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

Intraoperative Fluorescent Navigation of the Ureters, Vessels, and Nerves during Robot-Assisted Sacrocolpopexy

In this study, we aimed to demonstrate the feasibility and safety of navigating the ureters, middle sacral artery (MSA), and superior hypogastric nerve (SHN) using indocyanine green (ICG) and near-infrared fluorescence (NIRF) imaging during robot-assisted sacrocolpopexy (RSCP). Overall, 15 patients who underwent RSCP for apical vaginal prolapse were retrospectively enrolled. All patients underwent cystoscopic intraureteric instillation of 5 cc ICG (2.5 mg/mL) before RSCP and intravenous injection of 3 cc ICG during presacral dissection and mesh fixation. In all patients, the fluorescent right ureter was clearly identified in real time. The MSA was visualized on ICG-NIRF images in 80% (13/15) of patients. The mean time from ICG injection to MSA visualization was 43.7 s; the mean duration of the arterial phase was 104.3 s. Fluorescent SHN was detected in 73.3% (11/15) of patients. The time from ICG injection to SHN fluorescence was 48.4 s; the duration of fluorescence was 177.2 s. There was no transfusion, iatrogenic ureteral injury, or bowel or urinary dysfunction. Our results indicated that intraoperative ureter, MSA, and SHN mapping using ICG-NIRF images during RSCP is a valuable and safe technique to avoid iatrogenic ureteral, vascular, and neural injuries and to simplify surgical procedures. Nonetheless, further studies are required.

Role of lateral suspension for the treatment of pelvic organ prolapse: a Delphi survey of expert panel

INTRODUCTION AND HYPOTHESIS

Lateral suspension is an abdominal prosthetic surgical procedure used to correct apical prolapse. The procedure involves the placement of a T-shaped mesh on the anterior vaginal wall and on the isthmus or uterine cervix that is suspended laterally and posteriorly to the abdominal wall. Since its description in the late 90s, modifications of the technique have been described. So far, no consensus on the correct indications, safety, advantages, and disadvantages of this emerging procedure has been reached.

METHODS

A modified Delphi process was used to build consensus within a group of 21 international surgeons who are experts in the performance of laparoscopic lateral suspension (LLS). The process was held with a first online round, where the experts expressed their level of agreement on 64 statements on indications, technical features, and other aspects of LLS. A subsequent re-discussion of statements where a threshold of agreement was not reached was held in presence.

RESULTS

The Delphi process allowed the identification of several aspects of LLS that represented areas of agreement by the experts. The experts agreed that LLS is a safe and effective technique to correct apical and anterior prolapse. The experts highlighted several key technical aspects of the procedure, including clinical indications and surgical steps.

CONCLUSIONS

This Delphi consensus provides valuable guidance and criteria for the use of LLS in the treatment of pelvic organ prolapse, based on expert opinion by large volume surgeons' experts in the performance of this innovative procedure.

Trends and focal points in pelvic floor reconstruction for pelvic organ prolapse: A bibliometric analysis

OBJECTIVE

This study aims to investigate the current research trends and focal points in the field of pelvic floor reconstruction for the management of pelvic organ prolapse (POP).

METHODS

To achieve this objective, a bibliometric analysis was conducted on relevant literature using the Citespace database. The analysis led to the creation of a knowledge map, offering a comprehensive overview of scientific advancements in this research area.

RESULTS

The study included a total of 607 publications, revealing a consistent increase in articles addressing pelvic floor reconstruction for POP treatment. Most articles originated from the United States (317 articles), followed by Chinese scholars (40 articles). However, it is important to note that the overall number of articles remains relatively low. The organization with the highest publication frequency was the Cleveland Clinic in Ohio, where Matthew D. Barber leads the academic group. Barber himself has the highest number of published articles (18 articles), followed by Zhu Lan, a Chinese scholar (10 articles). Key topics with high frequency and mediated centrality include stress urinary incontinence, quality of life, impact, and age. The journal with the largest number of papers from both domestic and international researchers is INT UROGYNECOL J. The study's hotspots mainly focus on the impact of pelvic floor reconstruction on the treatment and quality of life of POP patients. The United States leads in this field, but there is a lack of cooperation between countries, institutions, and authors. Moving forward, cross-institutional, cross-national, and cross-disciplinary exchanges and cooperation should be strengthened to further advance the field of pelvic floor reconstructive surgery for POP research.

