Surgical management of the apical vaginal defect

Anterior and Apical Prolapse: Comparison of Vaginal Mesh Surgery to Vaginal Surgery with No Mesh

Aim of the study: The aim of this study was to evaluate the anatomical results after an anterior sacrospinous ligament fixation (ASSLF) with native tissue repair (anterior colporraphy and apical suspension with prolene) compared to mesh repair for the correction of anterior prolapse at 12 months after surgery. Materials and methods: A monocentric prospective study comparing two similar cohorts who underwent ASSLF was conducted. The primary endpoint was the gain in the position of the Ba point relative to its position before surgery and twelve months after surgery. The secondary endpoints consisted of objective results, which were assessed using validated questionnaires. Results: Fifty-three women were included in the native tissue repair group between June 2019 and March 2020. They were compared to 53 women operated on with anterior and apical mesh. There was no difference with respect to the Ba point after 1 year between the two groups (−2 [−3; 1.5]; −2 [−3; 1], p = 0.9789). The apex was significantly better corrected in the native tissue repair group (−7 vs. −6, p = 0.0007). There was also a better correction on the rectocele in the native tissue repair group (−3 vs. −2, p = 0.0178). The rate of Stage 2 anterior vaginal prolapse at one year was approximately 30% in both groups (no statistical difference). Conclusions: ASSFL without mesh does not increase the risk of cystocele recurrence at 1 year after surgery. A future prospective comparison of this native tissue repair technique with mesh suspension is necessary to explore these preliminary findings.

Vaginal Vault Prolapse in an Elderly Woman

Vaginal vault prolapse is a painful condition in which the vaginal cuff descends. This report presents a case of a 65-year-old obese and diabetic female who was suffering from a third-degree vault prolapse. Conventionally used non-surgical treatments, such as exercises for the pelvic floor, are not as effective as surgical approaches for the treatment of third-degree vault prolapse. Post-hysterectomy vaginal vault prolapse can be treated safely and effectively with abdominal sacral colpopexy using a permanent mesh. Due to several risk factors, such as grand parity, advancing age, and poor lifestyle mainly involving exercise to strengthen pelvic floor musculature, the vaginal route of surgery was employed, which was found to be effective, and thus the treatment was successful. In conclusion, such individualized as well as unique approaches to such rare cases can produce efficacious results.

Comparison of a human acellular dermal matrix and a polypropylene mesh for pelvic floor reconstruction: a randomized trial study in a rabbit model

Non-absorbable polypropylene (PP) meshes have been widely used in surgical reconstruction of the pelvic floor disorders. However, they are associated with serious complications. Human acellular dermal matrices (hADM) have demonstrated safety and efficacy in reconstructive medicine, but their suitability and efficacy at vaginal level is not known. This study compares the biological performance of PP mesh and a newly developed hADM. 20 rabbits were randomized to receive the hADM graft or the PP mesh. Grafts were surgically implanted in the abdominal wall and vagina. After 180 days, grafts were explanted and evaluated. The vaginal mesh extrusion rate was higher in the PP group (33% vs. 0%, p = 0.015). Full integration of the vaginal grafts was more frequent in the hADM group, where 35% of the grafts were difficult to recognize. In the PP group, the vaginal mesh was identified in 100% of the animals (p = 0.014). In PP group, the infiltrates had a focal distribution and were mostly located in the internal part of the epithelium, while in the hADM group, the infiltrates had a diffuse distribution. Additionally, the hADM group also presented more B-lymphocytes and less T-lymphocytes. Biomechanical analysis showed that hADM had lower resistance to stress. Moreover, PP mesh stiffness and elasticity were higher. Then, hADM is associated with fewer clinical complications, as well as better tissue integration. However, it shows greater incorporation into the surrounding native tissue, especially in the vaginal location, undergoing a reduction in its biomechanical properties 6 months after implantation.

Large-scale surgical workflow segmentation for laparoscopic sacrocolpopexy

Purpose

Laparoscopic sacrocolpopexy is the gold standard procedure for the management of vaginal vault prolapse. Studying surgical skills and different approaches to this procedure requires an analysis at the level of each of its individual phases, thus motivating investigation of automated surgical workflow for expediting this research. Phase durations in this procedure are significantly larger and more variable than commonly available benchmarks such as Cholec80, and we assess these differences.

