Sacrocolpopexy: Surgical Technique, Outcomes, and Complications

Comparing the efficacy of laparoscopic pectopexy and laparoscopic sacrocolpopexy for pelvic organ prolapse: A systematic review and meta-analysis

OBJECTIVE

To assess and compare the efficacy of laparoscopic pectopexy and laparoscopic sacrocolpopexy in managing pelvic organ prolapse.

DATA SOURCES

A systematic search of PubMed, Web of Science, Scopus, and Embase was conducted on July 3, 2024, using the search terms "Pectopexy" AND "Laparoscop*" with no publication date restrictions. Additional sources included citation screening and searches in Google Scholar and ProQuest.

METHODS OF STUDY SELECTION

We included all peer-reviewed, English full-text articles comparing intraoperative, short-term (up to six months), or long-term (six to twelve months) outcomes for laparoscopic pectopexy and sacrocolpopexy in pelvic organ prolapse management.

TABULATION, INTEGRATION, AND RESULTS

Our electronic search identified 269 records, of which 11 were deemed eligible after thorough screening. No additional eligible articles were found through a manual search. The final review included 11 studies, comprising 1,043 patients across four randomized controlled trials, six retrospective studies, and one prospective cohort. Meta-analyses using a random-effects model. Findings showed lower operation time (Hedges's g = -.978 [-1.629, -.327]; p = .003) and blood loss (Hedges's g = -.658 [-1.160, -.155]; p = .010) in pectopexy, with comparable organ injury rates (p > .05) between procedures. Short-term results showed a shorter hospitalization duration for pectopexy (Hedges's g = -.213 [-.426, -.000]; p = .049), while post-surgery outcomes like urinary tract infection, and voiding dysfunction were similar across groups (p > .05). All long-term outcomes were comparable, including apical prolapse recurrence, mesh-related complications, pelvic organ prolapse quantification system scores, constipation, urgency, stress urinary incontinence, dyspareunia, and patient satisfaction (p > .05).

CONCLUSION

This review highlights that laparoscopic pectopexy, despite its theoretical technical advantages, shows comparable intraoperative organ injury rates and similar urinary, defecation, and sexual function outcomes to laparoscopic sacrocolpopexy. However, pectopexy is linked to shorter operative times, less blood loss, and reduced post-operative hospitalization.

Abdominal Mesh Colpopexy Without Promontory Fixation: 10-Year Follow-up Results of the Peritoneocolpopexy Technique

OBJECTIVE

To restore apical vaginal prolapse support when the access to the promontory is challenging, a modified method of colpopexy may be needed. We present our 10-year results on the peritoneocolpopexy (PCP) technique without promontory fixation relying on unidirectional barbed delayed absorbable sutures (V-Loc).

METHODS

Fourteen women who underwent PCP for vaginal vault prolapse between 2011 and 2014 participated in an IRB-approved prospective study (11 noninfected; 3 with infected mesh needing excision). Ten-year follow-up data including validated questionnaires (Urinary Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire-7 (IIQ-7), QoL), pelvic organ prolapse quantifications (POP-Q), complications, reoperations, and secondary prolapses were collected. Paired statistical analyses compared various timepoints and mixed model analysis assessed questionnaire and POP-Q trends over time.

RESULTS

Median follow-up was 9.7years (interquartile range (IQR): 6.0-0.7) to last POP-Q and 10.4years (IQR: 9.6-11.5) to last contact. No patients were lost to follow-up. Mean baseline C point for all patients was -4.3 and -2.9; 1-year C point was -9.1 and -9.2 and -8.6 and -8.5, respectively at last visit. POP-Q findings improved between pre-PCP and 1-year post surgery and did not significantly change until the last visit. Trends in UDI-6, IIQ-7, QoL, and POP-Q findings showed no significant change in any category per year (95% confidence interval (CI), P=.2-.9). Secondary anterior compartment prolapse was noted in 3 patients with 1 requiring a repair.

CONCLUSION

PCP provides durable vaginal apical support when access to the promontory is compromised. PCP can also be used to prevent secondary prolapse after an infected mesh removal.

