Laparoscopic vaginal vault suspension using uterosacral ligaments: A review of 133 cases

Laparoscopic Versus Vaginal Uterosacral Ligament Suspension in Women With Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis of the Literature

OBJECTIVE

Uterosacral ligament suspension (USLS) is one of the most frequently used operations for the restoration of apical support in women with uterovaginal prolapse. However, existing studies are inconclusive as to whether and which surgical access route is superior. The aim of the present meta-analysis is tentatively to compare the efficiency and the postoperative complications of laparoscopic USLS (L-USLS) and vaginal USLS (V-USLS), highlighting that current evidence remains inconclusive regarding the superiority of either surgical access route.

DATA SOURCES

We performed a systematic literature review of 5 major databases (Medline, Scopus, Google Scholar Cochrane Central Register of Controlled Trials and Clinicaltrials.gov) from inception till April 2023.

METHODS OF STUDY SELECTION

No language restrictions were applied. All comparative studies that compared L-USLS and V-USLS for the management of women with uterovaginal prolapse were included.

TABULATION, INTEGRATION, AND RESULTS

Data from 6 retrospective cohort studies on 856 patients were extracted and analyzed. The methodological quality of the included studies was assessed using the risk of bias in nonrandomized studies of interventions tool and ranged between moderate to serious. The pooled results suggest that L-USLS was associated with a potentially decreased incidence of ureteral compromise (odds ratio [OR], 0.19; 95% confidence interval [CI] 0.04-0.89; p = .04) and seemingly lower objective (OR 0.47; 95% CI 0.23-0.97; p = .04) and subjective recurrence rates (OR 0.46; 95% CI 0.23-0.92; p = .03). There were no significant differences between the rates of postoperative pain from USLS sutures, postoperative pelvic hematomas, the suture exposure/granulation tissue formation, and the prolapse recurrence retreatment among the 2 groups.

CONCLUSION

The present meta-analysis indicates that L-USLS is possibly associated with significantly fewer ureteral compromise rates and decreased subjective and objective recurrences rates compared to V-USLS. Nevertheless, given the limitations in data quality and heterogeneity of the included studies, these findings should be interpreted with caution. Large-scale randomized studies are essential to more definitively determine the relative merits of the laparoscopic versus vaginal approach.

The effectiveness and safety of laparoscopic uterosacral ligament suspension: A systematic review and meta-analysis

BACKGROUND

Laparoscopic uterosacral ligament suspension (LUSLS) is a technique to correct apical pelvic organ prolapse (POP) by shortening the uterosacral ligaments with sutures.

OBJECTIVE

A systematic review with meta-analysis of the effectiveness and safety of LUSLS as treatment for apical POP.

SEARCH STRATEGY

PubMed and Cochrane search using 'pelvic organ prolapse', 'laparoscopy' and 'uterosacral', including synonyms.

SELECTION CRITERIA

All articles in English presenting outcome of an original series of women with LUSLS as treatment of apical POP. Case reports were excluded.

DATA COLLECTION AND ANALYSIS

Study enrollment was performed by two reviewers. Our primary outcome measures were objective and subjective effectiveness of the procedure. Secondary outcome measures regarded complications and recurrence. Bias was assessed with the Newcastle Ottawa Scale.

MAIN RESULTS

Of 138 hits, 13 studies were included with 933 LUSLS patients. The average follow-up was 22 months. All were nonrandomised cohort studies. The pooled anatomic success rate is 90% for all LUSLS procedures (95% confidence interval [CI] 83.3-95.5). LUSLS with hysterectomy resulted in an anatomic success rate of 96.6% (95% CI 87.5-100) and LUSLS with uterus preservation 83.4% (95% CI 67.7-94.6). The pooled subjective cure rate was 90.5% (95% CI 81.9-96.5). The rate of major complications was 1%.

CONCLUSIONS

Laparoscopic uterosacral ligament suspension (with or without uterus preservation) seems to be an effective and safe treatment for women with apical POP, but long-term prospective trials and randomised controlled trials are necessary to confirm these findings.

Laparoscopic uterosacral ligament suspension: a systematic review and meta-analysis of safety and durability

Introduction

Pelvic organ prolapse (POP) is a widespread condition affecting from 40% to 60% of women. Reconstructive vaginal surgeries are the most commonly performed procedures to treat POP. Among those, uterosacral ligament suspension (USLS), which is usually performed transvaginally, preserves pelvic statics and dynamics and appears to be an effective method. Laparoscopic USLS is a valid alternative to vaginal approach, and the aim of our review is to confirm its safety and feasibility and to compare clinical outcomes among the procedures.