Methodology

We introduce sequence-to-sequence (seq2seq) models for coarse-level phase segmentation in order to deal with highly variable phase durations in Sacrocolpopexy. Multiple architectures (LSTM and transformer), configurations (time-shifted, time-synchronous), and training strategies are tested with this novel framework to explore its flexibility.

Results

We perform 7-fold cross-validation on a dataset with 14 complete videos of sacrocolpopexy. We perform both a frame-based (accuracy, F1-score) and an event-based (Ward metric) evaluation of our algorithms and show that different architectures present a trade-off between higher number of accurate frames (LSTM, Mode average) or more consistent ordering of phase transitions (Transformer). We compare the implementations on the widely used Cholec80 dataset and verify that relative performances are different to those in Sacrocolpopexy.

Conclusions

We show that workflow segmentation of Sacrocolpopexy videos has specific challenges that are different to the widely used benchmark Cholec80 and require dedicated approaches to deal with the significantly larger phase durations. We demonstrate the feasibility of seq2seq models in Sacrocolpopexy, a broad framework that can be further explored with new configurations. We show that an event-based evaluation metric is useful to evaluate workflow segmentation algorithms and provides complementary insight to the more commonly used metrics such as accuracy or F1-score.

Supplementary Information

The online version supplementary material available at 10.1007/s11548-021-02544-5.

Role of Preoperative and Postoperative Pelvic Floor Distress Inventory-20 in Evaluation of Posthysterectomy Vault Prolapse

Background:

Posthysterectomy vault prolapse is a common problem after vaginal or abdominal hysterectomy. The objective was to assess the role of Pelvic Floor Distress Inventory 20 (PFDI-20) in evaluation of vault prolapse.

Materials and Methods:

Prospective study in 20 women with posthysterectomy vault prolapse of Stage 2 and above. The outcome measure was to calculate PFDI-20 score in all cases before surgical intervention and to recalculate it again in 6 months after different surgical procedures for vault prolapse and to statistically compare the PFDI-20 score in different types of surgery over 4 years period at a tertiary referral hospital for surgical treatment. Prolapse was classified using Pelvic Organ Prolapse Quantification and intraoperative findings. All women were operated for vault prolapse as per hospital protocol and stage of prolapse by either vaginal sacrospinous fixation or abdominal sacrocolpopexy.

Results:

Mean age, parity, and body mass index were 54.8 years, 3.5, and 22.71 kg/m² respectively. Preceding surgery was vaginal hysterectomy in 75% women and abdominal hysterectomy in 25% women. Complaints were bulge or mass feeling at perineum (100%), pressure in lower abdomen and perineum (55%), and constipation (60%). The type of prolapse was vault prolapse (100%), cystocele (100%), rectocele (100%), and enterocele (45%). The range of PFDI-20 was 88–152 with mean being 123.50 ± 22.71 before surgery while its range decreased significantly to 80–126 with mean being 106.40 ± 16.45 after surgery (P < 0.01). Mean postoperative PFDI-20 score was 107.40 in vaginal sacrospinous fixation group and was 105.30 in abdominal sacrocolpopexy group and was not statistically different (P = 0.18).

Conclusion:

PFDI-20 score can be used to see the adverse impact of vault prolapse on pelvic floor and to assess the beneficial effect of different types of surgeries on the score.

Prolapso de cúpula vaginal, prevalencia en mujeres en climaterio, en el Quindío, Colombia, 2007-2017

Objetivo establecer la prevalencia de prolapso de cúpula vaginal en mujeres del Quindío en climaterio, así como los factores asociados a su aparición.

Métodos Se realizó un estudio de corte transversal. Se evaluaron retrospectivamente las historias clínicas de 3,576 pacientes ambulatorias, en una clínica de alta complejidad de la ciudad de Armenia (Quindío), Colombia; entre enero de 2007 y junio de 2017. Se determinó la prevalencia de prolapso de cúpula vaginal y se analizaron los datos socio-demográficos, clínicos y quirúrgicos.