Literature review, surgical decision making algorithm, and AGREE II-S comparison of national and international recommendations and guidelines in pelvic organ prolapse surgery

The average lifespan has increased over time due to improvements in quality of life, leading to an aging population that stays healthy for longer. Pelvic organ prolapse (POP), whether uterine or vaginal, is a problem that severely impairs quality of life and imposes significant restrictions. The present study provides the reader with a summary of the many surgical techniques used in POP surgery, comparing international guidelines, offering an algorithm that is simple to understand, and allows the reader to quickly choose the table that includes the best surgical therapy for each individual. Using relevant keywords, the writers searched the PubMed and Scopus databases for relevant publications from 2000 to April 2023. Studies with cases of oncologic disorders or prior hysterectomy performed for another reason were not included in the analysis. Ten distinct international guidelines are highlighted and examined in the present study. We used the Appraisal of Guidelines for Research and Evaluation II-S (AGREE II-S) method to assess their quality, and incorporated the results into the conclusion. Worldwide, anterior colporrhaphy is the preferred method of treating anterior compartment abnormalities, and mesh is virtually always used when recurrence occurs (which happens in about half of the cases). Worldwide, posterior colporrhaphy is commonly used to repair posterior compartment abnormalities. Only a few national guidelines (the Iranian guideline, Acta Obstetricia et Gynecologica Scandinavica [AOGS], and the German-speaking countries) permit the use of mesh or xenograft in cases of recurrence. There is agreement on the abdominal approach (sacrocolpopexy) with mesh for treating apical deformities. Sacrospinous-hysteropexy is the standard method used to guide the vaginal approach; mesh is typically used to aid in this process. There are just three recommendations that do not include vaginal operations: HSE, AOGS, and Iran. Of obliteration techniques, colpocleisis is unquestionably the best. In conclusion, our analysis highlights the significance of customized methods in POP surgery, taking into account the requirements and preferences of each patient. To choose the best surgical therapy, criteria and patient features must be carefully considered.

Surgical Treatment of Enlarged Cervical Leiomyoma with Concomitant Uterine Prolapse: A Case Report

This case report details the surgical treatment of a rare enlarged cervical leiomyoma with uterine prolapse in a 48-year-old woman. She presented to Konyang University Hospital with a palpable vaginal mass, lower abdominal pain, and urinary incontinence. Despite being nulliparous, she had severe chronic constipation due to schizophrenia medication and lived in a health care facility separated from her family. Pelvic examination revealed stage 3 uterine prolapse with a large necrotic cervical leiomyoma. A robot-assisted vaginal hysterectomy followed by sacrocolpopexy was performed using the Da Vinci Xi Surgical System. Histopathology confirmed cervical leiomyoma with squamous metaplasia. At a three-month follow-up, there were no complications, pelvic anatomy was restored, and urinary incontinence improved. Although the patient had a systemic infection due to the necrotic cervical leiomyoma, raising concerns about the increased risk of infection associated with mesh use, she was high-risk for pelvic organ prolapse (POP) recurrence due to her medical history and living situation. Therefore, she underwent concurrent surgeries with pre- and postoperative antibiotic treatment, and recovered without complications. Given that the risk of developing POP increases after a hysterectomy, in high-risk patients, as demonstrated in this case, the concurrent surgical correction of POP may be an effective strategy.

Postoperative complications and unanticipated healthcare encounters following mini-laparotomy vs. laparoscopic/robotic-assisted sacrocolpopexy: a comparative retrospective study

BACKGROUND

Pelvic organ prolapse is a debilitating condition impacting lives of millions of women worldwide. Sacrocolpopexy (SCP) is considered an effective and durable surgical technique for treatment of apical prolapse. The aim of this study was to compare short-term outcomes including postoperative complications and unanticipated healthcare encounters between patients who underwent SCP with a mini-laparotomy approach compared to patients treated with laparoscopic and robotic-assisted laparoscopic SCP.

METHODS

This was a retrospective cohort study including patients treated for apical prolapse at a university affiliated urogynecology practice. Patients over the age of 18 who underwent abdominal SCP between 2019 and 2023 were included. The cohort was formed into two groups: (1) Patients who underwent SCP through a mini-laparotomy incision (Mini-lap group); (2) Patients who underwent laparoscopic or robotic-assisted laparoscopic SCP (Lap/Robot group).