Materials and methods

Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed and Scopus databases in December 2022. We made no restriction on the publication year nor on the country. Data about POP-Q recurrence rate (RR), intraoperative and postoperative complications (graded according to Clavien-Dindo classification), readmission rate, and reoperation rate were collected and analyzed. We used comparative studies for meta-analysis.

Results

A total of nine studies fulfilled inclusion criteria: two articles were non-comparative retrospective observational studies, three more articles were comparative studies where laparoscopic USLS was confronted with other surgical techniques (only data of laparoscopic USLS were analyzed), and four were comparative retrospective cohort studies between laparoscopic and vaginal USLS procedures. The comparative studies were enrolled in meta-analysis. Patients were analyzed concerning perioperative risks and the risk of recurrence. The meta-analysis highlighted that there was no clear inferiority of one technique over the other.

Discussion

Laparoscopic USLS is a technique with a low complication rate and low recurrence rate. Indeed, laparoscopic procedure allows better identification of anatomical landmarks and access to retroperitoneum. Moreover, efficacy over time and durability of Laparoscopic (LPS) USLS was also observed. However, these data should be weighed in light of the length of follow-up, which was in a very short range. Further, focused and prospective studies will be necessary to confirm this finding.

The effect of hysteropreservation versus hysterectomy on the outcome of laparoscopic uterosacral suspension in pelvic organ prolapse surgery

OBJECTIVES

This study compares the recurrence rate, complication rate and subjective satisfaction with laparoscopic uterosacral suspension with or without hysterectomy.

STUDY DESIGN

This retrospective cohort study included 105 patients between June 2014 and December 2019. Recurrent pelvic organ prolapse was defined as any prolapse to or beyond the hymen with straining or needing retreatment. Student's t-test, the Mann-Whitney U test, the chi square test or Fisher's exact test, multivariate Cox proportional hazards regression and Kaplan-Meier survival analysis were used for the data analysis.

MAIN OUTCOME MEASURES

Whether the durability of laparoscopic uterosacral suspension surgery is affected by uterine preservation.

RESULTS

60 patients underwent laparoscopic uterosacral suspension with concomitant hysterectomy (Hysterectomy group), and 45 underwent laparoscopic uterosacral hysteropexy (Hysteropexy group). The median (interquartile range) duration of follow-up for all 105 patients was 31 (22.5-47.5) months. The results of multivariate Cox proportional hazards regression showed that no difference was found in the risk of overall recurrence between the hysterectomy and hysteropexy groups (25 % vs. 22 %; HR, 0.37; 95 % CI, 0.14-1.00). Kaplan-Meier survival analysis also demonstrated that there were no significant differences in the overall rates of recurrent prolapse between the two groups (P = 0.30). In addition, the subjective success rates were high in both groups (82 %).

CONCLUSIONS

Our study demonstrated equally satisfactory objective and subjective long-term outcomes after laparoscopic uterosacral suspension with or without hysterectomy. Laparoscopic uterosacral hysteropexy can be safely and effectively offered to patients with pelvic organ prolapse who wish to preserve their uterus and do not have contraindications.

Laparoscopic uterosacral ligament suspension: a comprehensive, systematic literature review

OBJECTIVES

Laparoscopic uterosacral ligament suspension (LUSLS) of the vaginal apex for the treatment of pelvic organ prolapse (POP) has gained popularity. The aim of this systematic review is to investigate perioperative outcomes and complications, subjective and objective success rates and recurrence rates in women undergoing this surgical procedure.

STUDY DESIGN

A systematic literature search was performed in December 2021. The critical appraisal skills program (CASP) was used to assess the methodological quality of the selected studies. The Clavien-Dindo (CD) scale and the Satava scale were used to classify periprocedural complications. Continuous variables were described as means and standard deviations while categorical were expressed as percentages of the whole group. Statistical significance was set at p < 0.05.

RESULTS

26 articles were selected and analysed, with a total population of 1401 patients. Anatomical and subjective success rates after LUSLS ranged from 79% and 100% and from 76.2% to 100% respectively. The re-operation rate varied from 2% to 4.5% in the largest cohorts. The overall complication rate was 13.6%, however grade III CD complications occurred only in 1% of patients. Ureteral complications were described in only 2 cases.

CONCLUSIONS

LUSLS represent a safe and effective technique for vaginal apex resuspension in women with POP. Further larger prospective randomized studies are required to confirm these data.

