Uterus preservation is superior to hysterectomy when performing laparoscopic lateral suspension with mesh

Clinician perspectives on hysterectomy versus uterine preservation in pelvic organ prolapse surgery: A systematic review and meta-analysis

BACKGROUND

Previous reviews on hysterectomy versus uterine-sparing surgery in pelvic organ prolapse (POP) repair did not consider that the open abdominal approach or transvaginal mesh use have been largely abandoned.

OBJECTIVES

To provide up-to-date evidence by examining only studies investigating techniques currently in use for POP repair.

SEARCH STRATEGY

MEDLINE and Embase databases were searched from inception to January 2023.

SELECTION CRITERIA

We included randomized and non-randomized studies comparing surgical procedures for POP with or without concomitant hysterectomy. Studies describing open abdominal approaches or transvaginal mesh implantation were excluded.

DATA COLLECTION AND ANALYSIS

A random effect meta-analysis was conducted on extracted data reporting pooled mean differences and odds ratios (OR) between groups with 95% confidence intervals (CI).

MAIN RESULTS

Thirty-eight studies were included. Hysterectomy and uterine-sparing procedures did not differ in reoperation rate (OR 0.93; 95% CI 0.74-1.17), intraoperative major (OR 1.34; 95% CI 0.79-2.26) and minor (OR 1.38; 95% CI 0.79-2.4) complications, postoperative major (OR 1.42; 95% CI 0.85-2.37) and minor (OR 1.18; 95% CI 0.9-1.53) complications, and objective (OR 1.38; 95% CI 0.92-2.07) or subjective (OR 1.23; 95% CI 0.8-1.88) success. Uterine preservation was associated with a shorter operative time (-22.7 min; 95% CI -16.92 to -28.51 min), shorter hospital stay (-0.35 days, 95% CI -0.04 to -0.65 days), and less blood loss (-61.7 mL; 95% CI -31.3 to -92.1 mL). When only studies using a laparoscopic approach for both arms were considered, no differences were observed in investigated outcomes between the two groups.

CONCLUSIONS

No major differences were observed in POP outcomes between procedures with and without concomitant hysterectomy. The decision to preserve or remove the uterus should be tailored on individual factors.

A randomized, prospective, controlled study comparing uterine preserving laparoscopic lateral suspension with mesh versus laparoscopic sacrohysteropexy in the treatment of uterine prolapse

OBJECTIVES

Pelvic organ prolapse (POP) significantly affects women's quality of life, occurring in 20-30% of females aged over 20 globally. With aging populations, demand for pelvic reconstructive surgery is rising. Patients seek anatomical restoration while preserving uterus and sexual function. Sacrohysteropexy is the gold standard for apical prolapse, but carries risks. Lateral suspension, offers safer apical and anterior correction especially for obese, sexually active women. Our prospective study compares laparoscopic sacrohysteropexy and lateral suspension objectively and subjectively.

STUDY DESIGN

The study included patients who had laparoscopic lateral suspension (n = 22) or laparoscopic sacrohysteropexy (n = 22) for symptomatic stage 2 apical prolapse. Groups randomized with using block design. Anatomical cure was based on measurements taken by the same physician, unaware of intervention, before and at 12 months using POP-Q score. Pelvic floor ultrasound also used for objective rates. Subjective comparison used Prolapse Quality of Life (P-QoL), Pelvic Organ Prolapse-Symptom Score (POP-SS), Female Sexual Function Index (FSFI), Visual Analog Score (VAS), and Michigan Incontinence Severity Index (M-ISI).

RESULTS

Age, BMI, parity, menopause, sexual activity, complications, showed no significant difference between groups (p > 0.05). Surgical procedure duration significantly varied between groups lateral suspension group was shorter. There was no significant difference in post operative complications. No significant differences in posterior/enterocele stages.) Anterior staging showed no significant difference in sacrouteropexy (p = 0.130), but significant difference in lateral suspension group (p < 0.001). No significant differences in pre-op and post-op PQOL, POP-SS, FSFI, and M-ISI scores between the two groups.

CONCLUSION

Both methods effectively managed apical prolapse with similar outcomes. Objective measurements showed lateral suspension's superiority in reducing bladder descent.

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.