Mesh-less laparoscopic extraperitoneal linear suspension treatment of vaginal vault prolapse

OBJECTIVES

To report the results of a mesh-less laparoscopic extraperitoneal linear suspension technique for the treatment of post-hysterectomy vaginal vault prolapse (PHVP).

STUDY DESIGN

A retrospective observational study was conducted collecting medical records of 41 patients with symptomatic PHVP treated between November 2017 to November 2019 in Gynecologic department of China-Japan Friendship Hospital. All patients had Pelvic Organ Prolapse Quantification (POP-Q) scores indicating stage 3-4 PHVP and underwent mesh-less laparoscopic extraperitoneal linear suspension.The primary outcome was the subjective satisfaction rate based on responses to validated questionnaires. The secondary outcomes were the objective anatomical cure rate based on POP-Q scores and complication rates. All listed parameters were determined before the surgery and at control examinations in 1 year and 3 years after the treatment.

RESULTS

The operation was completed successfully without serious complications in all patients. Mean operation time was 53.8 mins. Comparison of the scores by the questionnaires revealed a significant improvement in the quality of life in the postoperative period.The subjective satisfaction rates were 100 % (41/41) and 95 % (38/40) at 1 year and 3 years after surgery. The objective cure rates were 100 % (41/41) and 97.5 % (39/40) at 1 year and 3 years after surgery, respectively. During the follow-up, none of the patients experienced suture exposure, infection, chronic pelvic pain, or other related complications.

CONCLUSION

The mesh-less laparoscopic extraperitoneal linear suspension technique avoids the use of implantable synthetic mesh. It has been shown to lead to favorable postoperative outcomes, considerable patient contentment, and low complication rates. It offers a new, cost-effective treatment option for PHVP patients.

A comparative study in learning curves of laparoscopic lateral suspension vs. laparoscopic sacrocolpopexy: preliminary results

Background

Determination of the learning curve of new techniques is essential to improve safety and efficiency. Limited information is available regarding learning curves of different techniques in laparoscopic pelvic floor surgery.

Objective

The aim of this study was to compare the learning curve of two operative techniques, laparoscopic lateral suspension (LLS) and laparoscopic sacrocolpopexy (LSC).

Material and methods

We conducted a prospective study to assess the learning curve of LLS and LSC by implementing a structured urogynecologic surgical training program with the use of pelvic trainers for our urogynecology fellow. The fellow was an experienced urogynecologic surgeon, but was laparoscopic suturing and dissection naive at the beginning of the study. She was required to assist in 20 laparoscopic urogynecologic surgeries and undertake laparoscopic suturing and knot tying training with mesh positioning on a laparoscopic trainer for 4 h/week during the trial period. After the completion of this structured training program, the fellow performed LLS and LSC under the supervision of an experienced subspecialist as the primary surgeon. Linear regression analysis was used to compare the data of LLS and LSC learning curves. Subjective pre- and post-operative evaluation of pelvic organ prolapse (POP) and pelvic floor disorders was undertaken preoperatively and 12 months postoperatively using the PFDI-20-Quality of Life validated questionnaire. Follow-up was scheduled 12 months after the surgery and performed by a skilled urogynecologist. Objective cure was defined as Pelvic Organ Prolapse-Qualification (POP-Q) stage

Results

The mean operative times of laparoscopic sacrocolpopexy and lateral suspension were 168.26 and 160.33 min, respectively. According to linear regression analysis after 43 procedures, the learning curve for laparoscopic lateral suspension was shorter than for laparoscopic sacrocolpopexy (OPTime 134.69 min). In both groups, there was a significant reduction in bothersome POP symptoms (p ≤ 0.005). Bladder injuries in two cases and lumbar pain in one case were recorded during the study. Overall objective success at 12 months was 90.7% for LSC and 89.1% for LLS.

Conclusion

Laparoscopic lateral suspension could be an alternative to laparoscopic sacrocolpopexy in the treatment of POP with its good objective and subjective outcomes. Lateral suspension has a shorter learning curve, and it is technically less demanding than LSC. Procedure-dedicated training can accelerate the move from a novice to a master laparoscopic surgeon.