RESULTS

A total of 116 patients were included in the final analysis. Ninety patients underwent either laparoscopic or robotic-assisted SCP, whereas 26 patients underwent SCP with a mini-laparotomy approach. Study participants exhibited a mean age of 63.1 ± 10.3 years, mean body mass index (BMI) of 25.8 ± 4.9 Kg/m2, and 77.6% of them identified as Caucasian. Upon comparison of demographic and past medical history between groups there were no statistically significant differences in age, BMI, menopausal status, race, parity or comorbid conditions. Patients in the Mini-lap group were less likely to have undergone previous abdominal surgery (11.5% vs. 50.6%, p < 0.001) and had more severe apical prolapse (stage 4 prolapse, 40% vs. 21.2%, p < 0.001) than their counterparts in the Lap/robot group. Regarding intraoperative parameters, length of surgery was significantly shorter in the Mini-lap group compared to the Lap/robot group (97.3 ± 35.0 min vs. 242.0 ± 52.6 min, p < 0.001). When focusing on the primary outcome, postoperative complications within the first 30 days after surgery, there were no differences noted between groups. Additionally, the number of unanticipated healthcare encounters, such as phone calls, clinic visits, emergency department visits, urgent care visits, readmissions and reoperations were similar between groups.

CONCLUSIONS

Mini-laparotomy approach for SCP is safe with comparable intra- and postoperative complications, and unanticipated healthcare encounters compared to conventional minimally invasive methods.

[Radiological imaging following pelvic prolapse surgery]

CLINICAL/METHODICAL ISSUE

Pelvic organ prolapse is a common condition in women, for which both conservative and surgical interventions are available. Knowledge of the different surgical procedures and the materials used is essential for adequate radiological diagnosis after prolapse surgery in order to differentiate potential complications from normal postoperative changes.

STANDARD RADIOLOGICAL METHODS

In the immediate postoperative period, computed tomography (CT) is often the modality of choice for evaluating acute complications such as bleeding or organ injuries. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and is therefore generally preferred for assessing subacute and chronic complications.

METHODICAL INNOVATIONS

Innovative techniques such as dynamic MRI protocols can improve the radiological assessment after prolapse surgery by enabling the evaluation of organ mobility.

PERFORMANCE

Radiological standard procedures such as computed tomography (CT) and MRI provide detailed and reliable information about the postoperative site and potential complications following prolapse surgery.

ACHIEVEMENTS

Radiological imaging plays an important role in the evaluation of patients after prolapse surgery, particularly when complications are suspected. Accurate radiological diagnosis can guide further appropriate therapeutic measures.

Anatomical and functional outcomes after bilateral sacrospinous colposuspension (BSC) for the treatment of female genital prolapse

BACKGROUND

Pelvic organ prolapse is a bothersome condition affecting many women at advanced age, but also frequently observed in young women with certain risk factors. Various surgical techniques have been developed with the aim of providing effective surgical treatment for apical prolapse. The vaginal bilateral sacrospinous colposuspension surgery (BSC) with ultralight mesh and utilization of the i- stich is a relatively new minimal invasive technique with very promising outcomes. The technique offers apical suspension, in the presence or absence of the uterus. The objective of this study is to evaluate the anatomical and functional outcomes of bilateral sacrospinous colposuspension with ultralight mesh in 30 Patients treated with the vaginal single incision standardized technique.

METHODS

In this retrospective study, 30 patients were treated by BSC for significant vaginal, uterovaginal or cervical prolapse. A simultaneous anterior colporrhaphy, posterior colporrhaphy or both were performed when indicated. Anatomical and functional outcomes were assessed 1 year postoperatively using the Pelvic Organ Prolapse Quantification system (POP-Q) and the standardised Prolapse Quality of Life (P-QOL) questionnair.

RESULTS

The POP-Q parameters were significantly improved at twelve months after surgery compared to baseline. The total score and all four subdomains of the P-QOL-questionnaire showed positive trends and improvement at twelve months after surgery when compared to preoperative values. All patients were asymptomatic and expressed high satisfaction one year after surgery. No intraoperative adverse events were recorded for all patients. Only minimal postoperative complications were recorded and they all resolved completely with conservative management.

