Laparoscopic management of genital prolapse

Laparoscopic cervicopexy for correction of apical genital prolapse in 10 steps: a pilot study

INTRODUCTION

Surgical repair of pelvic organ prolapse is one of the most frequent gynecological procedures, and its frequency is expected to increase as the population is gradually aging. Mesh use in urogynecological surgery should be limited because of important and life-treating complications. Sacral mesh-less and lateral procedures have been described as safe and effective to treat apical compartment prolapse. In this video, we describe a new laparoscopic mesh-less cervicopexy in women with symptomatic uterovaginal prolapse who did not desire uterine preservation.

METHODS

Eleven women with symptomatic uterovaginal prolapse [stage 2 or higher according to the Pelvic Organ Prolapse Quantitative (POP-Q) classification system] underwent laparoscopic mesh-less cervicopexy to the sacrum and transverse fascia between May 2018 and June 2019. We performed application of the right uterosacral ligament starting from the sacrum and two semicontinous sutures including the transverse fascia, round ligament, prevescical peritoneum, pubocervical fascia and cervix that were subsequently knotted.

RESULTS

At 6-month follow-up, the objective success rate for apical prolapse (POP-Q score C > -1) was 90.9% (10/11 women). Only one woman presented stage 3 apical prolapse recurrence with vaginal buldge.

CONCLUSION

Laparoscopic mesh-less cervicopexy for uterovaginal prolapse seems to be a feasible surgical technique at 6-month follow-up.

Laparoscopic Mesh-Less Cervicosacropexy for Uterovaginal Prolapse

OBJECTIVES

This study aimed to evaluate surgical and clinical outcomes of laparoscopic mesh-less cervicosacropexy for the treatment of uterovaginal prolapse.

METHODS

This single institutional review board-approved prospective cohort study enrolled 46 consecutive, sexually active symptomatic women requiring surgical correction of uterovaginal prolapse, from July 2013 to March 2016. After supracervical laparoscopic hysterectomy, the cervix was suspended to the anterior longitudinal ligament of the sacral promontory through a continuous suture with plication and shortening of the right uterosacral ligament. Pelvic organs' function was evaluated through validated questionnaires during preoperative and postoperative follow-up evaluations. The anatomical recurrences of genital prolapse with a Pelvic Organ Prolapse Quantitative stage 2 or higher, in particular of central compartment (Pelvic Organ Prolapse Quantitative score C ≥-1), were recorded.

RESULTS

Mean ± SD age was 55.5 ± 10.9 years. Mean ± SD operating time was 97.4 ± 25.6 (range, 60-180) minutes. Mean ± SD hospitalization length was 3.6 ± 0.9 (range, 2-6) days. No intraoperative complications were recorded. Median length of follow-up was 24 (range, 12-38) months. During the follow-up period, the objective success rates for central compartment prolapse and for all compartments were 93.5% and 89.1%, respectively. No woman presented dyspareunia at follow-up. Thirty-nine women (84.8%) reported very high satisfaction related to surgery and 6 (13%) a moderate satisfaction. Overall Female Sexual Function Index, Knowles-Eccersley-Scott Symptom, and Bristol Female Lower Urinary Tract scores improved significantly after surgery, except for incontinence score domain.

CONCLUSIONS

Laparoscopic mesh-less cervicosacropexy represents an effective and feasible option for the surgical treatment of uterovaginal prolapse in sexually active women, avoiding postoperative complications due to the mesh use.

Four-defect repair in women with symptomatic anterior compartment prolapse: a large cohort study

INTRODUCTION AND HYPOTHESIS

We aimed to collect long-term follow-up data and report on both objective and subjective outcome, including morbidity, reinterventions, and sexual function following four-defect repair (FDR) as surgical correction of symptomatic anterior vaginal wall prolapse with or without stress urinary incontinence (SUI).

METHODS

Consecutive patients who underwent FDR between 1999 and 2005 were included in this study. We performed a retrospective analysis to evaluate anatomical and functional outcome by reviewing medical charts and sending validated questionnaires (Urogenital Distress Inventory and Defecatory Distress Inventory) to all patients. We also sent a self-developed, nonvalidated questionnaire to assess sexual function and inform the patient about reinterventions for pelvic floor dysfunction.

RESULTS

Two hundred and twenty-nine (60 %) of the 381 patients who underwent FDR participated. At a median follow-up of 40 months (range 5-88), 21 % of patients reported bothersome prolapse symptoms, and 11 % reported bothersome SUI. Temporary postoperative urinary retention occurred in 23 %. During follow-up, posterior vaginal wall prolapse was observed in 14 % of patients. Overall surgical reintervention rates were 15 % and 4 % for (all types of) pelvic organ prolapse and SUI, respectively; dyspareunia was reported by 30 %.

CONCLUSIONS

Functional cure rates of FDR as surgical treatment for anterior vaginal wall prolapse with or without SUI are satisfying. Nevertheless, given the negative side effects of FDR (urinary retention, high reintervention rate for posterior vaginal wall prolapse, high risk of sexual dysfunction), we question the superiority of FDR over standard anterior colporrhaphy in patients with anterior vaginal wall prolapse only.

Robotic sacrocolpopexy: how does it compare with other prolapse repair techniques?

Abdominal sacrocolpopexy has been shown to have the highest, most durable success rates among techniques for apical pelvic organ prolapse repair. Recently, there has been increased application of minimally invasive techniques, such as laparoscopic and robotic approaches, to performing a sacrocolpopexy. We report an overview of the literature in order to compare between robotic sacrocolpopexy and other surgical techniques for the repair of apical pelvic organ prolapse. Our review will include a discussion of operative techniques, anatomic and subjective success rates, costs, and complications.

Robotic/Laparoscopic prolapse repair and the role of hysteropexy: a urology perspective

Approximately 11% of women will undergo a surgical procedure for the treatment of pelvic organ prolapse (POP) or urinary incontinence by age 80 years. Abdominal sacrocolpopexy has been found in multiple studies to have high long-term success rates for repair of severe vault prolapse. Robotic or laparoscopic sacrocolpopexy offer similar success to an open approach. This article describes the techniques of laparoscopic sacrocolpopexy and robotic sacrocolpopexy. The role of hysteropexy for the treatment of POP is also discussed.

[Prolapse surgery. With abdominal or vaginal meshes?]

In prolapse surgery several surgical techniques are available. The different open, laparoscopic and vaginal approaches are distinguished by distinct success and relapse rates and operation-specific complications. A safe and optimal therapeutic pelvic floor surgery should be based on the three support levels according to DeLancy and be individually adjusted for every patient. The vaginal approach may be used for all kinds of female genital prolapse and is a comparatively less invasive technique with a short time of convalescence. Apart from stress incontinence there is no need for synthetic meshes in primary approaches and excellent results with low complication and relapse rates can be achieved. An uncritical application of synthetic material is to be avoided in vaginal repair at all times. Abdominal surgical techniques, both open and laparoscopic, present their strengths in the therapeutic approach to level 1 defects or stress incontinence. They provide excellent functional and anatomical corrections and low relapse rates. Abdominally inserted meshes have lower complication rates than vaginal ones.