Resultados La edad media en las mujeres fue de 59,7 ± 14,7 años, con predominancia de las hispánicas (58,5%). La prevalencia de prolapso de cúpula vaginal fue del 14,17%. En el subgrupo de mujeres histerectomizadas, la prevalencia fue del 21,64% en las realizadas por prolapso y del 6,34% en las hechas vía abdominal. En el análisis multivariado, los factores asociados a prolapso de cúpula vaginal fueron: 65 o más años (OR: 4,76; 1,57–20,82), IMC3 25 (OR: 8,42; 2,68–31,04), multíparas (OR: 9,03; 2,75–32.27), antecedente de cirugía vaginal (OR: 7.04; 1.96–28.49) y presencia de enfermedades pulmonares crónicas (OR: 5,31; 1,64–23,57).

Conclusión la prevalencia global de prolapso de cúpula vaginal, en las mujeres del Quindío, fue del 14,17%. En Colombia existen pocos datos registrados al respecto, pero con la información presente, se manifiesta la necesidad de elaborar efectivas estrategias de prevención, detección y manejo.

The early benefits of Laparoscopic Sacrocolpopexy

BACKGROUND

Prospective evaluation of the 6 months functional and clinical outcome of 27 patients treated with Laparoscopic Sacrocolpopexy (LSC).

METHODS

Pelvic organ prolapse was assessed by Baden-Walker system along with a validated quality of life questionnaire preoperatively and at 6 months postoperatively to assess vaginal, urinary, bowel and sexual symptoms.

RESULTS

At a mean 6 months follow-up, 96% of the symptomatic women had successful vaginal vault support with no recurrence of prolapse symptoms. Successful anatomical outcome (any prolapse ≤ stage 1) was found in 89%. Regarding the urinary functional symptoms, significant improvement was reported in the voiding function, painful symptoms and the relevant quality of life. Stress urinary incontinence resolved in 67% without concomitant continence surgery; 4% from the stress incontinence was de novo. Bowel symptoms were common, both pre- and postoperatively; 40% from the postoperative bowel symptoms was de novo. Sexually active women reported significant improvement in sexual function; there was one case of de novo dyspareunia.

CONCLUSION

LSC is an effective treatment for vault prolapse as soon as in the 6-months follow-up. The outcome for anterior and posterior support is less predictable. The pelvic organ vaginal, urinary and sexual functional symptoms improve. The effects on bowel function are less clear. Long-term prospective studies are required to establish the duration of the benefits.

Computational comparison of different textile implants to correct apical prolapse in females

Prosthetic textile implants of different shapes, sizes and polymers are used to correct the apical prolapse after hysterectomy (removal of the uterus). The selection of the implant before or during minimally invasive surgery depends on the patient’s anatomical defect, intended function after reconstruction and most importantly the surgeon’s preference. Weakness or damage of the supporting tissues during childbirth, menopause or previous pelvic surgeries may put females in higher risk of prolapse. Numerical simulations of reconstructed pelvic floor with weakened tissues and organ supported by textile product models: DynaMesh®-PRS soft, DynaMesh®-PRP soft and DynaMesh®-CESA from FEG Textiletechnik mbH, Germany are compared.

Two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy: A novel approach in difficult laparoscopic hysterectomy

OBJECTIVE

To proposed a novel method for a difficult laparoscopic hysterectomy that spares the cervical ligaments and eliminates the cervical canal and transformation zone of the cervix.

CASE REPORT

A 40-year-old women, gravida 3 para 3, who had had a cesarean delivery previously, was referred to the gynecology clinic due to adenomyosis with menorrhagia and severe anemia. Ultrasonography showed that the uterus was enlarged to 13.5 cm × 10.7 cm × 8.8 cm. After obtaining informed consent, a two-phase laparoendoscopic single-site (LESS) cervical ligaments-sparing hysterectomy was performed smoothly. The patient discharged on 4th day and resumed her sexual life less than 2 months after surgery.

CONCLUSION

This novel minimal invasive method of hysterectomy makes difficulty laparoscopic hysterectomy easy and safe. Preservation of cervical ligaments retains stability in the pelvic floor and may reduce intraoperative complications and subsequent pelvic floor organ prolapse.

Laparoscopic pectopexy: a prospective, randomized, comparative clinical trial of standard laparoscopic sacral colpocervicopexy with the new laparoscopic pectopexy-postoperative results and intermediate-term follow-up in a pilot study

PURPOSE

The purpose of the study was to compare the outcome of laparoscopic sacral colpocervicopexy with laparoscopic pectopexy. Our aim was to show that the safety and effectiveness of the new technique is similar to the traditional technique. We expected differences regarding defecation disorders.