Clinical Analysis of the Discovery of Malignant Gynecological Tumors in the Diagnosis and Treatment of Pelvic Organ Prolapse

Background

Clinically, malignant gynecological tumors found by chance during the diagnosis and treatment of pelvic organ prolapse (POP) are rare, and they are usually missed, leading to delayed diagnosis and treatment. The initial treatment of these tumors cannot be standardized, and, as a single surgical intervention may not be able to treat both the tumor and prolapse, secondary surgery is usually needed, affecting the quality of life of patients.

Case presentation

The present study retrospectively analyzed the data of three patients who were diagnosed with malignant gynecological tumors during the diagnosis and treatment of POP. These patients were among 215 patients with POP treated in Yuncheng Central Hospital of Shanxi Province between January 2011 and May 2020. The case characteristics, surgical interventions, postoperative treatments, and follow-ups were summarized, and the characteristics of diagnosis and treatment were analyzed in the context of relevant literature.

Conclusion

As long as clinicians operate in strict accordance with the standards of diagnosis and treatment, obtain a complete medical history, undertake a physical examination, and remain diligent in auxiliary examinations, following existing clinical methods and diagnosis and treatment processes, patients with POP complicated with malignant gynecological tumors can be clearly diagnosed before and during surgery. In this way, initial treatment can be standardized, and surgical methods can be selected that address both the tumor and prolapse, thereby avoiding secondary surgery and improving the patient’s quality of life.

Laparoscopic High Uterosacral Ligament Suspension vs. Laparoscopic Sacral Colpopexy for Pelvic Organ Prolapse: A Case-Control Study

Introduction

Laparoscopic sacral colpopexy is the gold standard technique for apical prolapse correction but it is a technically challenging procedure with rare but severe morbidity. Laparoscopic high uterosacral ligament suspension could be a valid technically easier alternative using native tissue.

Material and Methods

In the period from 2015 to 2018, 600 women were submitted to laparoscopic sacral colpopexy while 150 to laparoscopic high uterosacral ligament suspension in three Italian urogynecology referral centers. We enrolled women with apical prolapse stage ≥2 alone or multicompartment descensus. To reduce allocation bias, we performed a propensity matched analysis. Women undergoing laparoscopic high uterosacral ligament suspension surgery were matched 1:2 to women undergoing laparoscopic sacral colpopexy. The cumulative proportion of relapse-free women in time was analyzed by the Kaplan–Meier method. The primary objective of this multicenter case-control retrospective study was to compare the recurrence rate while the secondary objectives were to compare feasibility, safety, and efficacy of laparoscopic sacral colpopexy and laparoscopic high uterosacral ligament suspension in surgical treatment of pelvic organ prolapse.

Results

Three hundred and nine women were enrolled (103 laparoscopic high uterosacral ligament suspension; 206 laparoscopic sacral colpopexy). Median operatory time was significantly shorter in the laparoscopic high uterosacral ligament suspension group (P = 0.0001). No statistically significative difference was found in terms of estimated blood loss, admission time, intraoperative, and major early postoperative complications, postoperative pelvic pain, dyspareunia and de novo stress urinary incontinence. Surgical approach was the only independent risk factor for prolapse recurrence (RR = 6.013 [2.965–12.193], P = 0.0001). The objective cure rate was higher in the laparoscopic sacral colpopexy group (93.7 vs. 68%, 193/206 vs. 70/103, P = 0.0001) with a highly reduced risk of recurrence (RR = 5.430 [1.660–17.765]). Median follow up was 22 months.

Conclusion

Both techniques are safe, feasible, and effective. Laparoscopic sacral colpopexy remains the best choice in treatment of multicompartment and advanced pelvic organ prolapse while laparoscopic high uterosacral ligament suspension could be appropriate for moderate and isolated apical prolapse when laparoscopic sacral colpopexy is not suitable for the patient or to prevent prolapse in women at high risk at the time of the hysterectomy.

Laparoscopic uterosacral ligament suspension versus vaginal colposuspension using the Uphold Lite™ mesh system: clinical outcome and patient satisfaction

INTRODUCTION AND HYPOTHESIS

The objective was to compare clinical and anatomical outcomes between laparoscopic uterosacral ligament suspension (LUSLS) and vaginal colposuspension using the Uphold Lite™ mesh system for the treatment of apical prolapse.

METHODS

We performed a comparative, retrospective cohort study. All women who underwent either vaginal colposuspension with the Uphold Lite™ System or LUSLS for treatment of apical prolapse between 2010 and 2019 were included. The groups were compared with regard to demographic, pre-operative, intra-operative, and post-operative data. Outcome measures included clinical and anatomical cure, as well as a composite outcome. The PGI-I questionnaire was used to determine patient satisfaction.

