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

McCall culdoplasty vs. vaginally assisted laparoscopic sacrocolpopexy in the treatment of advanced uterine prolapse: A randomized controlled study

OBJECTIVE

The primary aim of this study was to compare the anatomic outcomes of vaginally assisted laparoscopic sacrocolpopexy (VALS) with those of McCall culdoplasty (McCC) in patients undergoing concurrent vaginal hysterectomy.

MATERIALS AND METHODS

This randomized controlled study presents the outcomes of 68 patients who underwent hysterectomy and vaginal suspension for apical prolapse ≥ Stage III according to the Pelvic Organ Prolapse Quantification (POP-Q) system between October 2017 and December 2020. Among these patients, 33 underwent VALS and 35 underwent McCC. Clinical features, surgical data, concomitant surgical procedures, postoperative complications, and recurrence rates were assessed. Before and after one year of surgery, the short form of the Pelvic Floor Impact Questionnaire and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire were used to evaluate subjective symptoms. Patient Global Impression of Improvement Questionnaire was used to assess patient satisfaction.

RESULTS

The mean follow-up durations were 25.5 ± 7.63 months and 25.6 ± 5.96 months in the VALS and McCC groups, respectively. Prolapse recurrence occurred in 3 (9.1%) women in the VALS group versus 12 (34.3%) women in the McCC group (p = 0.031).

CONCLUSION

The McCC operation was associated with a shorter operation time, whereas the VALS operation had a significantly higher objective success rate. Based on this study, it may be concluded that McCC is not an effective procedure for advanced uterine 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.

The Role of Laparoscopic Surgery in the Treatment of Advanced Uterine Prolapse: A Systematic Review of the Literature

The aim of this review is to investigate and compare all laparoscopic techniques that can be used in the surgical repair of advanced uterine prolapse. A systematic search of the PubMed, Scopus, Cochrane CENTRAL, and Clinicaltrials.gov databases was performed for articles published up to December 2020, reporting data on the treatment of severe uterine prolapse using laparoscopic procedures. Only studies in the English language, with a patient sample of ≥20 and a follow-up time of ≥12 months were included. The final synthesis of this review consisted of six studies. The main laparoscopic procedures reported were vaginally assisted laparoscopic sacrocolpopexy, vaginally assisted laparoscopic uterine sacropexy, laparoscopic sacrocolpopexy with laparoscopic supracervical hysterectomy, laparoscopic inguinal ligament suspension with uterine preservation, and laparoscopic uterosacral ligament suspension combined with trachelectomy. All procedures involved mesh placement, except for laparoscopic uterosacral ligament suspension. All procedures reported anatomical cure rates > 90%. Vaginally assisted laparoscopic sacrocolpopexy had the largest amount of intraoperative blood loss whilst vaginally assisted laparoscopic uterine sacropexy was associated with bladder injuries intraoperatively. All vaginally assisted procedures reported cases of mesh extrusion postoperatively. Laparoscopic inguinal ligament suspension was the operation with the longest mean operative and hospitalization time. Conversions were not reported. The present study shows that minimally invasive surgery can be used efficiently as an alternative to open surgery in the treatment of severe uterine prolapse.