameda Medical Center, Japan from January 2013 to March 2016. Medical records of all the patients were retrieved and details on operating time, estimated blood loss, perioperative complications, anatomical recurrence (postoperative POP-Q stage≥II) rate and reoperation rate were assessed.Our procedure of LSC used two pieces of polypropylene mesh placed on the vesico-vaginal and recto-vaginal space in which the dissection was extended to the level of the bladder neck and levator ani muscle. Subtotal hysterectomy was performed in almost all patients with uterus except in 39 women who chose to preserve their uterus. Additionally, multivariate analysis of risk factors for recurrence-free survival was performed using the Cox regression method. (Results) Five hundred and five patients who were diagnosed as POP (cystocele, rectocele, enterocele, uterine prolapse, vaginal vault prolapse) were included. The mean operating time and estimated blood loss were 236 min and 27.2 ml. There were 2.6% perioperative complication rate and 1.0% severe complication rate (Clavien grade≥IIIa). With a median follow-up of 12 months, anatomical recurrence rate was 8.0%, significant anatomical recurrence (stage≥III) rate was 1.2% and reoperation rate was 1.0%. Preoperative POP-Q stage IV was found as independent risk factors for anatomical recurrence. (Conclusions) The present study demonstrated a relatively low complication rate, low significant anatomical recurrence rate and low reoperation rate. Therefore, LSC is a safe and effective surgical treatment for various types of POP.

Effect of mesh width on apical support after sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

We evaluated the effect of polypropylene mesh width on vaginal apical support, mesh elongation, and mesh tensile strength for abdominal sacrocolpopexy.

METHODS

Abdominal sacrocolpopexy was performed on ten cadavers using pieces of polypropylene mesh of width 1, 2, and 3 cm. Weights of 1, 2, 3, and 4 kg were sequentially applied to the vagina. The total distance moved by the vaginal apex, and the amount of stretch of the intervening mesh segment between the sacrum and the vagina were recorded for each width. The failure strengths of additional single and double layer sets of each width were also tested using a tensiometer. Data were analyzed with analysis of variance using a random effects model.

RESULTS

The mean (standard error of the mean) maximum distance moved by the vaginal apex was 4.63 cm (0.37 cm) for the 1 cm mesh compared to 3.67 cm (0.26 cm) and 2.73 cm (0.14 cm) for the 2 and 3 cm meshes, respectively (P < 0.0001). The 1 cm width ruptured during testing in four of the ten cadavers. The results were similar for mesh elongation, with the 1 cm mesh stretching the most and the 3 cm mesh stretching the least. Mesh failure loads for double-layer mesh were 52.9 N (2.5 N), 124.4 N (2.7 N), and 201.2 N (4.5 N) for the 1, 2, and 3 cm meshes, respectively, and were higher than the failure loads for single mesh (P < 0.001).

CONCLUSIONS

In a cadaver model, increasing mesh width is associated with better vaginal apical support, less mesh elongation, and higher failure loads. Mesh widths of 2-3 cm provide sufficient repair strength for sacrocolpopexy.

Minimally Invasive Sacrocolpopexy: How to Avoid Short- and Long-Term Complications

Sacrocolpopexy remains the "gold standard" procedure for management of posthysterectomy vaginal vault prolapse with improved anatomic outcomes compared to native tissue vaginal repair. Despite absence of clinical data, sacrocolpopexy is increasingly being offered to women as a primary treatment intervention for uterine prolapse. While reoperation rates remain low, recurrent prolapse and vaginal mesh exposure appear to increase over time. The potential morbidity associated with sacrocolpopexy is higher than for native tissue vaginal repair with complications including sacral hemorrhage, discitis, small bowel obstruction, port site herniation, and mesh erosion. Complications are more common during the learning curve of minimally invasive sacrocolpopexy. Appropriate case selection is paramount to balancing the potential for prolapse recurrence with the risk of surgical complications. Use of ultra-lightweight polypropylene mesh and vaginal mesh attachment with delayed absorbable suture may reduce the risks of vaginal mesh exposure.