RESULTS

One-hundred and nineteen women met the inclusion criteria, including 70 women who underwent LUSLS and 49 women who underwent vaginal colposuspension with the Uphold Lite™ mesh system. At a mean follow-up of 31.7 (SD = 18.1) months, the clinical cure rate was high for both groups, reaching 98.6% in the LUSLS group compared with 89.8% in the Uphold group (NS). Anatomical cure rate was 83.6% in the LUSLS group compared with 69.7% for the Uphold group (NS). With regard to the composite outcome, no difference was found, although a trend towards a higher success rate was noted in the LUSLS group (83.6% vs 66.7%, p = 0.055). Patient satisfaction measured using the PGI-I questionnaire was high, at 98.6% in the LUSLS group and 87.8% in the Uphold group (NS).

CONCLUSION

Laparoscopic uterosacral ligament suspension and vaginal colposuspension using the Uphold Lite™ mesh system both have high clinical cure rates.

Standardized terminology of apical structures in the female pelvis based on a structured medical literature review

The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica-accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.

Laparoscopic uterosacral ligament colpopexy for apical support in addition to hysterectomy for pelvic organ prolapse

AIM

To evaluate the perioperative complications and the anatomical outcomes of our laparoscopic uterosacral ligament (USL) colpopexy, which is a novel laparoscopic technique for the management of uterine prolapse. The objective was to report on outcome after 2 years of a technique using laparoscopic USL colpopexy.

METHODS

A total of 152 uterine prolapse patients underwent laparoscopic USL colpopexy from May 2013 to April 2015. We described the surgical technique and performed a retrospective analysis of this laparoscopic technique. Patients underwent standardized assessment and examination using pelvic organ prolapse quantification (POP-Q) score. The dependent values of Ba point (bladder), C point (vaginal cuff) and Bp point (rectum) were recorded preoperatively, and at 1, 3, 6, 12 and 24 months of postoperative examination. Pre/postoperative data were compared using the Kaplan-Meier method.

RESULTS

Mean age, operative time and amount of hemorrhage were 68.2 ± 7.5 years, 118.3 ± 36.4 min and 60.5 ± 73.3 mL, respectively. Overall recurrent prolapse, which was defined as POP-Q stage II or higher, was noted in 29 patients (19%). However, only 2 patients presented recurrent rectocele among 51 patients with preoperative POP-Q stage II of uterine prolapse alone (recurrence rate; 3.9%). The pre/postoperative average POP-Q scores were -0.2/-2.7 cm (P < 0.05) at Ba point, -1.9/-5.1 cm (P < 0.05) at C point and -2.4/-2.3 cm (P = 0.06) at Bp point.

CONCLUSION

Laparoscopic visualization of uterosacral ligaments may result in safe colpopexy. Our results show this will be a useful procedure for apical support as native tissue repair.

Effect of modified laparoscopic hysterectomy on pelvic floor function: A retrospective observational study

Hysterectomy is a potential risk factor for subsequent surgery for pelvic organ prolapse, especially when the prolapse exists before hysterectomy. Women without prolapse before hysterectomy may also experience prolapse after hysterectomy. This study aimed to describe a surgical modification of laparoscopic colposuspension with round ligaments after hysterectomy in women without preexisting genital prolapse and to evaluate the initial surgical results in these patients.We reviewed data of 54 patients who underwent laparoscopic hysterectomy with colposuspension with unilateral or bilateral round ligaments after hysterectomy at Chia-Yi Chang Gung Memorial Hospital from July 2012 to March 2015. Vaginal length was measured before and after colposuspension after complete hysterectomy. Preoperative characteristics of the patients, perioperative quality, postoperative outcomes, and vaginal length differences were analyzed.Vaginal length increased by a mean of 2.59 cm after colposuspension. The mean extra-operative time needed for laparoscopic colposuspension was about 10 minutes. No severe complications were reported in our patients, and we did not find any cystocele after completing vaginal cuff suspension to the round ligament.The vaginal apex level was maintained in our modified laparoscopic hysterectomy. Therefore, laparoscopic colposuspension with round ligaments is a promising option as a routine, first-line standard procedure in younger women without genital prolapse to maintain an acceptable vaginal length after laparoscopic hysterectomy.

Demonstration of a box-stitch technique for laparoscopic uterosacral ligament suspension

AIM

We demonstrate a novel box stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension for apical prolapse in restorative pelvic reconstructive surgery.