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Key Words

• laparoscopic surgery
• lateral suspension
• learning curve
• prolapse
• sacropexy

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Affiliation(s)

Ewelina Malanowska-Jarema Department of Gynecology, Endocrinology and Gynecologic Oncology, Pomeranian Medical University, Szczecin, Poland
Yana Osnytska Department of Gynecology, Endocrinology and Gynecologic Oncology, Pomeranian Medical University, Szczecin, Poland
Andrzej Starczewski Department of Gynecology, Endocrinology and Gynecologic Oncology, Pomeranian Medical University, Szczecin, Poland
Matteo Balzarro Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
Emanuele Rubilotta Department of Urology, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy

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Lateral suspension with V-NOTES for the treatment of pelvic organ prolapse with the Salman-Ketenci Gencer technique

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is a common morbidity and 10-20% of the patients need surgical correction. Sacrocolpopexy or sacrohysteropexy procedures are satisfactory but still difficult. Lateral suspension (LS) as a safe and simple technique has become an alternative technique recently. Vaginal natural orifice transluminal endoscopic surgery (V-NOTES) is also a new modality and LS using V-NOTES has not been performed previously and should be promising.

METHODS

This prospective observational pilot study was conducted with a total of 38 women with stage 3 and 4 POP according to the Pelvic Organ Prolapse Quantification grading system (POP-Q). Lateral suspension via V-NOTES was performed with the Salman-Ketenci Gencer technique using a mesh for POP. The preoperative and postoperative 6-month POP-Q stages together with Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) scores were recorded and compared.

RESULTS

Comparison of the preoperative and postoperative 6-month POP-Q stages of the patients were statistically significant except for the total vaginal length (p<0.01). Compared with the preoperative total and subscale scores of PISQ-12, the postoperative values were considerably improved (p<0.001).

CONCLUSIONS

With the Salman-Ketenci Gencer technique not only good anatomical but also good functional results were obtained with V-NOTES. Surgeons may focus on uterine sparing while using the Salman-Ketenci Gencer technique for apical prolapse owing to the higher rate of complications related to the colposuspension and better sexual results after the cervicosuspension.

Minimal Invasive Abdominal Sacral Colpopexy and Abdominal Lateral Suspension: A Prospective, Open-Label, Multicenter, Non-Inferiority Trial

BACKGROUND

Abdominal minimally invasive surgery has become increasingly prominent for the treatment of prolapse. Abdominal sacral colpopexy (ASC) is the gold standard for the treatment of advanced apical prolapse; however, alternative surgical approaches such as the abdominal lateral suspension (ALS) have been developed to improve patient outcomes. This study aims to determine whether ALS improves outcomes compared to ASC in multicompartmental prolapse patients.

METHODS

A prospective, open-label, multicenter, non-inferiority trial was conducted in 360 patients who underwent ASC or ALS for the treatment of apical prolapse. The primary outcome was anatomical and symptomatic cure of the apical compartment at 1-year follow-up; secondary outcomes included prolapse recurrence, re-operation rate, and post-operative complications. A 300-patient cohort was subdivided into 200-patients who underwent ALS and 100-patients who underwent ASC. The confidence interval method was used to calculate the p-value of non-inferiority.

RESULTS

At the 12-months follow-up, the objective cure rate of the apical defect was 92% for ALS and 94% for ASC (recurrence rates were 8% and 6%, respectively, and the p-value for non-inferiority was <0.01). The mMesh complication rates were 1% and 2% for ALS and ASC, respectively.

CONCLUSIONS

This study demonstrated that the ALS technique is not inferior to the gold standard ASC for the surgical treatment of apical prolapse.

Pelvic pain after laparoscopic lateral suspension for pelvic organ prolapse: an unrecognized problem?

INTRODUCTION AND HYPOTHESIS

The laparoscopic lateral suspension (LLS) represents an alternative mesh procedure to avoid the dissection at the promontory. However, mesh-related complications such as chronic pelvic pain, dyspareunia, and bladder pain are emerging. The present study is aimed to present a video case report and describe a small case series of patients referred to our center for chronic pelvic pain after LLS.

METHODS

A surgical video of the management of a 50-year-old woman with chronic abdominal and pelvic pain, dyspareunia, and recurrent urinary tract infection (UTIs) after uterus sparing LLS is provided. Moreover, we performed a retrospective chart review of similar cases in our institution.

RESULTS

The featured procedure was completed without complications and was successful in obtaining symptom relief. Between 2018 and 2022 five patients underwent total or subtotal mesh removal for pain-related symptoms after LLS. At the median follow-up of 24 months, all patients were free from pain, but two (40%) required reoperation for prolapse recurrence CONCLUSIONS: Our experience suggests that LLS involves a certain risk of chronic pelvic pain, which may be challenging to manage and require surgical treatment.