CONCLUSION

This study highlights the functional and anatomical outcomes of the minimally invasive vaginal bilateral sacrospinal colposuspension with ultralight mesh for the management of apical prolapse. The one year postoperative results of the proposed procedure reflect excellent outcomes with minimal complications. The data published here are very promising and warrant further investigations and more studies to evaluate the long-term outcomes of BSC in the surgical management of apical defects.

TRIAL REGISTRATION

The study protocol was approved by the Ethics Committee at the University Hospital of Cologne, Germany (Date of registration: 08.02.2022) (Registration number: 21-1494-retro) (retrospectively registered).

Long-term outcomes of cable-suspended suture technique versus conventional suture for anterior vaginal wall prolapse: a retrospective cohort study

BACKGROUND

Anterior colporrhaphy (AC) is a conventional surgical repair technique for cystocele but with high recurrence rate. We present a novel technique: Cable-suspended structure (CSS) by non-absorbable suture combined with "bridge" formation in surgical treatment of cystocele. This study aimed to evaluate and compare the long-term outcome of CSS technique for anterior vaginal wall repair with AC.

METHODS

A retrospective review was performed on patients who underwent anterior vaginal wall repair between January 2012 and March 2017 at our center. All the patients were under a follow-up survey. The primary outcomes were objective cure (anterior prolapse POP-Q ≤ stage 1) and subjective cure (no symptoms of bulge or retreatment for prolapse). Secondary outcomes included quality of life (QOL) and patients' satisfaction, outcomes of site-specific POP-Q points Aa, Ba and C, as well as postoperative complications.

RESULTS

Of 91 included participants, 43 underwent AC and 48 underwent CSS. The proportion of sarcrospinous ligament fixation in the CSS group was higher than in the AC group (81.4% vs. 77.1%, P < 0.05). At a median follow-up of 69 months, the CSS group showed significantly higher objective cure rate compared with the AC group (72.9% vs. 51.2%, odds ratio 2.57, 95%CI 1.07-6.16). After adjusting for sarcrospinous ligament fixation, the CSS group still significantly showed higher objective cure rate (adjusted odds ratio 2.88, 95%CI 1.16-7.21). The proportion of the patients with POP-Q 0 stage in the CSS group was particularly higher than the AC group (25% vs. 7.0%, P = 0.025). There was no difference between the groups with respect to subjective cure, patients' satisfaction and postoperative complication.

CONCLUSIONS

The CSS technique showed better objective outcome than AC, however, subjective cure rate did not significantly differ between the two. Future prospective trial with large-scale should confirm the effectiveness and safety of CSS in sexually active women.

Complications of Mesh Sacrocolpopexy and Rectopexy: Imaging Review

Sacrocolpopexy and rectopexy are commonly used surgical options for treatment of patients with pelvic organ and rectal prolapse, respectively. These procedures involve surgical fixation of the vaginal vault or the rectum to the sacral promontory with mesh material and can be performed independently of each other or in a combined fashion and by using an open abdominal approach or laparoscopy with or without robotic assistance. Radiologists can be particularly helpful in cases where patients' surgical histories are unclear by identifying normal sacrocolpopexy or rectopexy mesh material and any associated complications. Acute complications such as bleeding or urinary tract injury or stricture are generally evaluated with CT. More chronic complications such as mesh extrusion or exposure with or without fistulization to surrounding structures are generally evaluated with MRI. Other complications can have a variable time of onset after surgery. Patients with suspected bowel obstruction are generally evaluated with CT. Those with suspected infection, abscess formation, and discitis or osteomyelitis may be evaluated with MRI, although CT evaluation may be appropriate in certain scenarios. The authors review the sacrocolpopexy and rectopexy surgical techniques, discuss appropriate imaging protocols for evaluation of patients with suspected complications, and illustrate the normal appearance and common complications of these procedures. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Medium- to long-term outcomes of vaginally assisted laparoscopic sacrocolpopexy in the treatment of stage III-IV pelvic organ prolapse

BACKGROUND

Vaginally assisted laparoscopic sacrocolpopexy (VALS) refers to the placement of synthetic meshes through the vagina in addition to traditional laparoscopic sacrocolpopexy. In this study, we aimed to investigate the medium- to long-term efficacy and safety of VALS for treating stage III-IV pelvic organ prolapse (POP).

METHODS

The study was designed as a case series at a single center. Patients with stage III-IV POP in our hospital from January 2010 to December 2018 were included. Perioperative parameters, objective and subjective outcomes, and complications were assessed.

