Vaginal Sacral Colpopexy: A Natural Orifice Approach to a Gold Standard Procedure

Transvaginally Adjustable Apical Suspension and Compartment-Specific Tensioning in Vaginal Natural-Orifice Transluminal Endoscopic Surgery Sacrocolpopexy: Cadaveric and Live Patient Experience

Objective

This article provides a systematic approach to performing a vaginal natural-orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy (SCP) to create an anatomically aligned vaginal axis, an intraoperatively adjustable apical suspension, and variable compartment tensioning.

Methods

The technique presented for vNOTES SCP focuses on: (1) retroperitoneal tunneling; (2) direct sacrum access below the S-1 level, using uterosacral-ligament guidance; (3) transvaginal tensioning of the mesh to ensure both adequate vaginal length and cuff elevation using the DZOH apical-suspension technique; (4) circumvention of intrapelvic laparoscopic suturing; and (5) near-total peritoneal coverage of the mesh arms.

Results

This detailed description of a successful novel technique to perform vNOTES SCP was based on cadaveric experience as well as in live patients that is reproducible on living patients.

Conclusions

This apical suspension technique for vNOTES SCP may be a viable, reproducible, safe, and efficient transvaginal alternative to the commonly practiced minimally invasive approaches that involve abdominal-port placements. (J GYNECOL SURG 40:116).

Mesh Exposure and Prolapse Recurrence Following Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Sacrocolpopexy: Over 24 Months of Follow-up Data

STUDY OBJECTIVE

To describe the results of mesh exposure and prolapse recurrence of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for sacrocolpopexy after more than 24 months of postoperative follow-up.

DESIGN

A retrospective cohort study.

SETTING

A university hospital.

PATIENTS

Women with uterine prolapse who underwent vNOTES sacrocolpopexy with an ultralightweight polypropylene mesh between May 2018 and March 2020.

INTERVENTIONS

vNOTES sacrocolpopexy.

MEASUREMENTS AND MAIN RESULTS

Of 57 women, 55 women (96.5%) were included in the final analysis. The mean follow-up duration was 35.5 ± 7.6 (24-46) months. The total incidence of mesh exposure was 3 of 55 (5.5%). The total incidence of prolapse recurrence was 3 of 55 (5.5%). The changes in the Pelvic Organ Prolapse Quantification System scores, including Aa, Ba, C, Ap, Bp, and total vaginal length values, showed significant improvement after surgery (p <.05 for all).

CONCLUSION

The study demonstrates that vNOTES sacrocolpopexy appears to be an effective option with low risks of mesh exposure and prolapse recurrence. Studies including more patients and longer follow-up periods should be performed before a clear conclusion can be reached.

Standard practice of presacral exposure during transvaginal natural orifice transluminal endoscopic surgery for sacrocolpopexy

We describe the standard practice of presacral exposure during transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for sacrocolpopexy in women with uterine prolapse. In this video, we demonstrate the key techniques: identifying the right hypogastric nerve (rHN) before opening the pelvic peritoneum; removing the fat and loose connective tissue along the rHN to expose the presacral fascia; incising the presacral fascia to reach the presacral space to expose the middle sacral vasculature and the anterior longitudinal ligament (ALL) of the first sacral vertebra (S1) below the promontory; attaching the mesh to the ALL to avoid vessel injury; and completing the peritonealisation.

Apical pelvic organ prolapse repair via vaginal-assisted natural orifice transluminal endoscopic surgery: Initial experience from a tertiary care hospital

INTRODUCTION

Natural orifice transluminal endoscopic surgery has been used for gynecologic operations in recent years. The aim of the study is to describe our initial experience using vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) for apical pelvic organ prolapse repair.

METHODS

After patients underwent vaginal hysterectomy, vNOTES sacrocolpopexy (n = 4) or vNOTES high uterosacral ligament suspension (n = 7) were performed to treat symptomatic apical pelvic organ prolapse. Sociodemographic and clinical characteristics, Pelvic Organ Prolapse Quantification results, and recorded surgical data (eg, duration of surgery, intraoperative complications, additional prolapse and incontinence surgeries) were obtained from patient files and the hospital's database. Information from postoperative follow-up visits, including complications and anatomical results, were also recorded.

RESULTS

The mean age of the patients was 60.7 ± 9.1 years. The mean total operative time was 121.3 ± 22.7 minutes. The mean operative time for vaginal hysterectomy, vNOTES sacrocolpopexy, and vNOTES uterosacral ligament suspension was 46 ± 11.9, 65 ± 38, 25 ± 8.2 minutes, respectively. There were no intraoperative and postoperative complications observed. The mean postoperative 24-hour visual analog scale score was 3.5 ± 1.9 for vNOTES sacrocolpopexy patients and 3.2 ± 0.9 for vNOTES uterosacral ligament suspension patients. Only one patient in the vNOTES sacrocolpopexy group had a recurrence; she experienced stage 2 anterior compartment prolapse 8 months after surgery.