A modified laparoscopic lateral suspension with mesh for apical and anterior pelvic organ prolapse: a retrospective cohort study

Introduction

Pelvic organ prolapse (POP), a common and benign condition, is characterized by the descent of one or more aspects of the vagina and uterus. A wide variety of mesh-based surgical techniques have been proved to be effective in the treatment of pelvic organ prolapse (POP).

Aim

To evaluate the efficacy of a modified laparoscopic lateral suspension with mesh (mLLSM) in patients with apical and anterior pelvic organ prolapse.

Material and methods

All patients diagnosed with apical and anterior pelvic organ prolapse underwent a modified laparoscopic lateral suspension with mesh (mLLSM). Perioperative parameters including surgical time, blood loss and complications were recorded. At the minimal 12-month follow-up, primary outcome measures included both anatomical and functional points. The anatomical cure rate was evaluated using the Pelvic Organ Prolapse Questionnaire (POP-Q) assessment. Patient satisfaction was evaluated using questionnaires.

Results

Mean surgical time was 91.56 ±15.33 min; mean estimated blood loss was 55.42 ±36.73 ml; no intraoperative complications were noted in the perioperative period. After a minimal 12-month follow-up period, rates of anatomical success and subjective satisfaction were 96.33% and 94.50%, respectively. Symptom severity and quality of life also improved significantly.

Conclusions

We found mLLSM to be a safe and effective treatment for patients suffering apical and anterior pelvic organ prolapse. We found mLLSM to result in excellent outcomes and fewer mesh complications, underscoring its potential as an alternative treatment option for the management of apical and anterior pelvic organ prolapse.

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.

Postoperative results of laparoscopic lateral suspension operation: A clinical trials study

Background

Pelvic organ prolapse surgery carries potential risks, and Laparoscopic lateral suspension (LLS) surgery is being performed in increasing numbers with advances in minimally invasive surgery. Our study aims to report the postoperative results of LLS operations.

Patients and Methods

41 patients at POP Q stage 2 and above underwent LLS operations in a tertiary center between 2017 and 2019. Postoperative patients 12 (12-37) months and older were evaluated in terms of anterior and apical compartments.

Results

In our study, laparoscopic lateral suspension (LLS) was applied to 41 patients. The mean age of all patients was 51.45 ± 11.51, and the operation time was 71.13 ± 18.70 min, The mean hospital stay was 1.35 ± 0.4 days. The apical compartment success rate was 78% and the anterior compartment success rate was 73%. In terms of patient satisfaction, 32 (78.1%) patients were satisfied, While 37 (90.1%) patients did not have abdominal mesh pain, 4 (9.9%) patients had mesh pain. Dyspareunia was not observed.

Conclusions

Laparoscopic lateral suspension in pop surgery; Considering the success rate below expectation, some patient groups can be applied as an alternative surgical method.

Comparison of laparoscopic lateral suspension and laparoscopic sacrocolpopexy with concurrent total laparoscopic hysterectomy for the treatment of pelvic organ prolapse: a randomized controlled clinical trial

INTRODUCTION AND HYPOTHESIS

We compared the outcomes of women who underwent laparoscopic lateral suspension with concurrent total laparoscopic hysterectomy (LLS-TLH) with those of women who underwent laparoscopic sacrocolpopexy with concurrent total laparoscopic hysterectomy (LSC-TLH) for apical and/or anterior vaginal wall prolapse.

METHODS

Eighty women underwent LLS-TLH or LSC-TLH operations. According to the Pelvic Organ Prolapse Quantification System (POP-Q), women with symptomatic pelvic organ prolapse of stage 2 or higher apical and/or anterior compartment prolapse were enrolled in the study. The objective cure rate according to the POP-Q system was the primary (objective) outcome. The International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and Patient Global Impression of Improvement (PGI-I) questionnaire scores were the secondary (subjective) outcomes. The primary and secondary outcomes were evaluated at 1 year after surgery.

RESULTS

The primary and secondary outcomes indicated significant improvements in both groups (p < 0.05). The objective cure rate was 92.5% for apical and 78.6% for anterior compartment prolapse in the LLS-TLH group; the respective rates were 100% and 74.1% in the LSC-TLH group. The subjective cure rate was 87.5% for the LLS-TLH group and 90% for the LSC-TLH group. No statistically significant differences between groups were found in the objective cure rate, subjective cure rate, or ICIQ-VS, ICIQ-SF, or PGI-I scores at 1 year (p > 0.05).