MATERIAL AND METHODS

We present a case of a 58yo female with symptomatic stage III pelvic organ prolapse with a history of a total abdominal hysterectomy 30 years prior. She strongly desired the usage of no synthetic or biologic mesh for her restorative surgical repair. This video provides a step-by-step guide on how to perform a laparoscopic box stitch as a technique for uterosacral ligament suspension as an apical native tissue option for patients with the need for post hysterectomy apical prolapse.

CONCLUSION

This video demonstrates a novel box-stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension as a native tissue option for minimally invasive reconstructive surgery. The procedure is a reasonable option to address apical prolapse in patients who do not desire or who are unable to have synthetic or biologic mesh placed for restorative reconstructive prolapse surgery.

[Laparoscopic lateral suspension, another way to treat genital prolapse]

The laparoscopic sacrocolpopexy is the treatment of choice of pelvic organ prolapses since more than twenty years. The laparoscopic lateral suspension with mesh is an alternative technique. Its originality is the subperitoneal passing of the lateral arm of the mesh in the lateral abdominal wall, leaving the skin above the iliac crest, in a place without risks of vascular, nerve, bowel injuries. We report in this article the results of the three main publications on the subject. The indications are cystocele and apical descent. It can be envisaged when the access of the promontory is difficult; for instance in the presence of obesity, adhesions, sigmoid megacolon, or low position of the left common iliac vein, partially covering the promontory. It is also a practical technique for surgeons having a moderate experience of the promontory access.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Ureteral Compromise in Laparoscopic Versus Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort

OBJECTIVES

The aim of this study was to evaluate if ureteral compromise is significantly different between laparoscopic and vaginal uterosacral ligament suspension (USLS).

METHODS

This is a retrospective cohort study comparing all women who underwent laparoscopic and vaginal USLSs at 2 institutions (part of a single training program with procedures performed by 11 fellowship-trained Female Pelvic Medicine and Reconstructive Surgery gynecologic surgeons) between January 2008 and June 2013.

RESULTS

A total of 208 patients in the study underwent a USLS, 148 in the laparoscopic group and 60 in the vaginal group. At baseline, there were statistically significant differences between the groups in mean age (50.4 vs 55.3 years, P = 0.008), parity (2.44 vs 2.77, P = 0.040), and prior hysterectomy (3.4% vs 11.7% in the laparoscopic and vaginal groups, respectively; P = 0.042).There were no ureteral compromises in the laparoscopic group and 6 in the vaginal group (0.0% vs 10.0%, respectively; P < 0.001). In an analysis evaluating only those ureteral compromises requiring stent placement, the higher rate of ureteral compromise in the vaginal group persisted despite exclusion of those cases requiring only suture removal and replacement (0.0% vs 5.0% in the laparoscopic and vaginal groups, respectively; P = 0.023).There was a lower median blood loss in the laparoscopic group (137.5 vs 200.0 mL, respectively; P = 0.002) as well as a lower rate of readmission (0.7% vs 6.7%, respectively; P = 0.025). There were no other significant differences in postoperative complications between the 2 groups.

CONCLUSIONS

We found a lower rate of ureteral compromise in the laparoscopic approach to USLS compared with the traditional vaginal approach.

Micro-structural and Biaxial Creep Properties of the Swine Uterosacral-Cardinal Ligament Complex

The uterosacral ligament and cardinal ligament (USL/CL) complex is the major suspensory tissue of the uterus, cervix, and vagina. This tissue is subjected primarily to bi-axial forces in-vivo that significantly alter its structure and dimension over time, compromising its support function and leading to pelvic floor disorders. In this study, we present the first rigorous characterization of the collagen fiber microstructure and creep properties of the swine USL/CL complex by using scanning electron microscopy and planar biaxial testing in combination with three-dimensional digital image correlation. Collagen fiber bundles were found to be arranged into layers. Although the fiber bundles were oriented in multiple directions, 80.8% of them were aligned within ±45[Formula: see text] to the main in-vivo loading direction. The straightness parameter, defined as the ratio of the end-to-end distance of a fiber bundle to its length, varied from 0.28 to 1.00, with 95.2% fiber bundles having a straightness parameter between 0.60 and 1.00. Under constant equi-biaxial loads of 2 and 4 N, the USL/CL complex exhibited significant creep both along the main in-vivo loading direction (the parallel direction) and along the direction perpendicular to it (the perpendicular direction). Specifically, over a 120-min period, the mean strain increased by 20-34[Formula: see text] in the parallel direction and 33-41[Formula: see text] in the perpendicular direction. However, there was no statistically significant difference in creep strains observed after 120 min between the parallel and perpendicular directions for either the 2 or 4 N load case. Creep proceeded slightly faster in the perpendicular direction under the equi-biaxial load of 2 N than under the equi-biaxial load of 4 N ([Formula: see text]). It proceeded significantly faster in the parallel direction under the equi-biaxial loads of 2 N than under the equi-biaxial loads of 4 N ([Formula: see text]). Overall, our findings contribute to a greater understanding of the biomaterial properties of the USL/CL complex that is needed for the development of new surgical reconstruction methods and mesh materials for pelvic floor disorders.