PATIENTS AND METHODS

We randomly assigned patients to two treatment groups: 44 in the pectopexy and 41 in the sacropexy group. If necessary, the operative procedures were planned in a so-called multicompartment setting regarding the different pelvic floor disorders. All defects were managed at the same time. Eighty-one patients were examined 12 to 37 months after treatment (mean follow-up 20.67 months).

RESULTS

The long-term follow-up (21.8 months for pectopexy and 19.5 months for sacropexy) showed a clear difference regarding de novo defecation disorders (0% in the pectopexy vs 19.5% in the sacropexy group). The incidence of de novo stress urinary incontinence was 4.8% (pectopexy) vs 4.9% (sacropexy). The incidence of rectoceles (9.5% vs 9.8%) was similar in both groups. No de novo lateral defect cystoceles were found after pectopexy, whereas 12.5% were found after sacropexy. The apical descensus relapse rates, 2.3% for pectopexy vs 9.8% for sacropexy, were not statistically significant. The occurrence of de novo anterior defect cystoceles and rectoceles revealed no significant differences.

CONCLUSION

Laparoscopic pectopexy is a novel method of vaginal prolapse therapy that offers clear practical advantages compared with laparoscopic sacropexy. Because laparoscopic pectopexy does not reduce the pelvic space, it results in a zero percentage of defecation disorders.

Treatment of Vaginal Cuff Prolapses with Posterior Intravaginal Sling and Evaluation of Efficiency with International Consultation on Incontinence Questionnaire-Vaginal Symptoms Method in the Long Term: Preliminary Results

OBJECTIVES

The aim of this study was to research the efficiency of posterior intravaginal sling (PIVS) procedure in vaginal cuff prolapse, together with possible complications, long-term effects and effects of the method on vaginal and sexual function and quality of life of patients. This retrospective study comprised 21 patients with vaginal cuff prolapse.

METHODS

PIVS procedure was performed in 21 patients with vaginal cuff prolapse with quantification stages 2, 3, or 4 of pelvic organ prolapse. Patients were assessed according to the International Consultation on Incontinence Questionnaire-Vaginal Symptoms before and after operation.

RESULTS

The average follow-up period was 24.6 months. The rate of surgical success was 100%, the rate of mesh erosion was 14.2% and the rate of dyspareunia was 33.3%. Vaginal symptom, sexual matter and quality of life scores were statistically significant in the postoperative period compared to the preoperative period (P = 0.001, P = 0.001, P = 0.001, respectively).

CONCLUSION

PIVS is an effective and reliable method of treating vaginal cuff prolapse. However, its complication profile is not yet at an acceptable level. We believe that the rate of mesh erosion will regress to a more acceptable level with the improvement of mesh technology and postoperative method. The necessary incontinence surgery is easily performed together with PIVS procedure. PIVS restores the vaginal and sexual functions of patients and increases their quality of life significantly.

[Prolapse surgery. With abdominal or vaginal meshes?]

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

A novel technique for the management of advanced uterine/vault prolapse: extraperitoneal sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

Abdominal sacrocolpopexy is the gold standard for advanced uterovaginal/cuff prolapse repair; however, early and late bowel complications are of concern. We report our experience with extraperitoneal sacrocolpopexy (ESCP).

METHODS

Twenty-three patients who underwent ESCP between 2007 and 2010 were analyzed in this retrospective cohort study. Preoperative assessment included Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact (PFIQ-7) questionnaires, and pelvic examination according to Pelvic Organ Prolapse Quantification (POP-Q) system. Pre-operative findings were compared with postoperative values at the last follow-up using the Wilcoxon sign test.

RESULTS

Mean operation time was 86 ± 20 min. Twenty patients were discharged within 24 h. With a mean follow-up of 20 months, objective and subjective cure rates were 91.3% and 86.9%, respectively. No postoperative complications were evident with significant improvement in POP-Q, PFDI-20, and PFIQ-7 scores.

CONCLUSIONS

ESCP is a safe and effective sacrocolpopexy procedure that can potentially eliminate the risk of gastrointestinal complications.

Surgical outcomes following total Prolift: colpopexy versus hysteropexy

BACKGROUND

Total Prolift(®) is a pelvic floor repair system that is performed transvaginally and can be carried out with or without the uterus in situ.