CONCLUSIONS

LLS-TLH can serve as a safe, effective, and feasible alternative to LSC-TLH, with low complication rates and similar short-term objective and subjective outcomes.

Laparoscopic lateral suspension for pelvic organ prolapse: A systematic literature review

BACKGROUND

Abdominal lateral suspension with mesh represents an alternative treatment to suspend the vaginal apex.

OBJECTIVES

The aim of this study was to summarize literature data regarding the anatomical and functional outcomes, and intra- and postoperative complications of this technique with minimally invasive approach (laparoscopic/robotic).

SEARCH STRATEGY

Systematic literature search using MEDLINE/PubMed, SCOPUS, Web of Science.

DATA COLLECTION AND ANALYSIS

Two authors extracted data on baseline characteristics (age, BMI, prior pelvic reconstructive surgery, preoperative POP stage), perioperative outcomes (operative time, estimated blood loss, intraoperative and postoperative complications, admission time), objective and subjective success rate, surgical failure, time of follow-up. Data were presented descriptively.

MAIN RESULTS

Thirteen studies were included in the review. The overall number of patients for our analysis was 1066. Patients referred for laparoscopic/robotic lateral suspension were most frequently postmenopausal, aged 50 to 65 years, BMI ≥ 25 kg/m2; 22.2% were already hysterectomized, while 17% had already a previous POP surgery. Operative time ranged from 78.4 ± 29.7 to 254 ± 45 min. The overall anatomic success was more than 90% in the apical compartment and more than 88% in the anterior compartment. Subjective cure rate varies from 78.4% to 100% in medium-term follow-up. Post-operative complication grade >= 3 according to Claiven-Dindo Scale was 1.03%. Mesh erosion rate varied between 0% and 13%.

CONCLUSIONS

Results coming from our systematic review suggest safety, efficacy and feasibility of minimally invasive lateral suspension with optimal anatomical and functional outcomes. Well-designed, randomized, controlled trials are required to confirm this data.

Modified laparoscopic lateral suspension with a five-arm mesh in pelvic organ prolapse surgery

Background

Laparoscopic lateral suspension (LLS) is a laparoscopic technique used to treat pelvic organ prolapse (POP) in apical and anterior compartment defect with the use of a synthetic T-shaped mesh graft. The posterior compartment is repaired using a second mesh or a procedure along with LLS, such as posterior colporrhaphy. The aim of this study was to evaluate the clinical results of LLS for POP using a five-arm mesh instead of a T-shaped mesh graft to repair the defect of the posterior compartment in addition to the apical and anterior compartments.

Methods

Data from 37 patients with a diagnosis of advanced-stage (≥ 3) POP undergoing LLS with the use of a five-arm mesh were retrospectively analysed. Pre-operative and post-operative examinations and, surgical outcomes were determined. The results of measurements and examinations, reoperation rates, erosion rates, lower urinary tract symptoms, and complications were analysed. The Prolapse Quality of Life Questionnaire (P-QOL) was also used.

Results

The median post-operative follow-up was 20 (13–34) months. There was a significant improvement in POP-Q scores in all treated compartments, with overall objective cure rates of 94.5% for the apical compartment, 86.4% for the anterior compartment, and 91.8% for the posterior compartment. The median operative time was 96 (76–112) minutes. The median length of hospitalization was 2 (1–3) days. A significant improvement in vaginal bulge, urinary urgency, incomplete voiding, urinary frequency, and constipation was observed after surgery. The sexuality among patients increased from 13 (35.1%) preoperatively to 22 (59.4%) post-operatively. De novo stress urinary incontinence developed in 7 (18.9%) patients. The P-QOL scores improved significantly after surgery.

Conclusions

In advanced-stage POP patients, the posterior compartment damage can also be repaired in LLS with the use of a single five-arm mesh without the need for an additional procedure, and the recurrence rate can be reduced.

Laparoscopic latero-abdominal colposuspension: Description of the technique, advantages and preliminary results

INTRODUCTION

There are currently various fixation or suspension techniques for pelvic organ prolapse (POP) surgery. Laparoscopic colposacropexy is considered the gold standard. We present the surgical steps of the laparoscopic latero-abdominal colposuspension (LACS) technique and the preliminary results obtained.