Comparison of complications and prolapse recurrence between laparoscopic and vaginal uterosacral ligament suspension for the treatment of vaginal prolapse

INTRODUCTION AND HYPOTHESIS

Our objective was to compare complications and prolapse recurrence between laparoscopic (L-USLS) and vaginal (V-USLS) uterosacral ligament suspensions.

METHODS

This is a retrospective study of USLS procedures performed at a large academic center from 2011 to 2014. Patient demographics, surgical data, complications, and prolapse recurrence of L-USLS and V-USLS were compared. Logistic regression identified predictors of operative time, complications, and prolapse recurrence.

RESULTS

There were 54 L-USLS and 119 V-USLS procedures with median follow-up of 21.5 weeks (IQR 9.3-50.8). Women undergoing L-USLS were less likely to have medical comorbidities and had less severe prolapse, but were more likely to report prior hysterectomy. L-USLS had longer operative times (190.1 ± 46.8 vs 172.7 ± 47.3 min, p = 0.03), but after correcting for concomitant procedures, the operative times of the two approaches were not significantly different (adjusted OR 1.00, 95%CI 0.99-1.00). There was no significant difference in complications between groups (24.1 % vs 21.8 %, p = 0.75). However, there were nonsignificant trends toward more ureteral injuries and suture removals following V-USLS. Postoperative POP-Q points of the groups did not differ, except for total vaginal length (TVL), which was longer after L-USLS (8.3 ± 1.1 cm vs 7.4 ± 1.2 cm, p < 0.001). 19 patients met the composite definition of prolapse recurrence, with no significant difference between groups (16.2 % vs 16 %, p = 0.98). After adjusting for preoperative prolapse stage, route was not a significant predictor of prolapse recurrence (adjusted OR 0.39, 95 % CI 0.12-1.30).

CONCLUSIONS

L-USLS has comparable clinical outcomes, with similar rates of complications and prolapse recurrence to the traditional vaginal approach.

Laparoscopic colposuspension to the Cooper's ligament after hysterectomy for uterovaginal prolapse

AIM

The goal of this study was to evaluate the long-term outcomes of laparoscopic colposuspension to the Cooper's ligament after hysterectomy for uterovaginal prolapse.

MATERIAL AND METHODS

We performed chart reviews of 43 patients with uterovaginal prolapse who underwent laparoscopic colposuspension to the Cooper's ligament after hysterectomy at Daejeon St. Mary's Hospital, Catholic University of Korea from 2003 to 2009. These patients exhibited grade 3 (29 patients) or grade 4 (14 patients) uterovaginal prolapse.

RESULTS

The mean age was 63.2 years (range, 39-76). The mean follow-up period was 44.2 months (95% CI, 36.8-51.5). Forty-three patients showed no sign or recurrence of prolapse. Postoperative complications were tolerable and curable. Urinary frequency (2 patients, 4.7%), voiding difficulty (2 patients, 4.7%), nocturia (1 patient, 2.3%) and vaginal spotting (1 patient, 2.3%) were reported.

CONCLUSION

Laparoscopic colposuspension using Cooper's ligament after hysterectomy could be an effective surgical option for the treatment of uterovaginal prolapse.

[Laparoscopic surgery in the treatment of urogenital prolapse. Current status]

Urogenital prolapse is an emerging problem because of the increasing life expectancy of populations. Nearly 42% of women between 15 and 97 years have a pelvic floor disorder (PFD). On the basis of Medline search, we present the main laparoscopical techniques to treat PFD: Burch, sacrocolpopexy, lateral suspension, uterosacral suspension, paravaginal repair, the benefits of laparoscopic surgery, its success rates and complications, and response to various questions that frequently arise about some techniques: should we perform a hysterectomy? Should we make a paravaginal repair? Should we treat prophylactically a stress urinary incontinence? What type of mesh should we use? What to prefer: staples or sutures? Is the posterior mesh necessary?