CONCLUSION

As a treatment for apical pelvic organ prolapse, vNOTES is a feasible approach in both sacrocolpopexy and uterosacral ligament suspension.

Integration of a Robotic Platform for Sacrocolpopexy in Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Novel Surgical Technique

OBJECTIVE

To demonstrate the feasibility and the simplified surgical techniques of intraabdominal suturing and knot-tying in robotic transvaginal natural orifice transluminal endoscopic surgery (RV-NOTES) sacrocolpopexy.

MATERIALS AND METHODS

We report on two patients with symptomatic stage II apical pelvic organ prolapse who underwent a new technique of RV-NOTES sacrocolpopexy. Case one: A 69-year-old G2P2002 with a history of two prior vaginal deliveries presented with a vaginal bulge and pressure symptoms. She was initially fitted for a pessary but was unsatisfied and elected to proceed with surgical intervention. Case two: A 50-year-old G2P0011 female with a history of one prior vacuum-assisted vaginal delivery presented with symptoms of vaginal mass and bleeding due to an endometrial polyp. She was noted to have stage 2 apical prolapse and opted for transvaginal sacrocolpopexy.

RESULTS

Both patients were observed overnight and discharged home twelve hours after surgery on postoperative day 1, after completing a voiding trial. For both patients, the postoperative course was unremarkable, and they only required one day of pain medications. At the three-week follow-up visit, they endorsed no postoperative pain or complications, and the POP-Q stage was noted to be 0. Patients had telemedicine visits at eight weeks postoperatively, at which time they had returned to their regular activities and denied symptoms of vaginal bulge or pressure.

CONCLUSION

Robotic assisted transvaginal NOTES sacrocolpopexy is a feasible and an alternative to traditional laparoscopic NOTES sacrocolpopexy.

Joint Report on Terminology for Surgical Procedures to Treat Pelvic Organ Prolapse

Surgeries for pelvic organ prolapse (POP) are common, but standardization of surgical terms is needed to improve the quality of investigation and clinical care around these procedures. The American Urogynecologic Society and the International Urogynecologic Association convened a joint writing group consisting of 5 designees from each society to standardize terminology around common surgical terms in POP repair including the following: sacrocolpopexy (including sacral colpoperineopexy), sacrocervicopexy, uterosacral ligament suspension, sacrospinous ligament fixation, iliococcygeus fixation, uterine preservation prolapse procedures or hysteropexy (including sacrohysteropexy, uterosacral hysteropexy, sacrospinous hysteropexy, anterior abdominal wall hysteropexy, Manchester procedure), anterior prolapse procedures (including anterior vaginal repair, anterior vaginal repair with graft, and paravaginal repair), posterior prolapse procedures (including posterior vaginal repair, posterior vaginal repair with graft, levator plication, and perineal repair), and obliterative prolapse repairs (including colpocleisis with hysterectomy, colpocleisis without hysterectomy, and colpocleisis of the vaginal vault). Each of these terms is clearly defined in this document including the required steps of the procedure, surgical variations, and recommendations for procedural terminology.

Transvaginal Natural Orifice Transluminal Endoscopic Surgery for Sacrocolpopexy: A Pilot Study of 26 Cases

STUDY OBJECTIVE

To describe the surgical technique and short-term outcomes for 26 cases of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) sacrocolpopexy for the treatment of pelvic organ prolapse (POP).

DESIGN

Retrospective case series study (Canadian Task Force classification II-2).

SETTING

Academic tertiary care university hospital in Guangdong, China.

PATIENTS

Women diagnosed with stages II to IV POP between May 2017 and May 2018.

INTERVENTIONS

vNOTES sacrocolpopexy.

MEASUREMENTS AND MAIN RESULTS

A total of 26 patients were identified. vNOTES sacrocolpopexy was standardized after case 4, and 23 cases were completed successfully. Operative duration was a median of 184 minutes (interquartile range, 158.5-202.5), and mean estimated blood loss was 30.87 ± 20.8 mL. Mean pre- and postoperative POP Quantification System scores for the Aa point were, respectively, 1.4 ± 1.7 cm (range, -2 to 3) versus -1.85 ± .6 cm (p <.0001) and for the C point were 2.2 ± 1.9 cm (range, -1 to 5) versus -6.1± .7 cm (p <.0001). Mean pre- and postoperative Pelvic Floor Impact Questionnaire scores were 163.1 ± 46.2 versus 18.4 ± 29.3 (p <.0001). These suggest significant improvements in both physical prolapse and quality of life at 1 month after surgery. There were no complications of mesh exposure, pain, hematoma, infection, or new urinary incontinence.

CONCLUSION

vNOTES is a feasible approach for sacrocolpopexy, with promising short-term efficacy and safety data. Larger studies across multiple sites and surgeons should evaluate the long-term efficacy and safety profile of vNOTES sacrocolpopexy.