MATERIAL AND METHODS

Patients with anterior and/or apical compartment symptomatic POP undergoing LACS are included. The Baden-Walker scale, the Overactive Bladder Questionnaire-Short Form (OAB-q SF), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Patient Global Impression of Improvement (PGI-I) scale were used to assess the degree of prolapse, urinary filling and sexual symptoms and the level of satisfaction before and after surgery, respectively. Conventional laparoscopic material and a polyvinylidene fluoride (PVDF) mesh were used.

RESULTS

Eighteen patients were included with a minimum follow-up time of 6months. The mean surgical time was 70.3±23.8min. Anatomic correction of prolapse was seen in all cases. Only one recurrence was detected. High levels of patient satisfaction were achieved.

CONCLUSION

LACS allowed the anatomical reconstruction of the pelvic floor and proved to be a minimally invasive, fast, effective, safe and reproducible technique. More series are needed to evaluate its role against laparoscopic colposacropexy.

Joint Report on Terminology for Surgical Procedures to Treat Pelvic Organ Prolapse

Surgeries for pelvic organ prolapse (POP) are common, but standardization of surgical terms is needed to improve the quality of investigation and clinical care around these procedures. The American Urogynecologic Society and the International Urogynecologic Association convened a joint writing group consisting of 5 designees from each society to standardize terminology around common surgical terms in POP repair including the following: sacrocolpopexy (including sacral colpoperineopexy), sacrocervicopexy, uterosacral ligament suspension, sacrospinous ligament fixation, iliococcygeus fixation, uterine preservation prolapse procedures or hysteropexy (including sacrohysteropexy, uterosacral hysteropexy, sacrospinous hysteropexy, anterior abdominal wall hysteropexy, Manchester procedure), anterior prolapse procedures (including anterior vaginal repair, anterior vaginal repair with graft, and paravaginal repair), posterior prolapse procedures (including posterior vaginal repair, posterior vaginal repair with graft, levator plication, and perineal repair), and obliterative prolapse repairs (including colpocleisis with hysterectomy, colpocleisis without hysterectomy, and colpocleisis of the vaginal vault). Each of these terms is clearly defined in this document including the required steps of the procedure, surgical variations, and recommendations for procedural terminology.

Laparoscopic lateral suspension: a single-site and single-surgeon experience

Background

In the reconstructive surgery for pelvic organ prolapse (POP), different newer mesh fixation techniques as an alternative to sacrocolpopexy has been developed. In order to gain more data about the different techniques, it is important to analyze success and recurrence rates of surgical procedures.

Methods

Collection and analysis of data from patients treated with laparoscopic lateral suspension (LLS). Patients were followed up for 6 weeks after surgery. Consultations were continued, if needed, up to 2.5 years. Main outcome measures were anatomic results, POP recurrence, mesh exposure and reoperation rate, and potential risk factors for relapse.

Results

Thirty-nine patients were treated between July 2015 and November 2017. In the first visit, one patient was diagnosed with an early relapse (success rate: 95%). Another six women relapsed during follow-up (mean, 13.5 months; success rate, 82%). Patients with recurrence were younger (62 vs. 68 years) and had initially a higher degree of prolapse, a higher parity (3.8 vs. 1.9), more previous surgeries, and longer operating times.

Early exposures were seen in 5.3% patients and raised up to 13% during follow-up; all but one were treated successful with local estrogen therapy. Risk factors for exposure were higher age and longer operating time.

The whole reoperation rate was 13%.

Conclusions

LLS might be a valid alternative to the laparoscopic sacrocolpopexy in women with prolapse in the anterior compartment and apical descent. Younger women with higher parity and higher degree of prolapse in the middle compartment had a higher recurrence rate after LLS.

Laparoscopic uterine ventrosuspension procedure by using anterior mesh incorporated with bilateral round ligamentopexy: Kahyaoglu technique

A number of vaginal and abdominal surgical techniques have been described for the treatment of apical uterine prolapse. A 38-year-old parous woman has been operated laparoscopically due to grade 3 apical uterine prolapse. A new surgical technique for the treatment of apical uterine prolapse performed by incorporation of the lateral arms of anteriorly anchored uterine polypropylene mesh to bilateral round ligaments has been developed. Due to the young age of the patient and lack of any other uterine pathology, a laparoscopic uterine ventrosuspension procedure combined with bilateral round ligamentopexy has been performed as a low risk uterine prolapse surgery.