Abdominal, laparoscopic, and robotic surgery for pelvic organ prolapse

Abdominal correction of pelvic organ prolapse remains a viable option for patients and surgeons. The transition from open procedures to less invasive laparoscopic and robotic-assisted surgeries is evident in the literature. This article reviews the surgical options available for pelvic organ prolapse repair and their reported outcomes. Procedures reviewed include apical support (sacral, uterosacral, and others), and abdominal anterior and posterior vaginal wall support. Long-term follow-up and appropriately designed studies will further help direct surgeons in deciding which approach to incorporate into their practice.

Outcomes of transvaginal uterosacral ligament suspension: systematic review and metaanalysis

This systematic review of uterosacral ligament suspension provides a metaanalysis of anatomic outcomes and a summary of subjective outcomes. A successful anatomic outcome was considered present when women had "optimal" or "satisfactory" (pelvic organ prolapse quantification system stage 0 or 1) outcomes. In the anterior, apical, and posterior compartments, the pooled rates for a successful outcome were 81.2% (95% confidence interval [CI], 67.5-94.5%), 98.3% (95% CI, 95.7-100%), and 87.4% (95% CI, 67.5-94.5%). In the anterior compartment, women with preoperative stage 2 prolapse were more likely than those with preoperative stage 3 prolapse to have a successful anatomic outcome (92.4% vs 66.8%; P = .06). Outcomes, with respect to subjective symptoms, were reassuring; however, it was not possible to pool data because of methodologic differences between studies.

[Reconstructive pelvic surgery. Current status and future perspectives]

Pelvic organ prolapse is a widespread condition that especially affects women. There are a number of conservative and surgical therapeutic options. The choice of therapy should be individually made, depending on factors such as the grade of prolapse and concomitant secondary disorders as well as the age and general condition of the patient. This article presents current surgical options, analyzes recent studies, and offers future perspectives for reconstructive pelvic surgery.

Uterosacral ligament vaginal vault suspension: anatomy, outcome and surgical considerations

PURPOSE OF REVIEW

With aging populations, primary pelvic organ and recurrent pelvic organ prolapse have become a large-scale public health concern. Surgical options for patients include both abdominal and vaginal approaches, each with its own safety and efficacy profiles. This review summarizes the most recent anatomic, surgical and outcome data for uterosacral ligament vault suspension. It offers data on methods to avoid complications and difficult surgical scenarios.

RECENT FINDINGS

Uterosacral ligament suspension allows reattachment of the vaginal vault high within the pelvis. New modifications in technique including the extraperitoneal and laparoscopic approaches allow surgeons more freedom when planning surgery. Five-year data on the durability of the procedure make it a viable surgical option.

SUMMARY

As a technique widely used by many pelvic reconstructive surgeons, uterosacral ligament vault suspension provides a safe, anatomically correct and durable approach to uterine and vault prolapse. It requires advanced surgical training and an intimate understanding of pelvic anatomy to avoid and identify ureteral injury.

An update on the laparoscopic approach to urogynecology and pelvic reconstructive procedures

PURPOSE OF REVIEW

To review the evidence behind laparoscopic pelvic organ prolapse and urinary incontinence repair.

RECENT FINDINGS

A review of the recent literature continues to support the use of laparoscopy for colposuspension and sacral colpopexy as a viable alternative for open surgery. Polypropylene mid-urethral slings are comparable, if not better than laparoscopic Burch, though most data are short-term. The literature regarding other laparoscopic prolapse procedures, such as uterosacral ligament suspension, paravaginal defect repair, and rectocele repair is sparse.

SUMMARY

Short-term studies support the use of laparoscopy in urogynecology and reconstructive pelvic surgery. However, longer term studies are needed to confirm these findings.

Laparoscopic sacrocervicopexy for the treatment of uterine prolapse: a retrospective case series report

STUDY OBJECTIVE

To evaluate apical support in patients desiring uterine preservation with pelvic organ prolapse who underwent laparoscopic sacrocervicopexy.

DESIGN

Retrospective case series report (Canadian Task Force classification III).

SETTING

Academic community teaching hospital.

PATIENTS

Forty consecutive women who underwent laparoscopic sacrocervicopexy.

INTERVENTIONS

Synthetic mesh was used to attach the distal uterosacral ligaments and posterior endopelvic fascia to the anterior longitudinal ligament of the sacral promontory.

MEASUREMENTS AND MAIN RESULTS

Pelvic organ prolapse quantification system measurements were used and apical support was evaluated using point C. Mean C was -1.13 (+9 to -4) preoperatively, -5.28 (-3 to -13) at 6 weeks postoperatively, -5.26 (-3 to -8) at 6 months postoperatively, and -4.84 (-3 to -7) at 1 year postoperatively.