RESULTS

A total of 106 patients completed the follow-up and were included in our study. Within a median follow-up duration of 35.4 months, the objective cure ratio of VALS reached 92.45% (98/106), and the subjective success rate was 99.06% (105/106). Patients reported significant improvements in subjective symptoms. In eight patients suffering anatomic prolapse recurrence, two posterior POP cases were treated by posterior pelvic reconstruction surgery, while six anterior POP cases did not need surgical therapies. The reoperation rate was 1.89% (2/106). No intraoperative complications occurred. Three patients (2.83%) had postoperative fever, and one (0.94%) had wound infection during hospitalization. Six patients (5.66%) had mesh exposure on the vaginal wall, and de novo urinary incontinence occurred in two patients (1.89%) during the follow-up period.

CONCLUSION

VALS is an effective and safe surgical method for treating severe POP. Therefore, VALS should be considered in the treatment of severe POP due to its favorable subjective and objective outcomes, relatively low rate of infection and acceptable rate of mesh exposure.

A modified technique for paravaginal repair of cystocele with paravaginal defect: A retrospective study

OBJECTIVE

We aimed to determine the efficacy and safety of a modified protocol for paravaginal repair of symptomatic paravaginal defects and cystocele.

METHODS

This study was an observational case series of 98 consecutive female patients, referred to our hospital between June 2014 and May 2018, with symptomatic grade II to IV paravaginal defects and cystocele. Our modified technique for paravaginal repair is based on the conventional protocol but incorporates reverse bridge repair and the cross-stitching of bilateral sutures. The curative effect of this new technique was evaluated subjectively and objectively during postoperative follow-up.

RESULTS

All operations were successful. Patients were followed up for 12 to 48 months, until June 2019; the mean follow-up period was 32.4 months. Three months after surgery, the rate of success was 100% (98/98 cases); in each case, the top of the vagina lay above the level of the sciatic spine. The rate of success was 94.9% (93/98 cases) at 12 months after surgery, 91.0% (61/71 cases) at 24 months after surgery, and 76.2% (16/21 cases) at 48 months after surgery. Four cases required a second surgery; three of these cases were treated with sacrocolpopexy, and one case was treated with sacrospinous ligament fixation.

CONCLUSION

Our modified technique for paravaginal repair was safe and effective for anterior vaginal prolapse and cystocele, as confirmed by the results observed over a mean follow-up period of 32.4 months.

A biomechanical analysis of different meshes for reconstructions of the pelvic floor in the porcine model

Purpose

Many different surgical approaches have been established for the repair of a pelvic organ prolapse. Especially in laparoscopic surgery, it is important to generate easy surgical techniques with similar stability. This study shall simplify the choice of mesh by evaluating three polypropylene meshes regarding their biomechanical properties.

Methods

Biomechanical testing was performed in the porcine model. The meshes are fixated on porcine fresh cadaver cervices after subtotal hysterectomy. The apical part of the mesh is fixated with parallel screw clamps at the testing frame. Forty-one trials were performed overall, subdivided into four subgroups. The groups differ in mesh type and fixation method. Maximum load, displacement at failure and stiffness parameters were evaluated with an Instron 5565^® test frame.

Results

SERATEX^® E11 PA (E11) showed the highest values for maximum load (199 ± 29N), failure displacement (71 ± 12 mm) and stiffness (3.93 ± 0.59 N/mm). There was no significant difference in all three evaluated parameters between SERATEX^® B3 PA (B3) and SERATEX^® SlimSling^® with bilateral fixation (SSB). SERATEX^® SlimSling^® with unilateral fixation (SSU) had the lowest stiffness (0.91 ± 0.19 N/mm) and maximum load (30 ± 2 N) but no significant difference in displacement at failure.

Conclusion

All meshes achieved a good tensile strength, but the results of maximum load show that the E11 is superior to the other meshes. Through a bilateral fixation of SERATEX^® SlimSling^®, a simple operating method is generated without a loss of stability.

Full-thickness vascularized vaginal flap as the fixation point in the surgical treatment of vaginal vault prolapse

INTRODUCTION AND HYPOTHESIS

Post-hysterectomy vaginal vault prolapse is quite frequent and at the same time a challenging surgery for pelvic organ prolapse.