Uterus-preserving Laparoscopic Lateral Suspension with Mesh Operation in Pelvic Organ Prolapse: Initial Experience in a Single Tertiary Center with a Median 24-Month Follow-up

Introduction Laparoscopic lateral suspension with mesh (LLSM) is an effective and less invasive technique for the correction of pelvic organ prolapse. We discuss the primary objectives, subjective success rate and pelvic floor ultrasound outcomes of uterus-preserving LLSM operations. Patients and Methods Seventeen patients who underwent uterus-preserving LLSM (abdominocervicopexy) in a tertiary center were included in this prospective study. Anatomical cure was defined separately for the apical and anterior compartments as a Pelvic Organ Prolapse Quantification (POP-Q) score of less than - 1 cm for each compartment. Subjective cure was defined as the absence of bulge symptoms. Patient satisfaction, sexual function, prolapse-related quality of life, voiding dysfunction, nocturia and constipation were assessed. Transperineal ultrasonography was used to measure anterior compartment mobility and hiatal anteroposterior diameter. Results The anatomical cure rate was 100% for the apical and 88.2% for the anterior compartment, with one symptomatic stage-II cystorectocele and one asymptomatic stage-II cystocele. The subjective cure and patient satisfaction scores were 94.12 and 100%, respectively. Ba and C points were significantly improved, and vaginal lengthening was 10.14 ± 4.19 mm. Bp ascent was 5.72 ± 11.27 mm (p = 0.053). Proximal urethral rotation and retrovesical angles were reduced by 6.24 ± 11.95° and 27 ± 47.2°, respectively (p1 = 0.047; p2 = 0.032). The hiatal anteroposterior diameter was shortened by 4.36% (p = 0.039). A significant improvement was seen with regard to nocturia episodes but not for constipation. No mesh exposure was observed. Conclusions Uterus-preserving LLSM (abdominocervicopexy) was found to be effective for the correction of apical and anterior prolapse with high levels of patient satisfaction. Significant improvements in urge symptoms and frequency of nocturia were observed. Pelvic floor ultrasound outcomes may be useful when comparing this procedure with other surgical techniques.

Comparison of laparoscopic techniques for apical organ prolapse repair - a systematic review of the literature

AIMS

Apical defect is a pelvic organ prolapse disorder, with 5%-15% prevalence. The aim of the study was to investigate methods of laparoscopic repair of apical defect and compare them with other techniques (open, vaginal, and robotic).

METHODS

A systematic search of the literature was conducted in MEDLINE/PubMed and ClinicalTrials.gov databases using the following key words: apical prolapse and treatment procedures. The search was limited by using the humans filters. Only articles published in English between 2010 and 2018 were considered. Two independent authors reviewed the publications for inclusion on the basis of the following criteria: (a) use of laparoscopic techniques, and (b) apical support loss as indication for surgery.

RESULTS

A total of 1002 papers were initially identified; 24 studies fulfilled the inclusion criteria. Four main laparoscopic procedures were found. The reported anatomical success rate (POP-Q < II stage) was 77%-100%, with patient satisfaction for pectopexy, laparoscopic sacropexy (LS), lateral ligament suspension and laparoscopic uterosacral ligament suspension (LUSLS) of 96.4%-97.6%, 71.0%-100%, 66.7%-87.8%, and 95%-95.5%, respectively. Major complications included hemorrhage, bladder, ureter, and/or bowel injuries were rare. Prolapse recurrences after LUSLS and LS were reported in 13.2% and 10.4% of patients, respectively; with reoperation rate for LS 2.2%-12.8%.

CONCLUSIONS

Most studies reported anatomical and subjective outcomes, with follow-up ranging from 1 month to >7 years. Success rates for laparoscopic and abdominal corrections of apical defect were similar; laparoscopy was superior in terms of perioperative blood loss, length of hospital stay, and recovery.