CONCLUSION

Laparoscopic sacrocervicopexy is an effective option for women with pelvic organ prolapse who desire uterine preservation.

Laparoscopic management of uterine prolapse with cystocele and rectocele using "Gynemesh PS"

OBJECTIVE

Our department performed laparoscopic correction of uterine or vault prolapse with cystocele and rectocele using the "Gynemesh PS." The aim of this study was to evaluate the surgical outcomes and perioperative morbidity after a laparoscopic operation.

MATERIALS AND METHODS

From August 2004 to September 2005, we performed laparoscopic pelvic floor repairs in 6 cases of vault prolapse and 15 cases of uterine prolapse at the Department of Obstetrics and Gynecology at the Kyungpook National University Hospital (Daegu, Korea). Uterine and vault prolapse were repaired by laparoscopic rectocele and cystocele repair using the Gynemesh PS, uterosacral ligament suspension, paravaginal repair, and Burch colposuspension. In uterine prolapse, we also carried out a subtotal hysterectomy. The stage of prolapse was classified by means of the pelvic organ prolapse quantification (POPQ) system.

RESULTS

The mean age, Q-index, and parity were 64 years (range, 47-79), 24.6 (range, 18.7 approximately 27.8), and 5 (range, 3 approximately 10), respectively. Mean operation time was 141 minutes (range, 90 approximately 211). Mean estimated blood loss was 53 mL (range, 20 approximately 80). Mean hospital stay was 5 days (range, 3 approximately 9 days). There were no major complications, but postoperative voiding difficulty developed in 1 case. Mean preoperative POPQ stage was 3 and immediate, 6-week, 3-month, 6-month, and 1-year postoperative POPQ score was 0. Mean follow-up period was 7.5 months (range, 3 approximately 13). The objective success rate was 100%.

CONCLUSIONS

Laparoscopic pelvic floor repair is an effective procedure and enables us to combine the advantages of laparotomy with the low morbidity of the vaginal route. In Europe, the sacrocolpopexy was more popular, but uterosacral ligament suspension is the most natural anatomic repair of defects and, hence, the least likely to be predisposed to future defects in the anterior or posterior vaginal wall or to compromise vaginal function. However, further studies are required on the long-term efficiency and reliability in order to evaluate the value of this technique.

Positive symptom improvement with laparoscopic uterosacral ligament repair for uterine or vaginal vault prolapse: Interim results from an active multicenter trial

STUDY OBJECTIVE

To evaluate the use of laparoscopic uterosacral ligament repair for long-term patient symptom improvement in patients with uterine prolapse or posthysterectomy vaginal vault prolapse and to evaluate how laparoscopic instrumentation kits facilitate procedure performance for the surgeon.

DESIGN

Nonrandomized, prospective, multicenter case series (Canadian Task Force classification II-2).

SETTING

Five clinical sites consisting of 4 community hospitals and 1 university medical center.

PATIENTS

Seventy-two patients with stage II or worse uterine prolapse (58%, n = 42) or posthysterectomy vaginal vault prolapse (42%, n = 30). One patient with stage I vaginal vault prolapse was included in the group due to her significant symptoms.

INTERVENTIONS

Laparoscopic uterosacral ligament repair was performed on all patients; round ligament truncation was also performed selectively on patients with uterine prolapse. Fifty-seven percent (41 patients) had concomitant pelvic procedures.

MEASUREMENTS AND MAIN RESULTS

At 12-month follow-up, Pelvic Organ Prolapse Quantification (POP-Q) scores and patient self-reported symptom scores were significantly improved over baseline after laparoscopic repair of pelvic organ prolapse. Positive mean change in POP-Q score was 14.4 (p = .0003) for uterine prolapse repair and 9.28 (p = .017) for vaginal vault prolapse repair. Positive mean change in total symptom score was 20.36 (p <.0001) for uterine prolapse repair and 11.43 (p = .005) for vaginal vault prolapse repair. Surgeons reported a mean procedure time of 31.6 minutes for uterine prolapse repair and 21.7 minutes for vaginal vault prolapse repair. A mean rating of 7.5 was documented for ease of use for the uterine prolapse kit and 4.1 for the vaginal vault prolapse kit on a scale of 1 to 10.

CONCLUSION

Laparoscopic uterosacral ligament repair improves symptoms and POP-Q scores over the long term in patients with uterine or vaginal vault prolapse. Laparoscopic instrumentation kits facilitate procedure performance for the surgeon with expedited surgery times.