METHODS

One of the most popular methods of treatment is sacrospinous fixation, including its mesh modification.

RESULTS

Despite the high efficiency in the apical compartment, the incidence of the anterior compartment prolapse is quite high. Erosion remains an unsolved problem. A 44-year-old patient with grade IV post-hysterectomy prolapse underwent a sacrospinous fixation procedure with mesh according to the described technique. Surgery was performed successfully without complications. The duration of the operation was 40 min. A year after the operation, the recurrence of POP was not recorded in any compartments of the pelvic floor. It was possible to maintain the length of the vagina. Dyspareunia and vaginal erosion were not detected. The patient also noted a significant improvement in her quality of life.

CONCLUSION

The demonstrated approach allows performing minimally invasive reconstruction of all three compartments of the pelvic floor. Moreover, the use of a full-thickness vascularized vaginal flap allows safely fixing the mesh to the vaginal vault, minimizing the risk of erosion and pain syndrome due to excessive tension.

Short and middle-term outcomes of vaginally assisted laparoscopic sacropolpopexy

OBJECTIVE

Vaginally assisted laparoscopic sacrocolpopexy (VALS), which is a combined surgical approach where a vaginal hysterectomy is initially performed, followed by transvaginal placement of synthetic mesh and laparoscopic suspension, can be an alternative to overcome the dissection, suturing limitations of laparoscopic sacrocolpopexy. The aim of this study was to compare the operative times and middle-term anatomic outcomes of women with uterovaginal prolapse undergoing VALS with those of women undergoing abdominal sacrocolpopexy.

METHODS

This is a prospective cohort study that evaluates operation times, anesthesia times, estimated blood loss, middle-term outcomes, perioperative and postoperative complications. We compared the results of 47 women who had the VALS to that of 32 abdominal sacrocolpopexy (AS).

RESULTS

The mean follow up was 22.4 months for AS group and 20.5 months for VALS group. The VALS group (median 1 day) had shorter hospitalization duration than the AS group (median 3 days). The mean operation time was significantly shorter in the VALS group (125.9 minutes) than the AS group (151.9 minutes) (P = .03). There was no significant difference in perioperative and postoperative complication rates. Objective failure rate (8.5% in VALS, 15.6% in AS), subjective failure rates (6.4% in VALS, 9.4% in AS), recurrence (2.1% in VALS, 9.4% in AS) and mesh exposition rates (2.1% in VALS, 9.4% in AS) were similar in both procedures.

CONCLUSIONS

VALS with shorter operative time and hospitalization than conventional AS is a promising modification minimally invasive technique for sacrocolpopexy especially for those inexperienced in laparoscopic sacrocolpopexy.

A systematic review of best practices for the perioperative management of abdominal sacrocolpopexy

PURPOSE

Enhanced recovery after surgery (ERAS) pathways have been shown to reduce surgical morbidity and length of stay across various procedures. Our objective was to systematically evaluate the literature for best practices of ERAS elements in abdominal sacrocolpopexy (ASC), to determine if there is sufficient evidence to create best practice guidelines for this procedure.

MATERIALS AND METHODS

Following the preferred reporting items for systematic review and meta-analysis (PRISMA) statement, we performed a review using Pubmed, Embase, and Cochrane Library. Eligible articles contained ERAS components and postoperative outcomes of ASC published in English since 1997. Thirty-five full-text articles were selected for final qualitative analysis.

RESULTS

Poor functional status before ASC was associated with a longer length of hospital stay. Laparoscopic ASC was associated with a shorter postoperative hospital stay, with no difference between laparoscopic and robotic approaches. Epidural analgesia in addition to spinal anesthesia lowered levels of pain throughout the postoperative stay in laparoscopic ASC. A multimodal bowel regimen shortened time to first bowel movement compared to a single agent regimen. Removing a Foley catheter may lead to sooner first spontaneous void but may result in higher rates of urinary retention and urinary tract infection. Studies investigating preoperative bowel preparation, preanesthesia medication, and multidose antimicrobial prophylaxis did not show significant benefit.

CONCLUSIONS

Best practices for ASC can be developed based on current findings from the literature and extrapolation of evidence from other surgeries where ASC-specific elements are missing, with the ability to modify the pathways as new data become available.