[Uterine preservation or not during prolapse surgery: Review of the literature]

OBJECTIVE

To evaluate the impact of hysterectomy in case of genital prolapse on the anatomical and functional results, and on per and post operative complications compared with uterine preservation.

MATERIAL AND METHODS

We conducted a review of the Pubmed, Medline, Embase and Cochrane literature using the following terms and MeSH (Medical Subject Headings of the National Library of Medicine): uterine prolapse; genital prolapse; prolapse surgery; vaginal prolapse surgery; abdominal prolapse surgery; hysterectomy; hysteropexy; sacrocolpopexy; surgical meshes; complications; sexuality; neoplasia; urinary; incontinence; cancer.

RESULTS

Among the 168 abstracts studied, 63 publications were retained. Whatever performance of hysterectomy or not, anatomical and functional results were similar in abdominal surgery (sacrocolpopexy) (OR=2.21 [95% CI: 0.33-14.67]) or vaginal surgery (OR=1.07 [95% CI: 0.38-2.99]). There was no difference in terms of urinary symptoms or sexuality after surgery. Hysterectomy was associated to a higher morbidity (bleeding, prolonged operating time, longer hospital stay), to an increased risk of mesh exposure particularly in case of total hysterectomy (8.6%; 95% CI: 6.3-11).

CONCLUSION

In the absence of evidence of superiority in terms of anatomical and functional outcomes, with an increased rate of complications, concomitant hysterectomy with prolapse surgery should probably not be performed routinely.

Role of robotic surgery on pelvic floor reconstruction

Over the past two decades, minimally invasive surgery (MIS) abdominal surgery has increasingly been used to treat pelvic organ prolapse. Besides the several advantages associated with minimal invasiveness, this approach bridged the gap between the benefits of vaginal surgery and the surgical success rates of open abdominal procedures. The most commonly performed procedure for suspension of the vaginal apex for postoperative vaginal prolapse by robotic-assisted laparoscopy is the sacrocolpopexy. Conventional laparoscopic application of this procedure was first reported in 1994 by Nezhat et al. and had not gained widespread adoption due to lengthy learning curve associated with laparoscopic suturing. Since FDA approval of the da Vinci® robot for gynecologic surgery in 2005, minimally invasive abdominal surgery for pelvic organ prolapse has become increasingly popular, as robotic-assisted laparoscopic sacrocolpopexy is an option for those surgeons without experience or training in the conventional route. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the "gold standard" technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. In fact, repair of pelvic organ prolapse can be performed robotically, and sometimes surgeons can feel suturing and dissection during the procedures less challenging with the assistance of the robot. However, even if robotic surgery may confer many benefits over conventional laparoscopy, these advantages should continue to be weighed against the cost of the technology. To date, as long-term outcomes, evidence about robotic sacrocolpopexy for a repair of pelvic organ prolapse are not conclusive, and much more investigations are needed to evaluate subjective and objective outcomes, perioperative and postoperative adverse events, and costs associated with these procedures. It is plausible to think that the main advantage is that robotics may lead to a widespread adoption of minimally invasive techniques in the field of pelvic floor reconstructive surgery. The following review will address the development and current state of robotic assistance in treating pelvic floor reconstruction discussing available data about the techniques of robotic prolapse repair as well as morbidity, costs and clinical outcomes.

Effectiveness, quality of life and sexual functions in women with anterior compartment prolapse treated by native tissue repair

Anterior compartment defect is the most common pelvic organ prolapse. It is defined as the descent of the bladder into the anterior vaginal wall. The etiology is multifactorial and the main risk factors are vaginal delivery and conditions associated with increased abdominal strain. Aging is significantly associated with the prevalence and severity of pelvic organ prolapse. Treatment may be conservative or surgical according to symptoms, prolapse degree and not forgetting both patient and doctor preferences. The aim of this work is to identify the most efficient surgical treatment of cystocele and its recurrences. There are two different surgical approaches for the treatment of cystocele: traditional repair and mesh repair. Prosthetic treatment gives higher anatomical success rate but traditional anterior repair has less complication demonstrating a lower risk of reoperation. Surgical treatment in general improves both the quality of life (QoL) and the sexual function. We carried out a research on the impact of the anterior defect before and after native tissue surgery on QoL and sexual function. The efficacy and complications of the treatment were also assessed.