Case report: Transvaginal single-port extraperitoneal laparoscopic sacrospinous ligament fixation for apical prolapse: A single-center case series

Background

Sacrospinous ligament fixation (SSLF) is a minimally invasive and effective procedure for the treatment of apical prolapse. Because intraoperative exposure of the sacrospinous ligament is difficult, SSLF is difficult. The aim of our article is to determine the safety and feasibility of single-port extraperitoneal laparoscopic SSLF for apical prolapse.

Methods

This single-center, single-surgeon case series study included 9 patients with pelvic organ prolapse quantification (POP-Q) III or IV apical prolapse who underwent single-port laparoscopic SSLF. Additionally, transobturator tension-free vaginal tap (TVT-O) was performed in 2 patients, and anterior pelvic mesh reconstruction was performed in 1 patient.

Results

The operative time ranged from 75 to 105 (mean, 88.9 ± 10.2) min, and blood loss ranged from 25 to 100 (mean, 43.3 ± 22.6) ml. No serious operative complications, blood transfusions, visceral injuries, or postoperative gluteal pain were reported for these patients. After 2–4 months of follow-up, no recurrence of POP, gluteal pain, urinary retention/incontinence, or other complications was observed.

Conclusion

Transvaginal single-port SSLF is a safe, effective, and easy-to-master operation for apical prolapse.

Comparison of 2-year follow-up outcomes of laparoscopic lateral suspension and sacrospinous fixation in apical compartment prolapse: an observational study

PURPOSE

This study aimed to compare the results of patients with laparoscopic lateral suspension (LLS) and sacrospinous fixation (SSF).

METHODS

This prospective observational study included 52 patients who underwent LLS and 53 patients who underwent SSF due to pelvic organ prolapse. The pelvic organ prolapse's anatomical cure and the frequency of recurrence have been recorded. Female Sexual Function Index, Pelvic Organ Prolapse Symptom Score, and complications were evaluated preoperatively and at the postoperative 24th month.

RESULTS

In the LLS group, the subjective treatment rate was 88.4% and the anatomical cure rate for apical prolapse was 96.1%. In the SSF group, the subjective treatment rate was 83.0% and the anatomical cure rate for apical prolapse was 90.5%. There was a significant difference between the groups regarding Clavien-Dindo classification and reoperation (p < 0.05). Female Sexual Function Index, and the Pelvic Organ Prolapse Symptom Score were different between the groups (p < 0.05).

CONCLUSIONS

This study showed that there is no difference between two surgical techniques in apical prolapse cure rates. However, the LLS seem preferable in terms of the Female Sexual Function Index, Pelvic Organ Prolapse Symptom Score, reoperation, and complications. We need larger sample size studies in terms of incidence of complications and reoperation.

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.

Long-Term Outcomes after Pelvic Organ Prolapse Repair in Young Women

The aim of the study was to describe the long-term outcomes of Pelvis Organ Prolapse (POP) repair in women under 40 years old. A retrospective chart review of all POP repairs performed in women ≤40 years old between January 1997 and December 2015 in the Gynecologic Surgery Department of Lille University Hospital was performed. Inclusion criteria were all women ≤40 years old who underwent a POP repair with a stage ≥2 POP according to the Baden and Walker classification. The study population was separated into three groups: a sacrohysteropexy group, a vaginal native tissue repair (NTR) group, and a transvaginal mesh surgery (VMS) group. The primary outcome was reoperation procedures for a symptomatic recurrent POP. Secondary outcomes were other complications. During the study period, 43 women ≤ 40 years old who underwent a POP repair were included and separated into three groups: 28 patients (68%), 8 patients (19%), and 7 patients (16%) in the sacrohysteropexy, VMS, and NTR groups respectively. The mean followup time was 83 ± 52 months. POP recurrence, reoperated or not, was essentially diagnosed in the VMS group (87.5%) and the NTR group (50%). POP recurrence repairs were performed for nine patients (21%): 7%, 62.5%, and 25% in the sacrohysteropexy, VMS, and NTR groups, respectively. Global reoperation concerned 10 patients (23%) whatever the type of POP surgery, mainly patients from the VMS group (75%) and from the NTR group (25%). It occurred in only 7% of patients from the sacrohysteropexy group. Two patients (4%) presented a vaginal exposure of the mesh (in the VMS group). De novo stress urinary incontinence was encountered by nine patients (21%): 29% and 12.5% in the sacrohysteropexy and NTR groups, respectively. Despite the risk of recurrence, POP repair should be proposed to young women in order to restore their quality of life. Vaginal native tissue repair or sacrohysteropexy should be performed after explaining to women the advantages and disadvantages of each procedure.