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.

Titanized polypropylene mesh in laparoscopic sacral colpopexy

INTRODUCTION

This study investigated perioperative and mid-term clinical outcomes after laparoscopic sacrocolpopexy (LSCP) with light titanium-coated polypropylene (TCP) mesh in a large group of patients affected by International Continence Society stage II-IV pelvic organ prolapse (POP).

METHODS

This multicenter retrospective study included 217 patients treated with LSCP using TCP mesh. We aimed to (1) analyze the intra- and postoperative complication rates according to the ICS/IUGA Complication Classification Code guidelines, (2) evaluate the anatomical results and (3) assess postoperative patient satisfaction with the Patient Global Impression Improvement questionnaire. Nonparametric Wilcoxon signed-rank tests, χ2 test and Fisher's exact test were used where appropriate.

RESULTS

The intraoperative complications were two (0.9%) cases of hemorrhage, two (0.9%) cases of incidental cystotomy and four (1.8%) cases of incidental colpotomy. During the postoperative follow-up, we recorded mesh exposure in 3 (1.4%) out of 217 patients. These 3 patients were from a group of 22 women who underwent vaginal opening during surgery, while in the remaining 195 patients without incidental colpotomy, no mesh exposure was observed (13.6% vs. 0.0%, p < 0.001). No failure of the apical compartment was observed, while 3 (1.4%) out of 217 patients experienced isolated anterior recurrence, and 1 (0.4%) patient had isolated posterior recurrence. All patients reported PGI-I scores ≥ 3, and 209 patients (96.3%) had a PGI-I score ≥ 2.

CONCLUSIONS

The use of light TCP mesh is safe and effective during LSCP for POP repair from both an anatomical and a functional point of view, posing a very low postoperative mesh-related complication risk.

Tobacco use, immunosuppressive, chronic pain, and psychiatric conditions are prevalent in women with symptomatic mesh complications undergoing mesh removal surgery

Purpose

To identify demographic and clinical characteristics of patients with symptomatic pelvic floor mesh complications who underwent mesh removal at our academic medical center. The secondary goal was to determine patient-reported outcomes after mesh removal.

Materials and Methods

We conducted a retrospective review of consecutive patients from 2011-2016 undergoing removal of mesh graft for treatment of symptomatic mesh-related complications. Patient demographics, comorbidities, symptoms, and mesh factors were evaluated. Outcomes after explant were determined by the Patient Global Impression of Improvement and a Likert satisfaction scale.

Results

One hundred fifty-six symptomatic patients underwent complete or partial pelvic floor mesh removal during the study period. Mid-urethral slings comprised 86% of explanted mesh grafts. Mesh exposure or erosion was identified in 72% of patients. Eighty-one percent of patients presented with pain, and 35% reported pain in the absence of exposure or erosion. Pre-operative comorbidities included psychiatric disease (54.5%), chronic pain (34.0%), irritable bowel syndrome (20.5%) and fibromyalgia (9.6%). Forty-three percent of patients reported current or past tobacco use. At mean follow-up of 14 months, 68% of responding patients reported improvement on the Patient Global Impression of Improvement after surgery.

Conclusions

This research identified tobacco use, and psychiatric, immunosuppressive, and chronic pain conditions as prevalent in this cohort of patients undergoing mesh removal. Surgical removal can improve presenting symptoms, including for patients with pain in the absence of other indications.

Fungal Lumbosacral Osteomyelitis After Robotic-Assisted Laparoscopic Sacrocolpopexy

Sacral osteomyelitis is a rare complication after robotic sacrocolpopexy, with previous reports of enteric and skin flora as inciting organisms. We report a patient who presented with severe low back pain and fever 6 weeks after a robotic sacrocolpopexy, who was subsequently diagnosed as having lumbosacral discitis and osteomyelitis with thoracic intervertebral extension. Empiric antibiotic therapy was initially administered. After laparoscopic mesh excision and abdominal wash out, Candida albicans was isolated from the excised mesh. Postoperatively, the patient was treated with a 12-month course of oral fluconazole with significant clinical improvement. To our knowledge, this is the second reported case of fungal osteomyelitis, providing further recommendations for the management of postoperative sacral osteomyelitis using a minimally invasive surgical technique and guidance by a multidisciplinary team.