AIM

To compare surgical outcomes following total Prolift colpopexy (TPC) and total Prolift hysteropexy (TPH).

METHODS

This was a retrospective cohort study of women that underwent TPC (n = 65) or TPH (n = 24). Outcomes were compared between groups using Student's t-test, ANCOVA and Fisher's exact tests (P ≤ 0.05).

RESULTS

There were no significant differences between TPC and TPH for all peri-operative variables. Patients were followed 6-12 months after surgery. Post-operatively, TPC patients had significantly higher pelvic organ prolapse-quantification (POP-Q) point C measurements (P = 0.05); however, all other POP-Q measurements were similar, including POP-Q apical stage of prolapse, with 99% in the TPC group and 92% in the TPH group at stage I or less. Post-operative mesh erosion, prolapse symptoms, surgical satisfaction, sexual activity and dyspareunia rates did not significantly differ between groups.

CONCLUSIONS

This study showed that TPC and TPH have similar surgical outcomes, except for vaginal vault measurements reflected by POP-Q point C.

Laparoscopic sacrocolpopexy: an observational study of functional and anatomical outcomes

INTRODUCTION AND HYPOTHESIS

the aim of the study was to evaluate the clinical and functional outcomes of laparoscopic sacrocolpopexy, in particular its effect on female sexual function.

METHODS

a retrospective observational study of women undergoing laparoscopic sacrocolpopexy between February 2005 and March 2009 was undertaken. Pelvic organ support was assessed objectively using the pelvic organ prolapse quantification scale (POP-Q). Functional outcomes were assessed using the International Consultation on Incontinence questionnaire for vaginal symptoms (ICIQ-VS), both preoperatively and at 6-36 months postoperatively.

RESULTS

eighty-four women with a mean age of 65 years (range, 49-78 years) were studied. At follow-up in clinic, all women had good vault support (mean point C, -8.9; range, 10 to -8). Subjective improvements in prolapse symptoms and sexual well-being were observed with significant reductions in the respective questionnaire scores.

CONCLUSIONS

our results confirm previous findings that laparoscopic sacrocolpopexy is a safe and efficacious surgical treatment for post-hysterectomy vaginal vault prolapse. It provides excellent apical support and good functional outcome with overall improvement in sexual function.

[Vaginal pelvic repair. Always with mesh or not?]

Several surgical methods are possible when aiming at reconstruction of pelvic organ prolapse in women, and the experienced surgeon implements the knowledge gained from open, laparoscopic, and vaginal techniques. These feature different rates of success and relapse as well as different complication risks. Because of the accumulating morbidity of aging patients, there is a search for a safe minimally invasive technique. With the advent of synthetic meshes, surgeons have used them frequently and often uncritically for reconstruction of the female pelvic floor. In these cases the vaginal approach is preferred as opposed to alternative techniques, as it is less invasive and allows for better convalescence. Furthermore, this approach leads to low complication and relapse rates even when synthetic meshes are omitted.

Vaginal vault prolapse

Introduction. Vaginal vault prolapse is a common complication following vaginal hysterectomy with negative impact on women's quality of life due to associated urinary, anorectal and sexual dysfunction. A clear understanding of the supporting mechanism for the uterus and vagina is important in making the right choice of corrective procedure. Management should be individualised, taking into consideration the surgeon's experience, patients age, comorbidities, previous surgery and sex life. Result. Preexisting pelvic floor defect prior to hysterectomy is the single most important risk factor for vault prolapse. Various surgical techniques have been advanced at hysterectomy to prevent vault prolapse. Studies have shown the McCall's culdoplasty under direct visualisation to be superior. Vault prolapse repair rely on either the use of patient's tissue or synthetic materials and can be carried out abdominally or vaginally. Sacrospinous fixation and abdominal sacrocolpopexy are the commonly performed procedures, with literature in favour of abdominal sacrocolpopexy over sacrospinous fixation due to its reported higher success rate of about 90%. Other less commonly performed procedures include uterosacral ligament suspension and illiococcygeal fixation, both of which are equally effective, with the former having a high risk of ureteric injury. Colpoclesis will play a greater role in the future as the aging population increases. Mesh procedures are gaining in popularity, and preliminary data from vaginal mesh procedures is encouraging. Laparoscopic techniques require a high level of skill and experience. There are many controversies on the mechanism of prolapse and management techniques, which we have tried to address in this article. Conclusion. As the aging population increases, the incidence of prolapse will also rise, older techniques using native tissue will continue, while new techniques using the mesh needs to be studied further. The later may well be the way forward in future.

Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results, quality of life and perioperative outcome-a prospective study with 101 cases

Our prospective study evaluates laparoscopic sacrocolpopexy for vaginal vault prolapse focusing on perioperative data, objective anatomical results using the pelvic organ prolapse quantification (POP-Q) system and postoperative quality of life using the Kings Health questionnaire. One hundred one patients completed the study. Fifty five had laparoscopic supracervical hysterectomy and sacrocolpopexy for uterine prolapse and 46 had laparoscopic sacrocolpopexy for post-hysterectomy prolapse. Median follow-up was 12 months. The subjective cure rate was 93% the objective cure rate (no prolapse in any compartment) according to the International Continence Society classification of prolapse was 98%. The main site of objective recurrence (6%) was the anterior compartment. No apical recurrences and no vaginal mesh erosion occurred. Postoperatively overall quality of life and sexual quality showed significant improvement with less than 1% de-novo dyspareunia. The procedure is recommended for experienced laparoscopic surgeons because of severe intraoperative complications like bladder or rectal injuries.

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.

Comparison of laparoscopic and abdominal sacrocolpopexy for the treatment of vaginal vault prolapse

BACKGROUND AND PURPOSE

Laparoscopic sacrocolpopexy (LSCP) offers a minimally invasive treatment for vaginal vault prolapse. We describe the surgical technique and offer insight into the learning curve. In addition, we performed a case series review comparing the laparoscopic procedure with its open surgical counterpart with respect to various demographic and perioperative parameters.

PATIENTS AND METHODS

The Institutional Review Board-approved continence database at our institution was queried to identify all patients undergoing sacrocolpopexy between August 1999 and October 2004. The LSCP was performed in 25 patients, and open abdominal sacrocolpopexy (ASCP) was performed in 22 patients. Data were analyzed using Student's t-test and the Fisher exact test.

RESULTS

No significant difference was observed in the demographic characteristics of the patients undergoing the two approaches. The mean estimated blood loss (P = 0.0002) and mean length of hospitalization (P < 0.0001) were significantly less for LSCP, whereas the operative time was significantly longer (219.9 minutes v 185.2 minutes; P = 0.045). The success rate for LSCP at 5.9 months was 100%; the ASCP success rate at 11.0 months was 95%.

CONCLUSIONS

Laparoscopic sacrocolpopexy led to shorter hospitalization, better hemostasis, and less pain than the open procedure. Early follow-up suggests that LSCP is as effective as ASCP for the treatment of vaginal vault prolapse.

Bilateral extraperitoneal uterosacral suspension: a new approach to correct posthysterectomy vaginal vault prolapse

Restoration of apical vaginal support remains a challenging problem for the pelvic reconstructive surgeon. The transvaginal use of the uterosacral-cardinal ligament complex is gaining increasing popularity in the surgical treatment of uterovaginal and posthysterectomy vault prolapse. We describe an extraperitoneal surgical approach using this ligamentous complex to reattach the vaginal apex in women with posthysterectomy vault prolapse and report our surgical experience with this procedure in 123 women over 5 years. The relevant anatomy related to the procedure and risk of ureteric injury with uterosacral suspension is also reviewed. Extraperitoneal vault suspension can be combined with the use of polypropylene mesh if required. The extraperitoneal approach is an alternative procedure in women with vault prolapse with or without concomitant enterocele or where access to the Pouch of Douglas is difficult particularly after previous pelvic surgery. We believe this procedure to have less risk of ureteral injury than the intraperitoneal approach.

Morbidity associated with posterior intravaginal slingplasty for uterovaginal and vault prolapse

OBJECTIVE

This study was carried out to evaluate the safety and efficacy of posterior intravaginal slingplasty (IVS) for upper genital prolapse.

SETTING

Gynaecology Department, Benenden Hospital, Kent, UK.

MATERIALS AND METHODS

An observational study was conducted on 127 women, who underwent posterior IVS using the IVS Tunneller (Tyco HealthCare, USS, Norwalk, CT, USA). The indications for surgery were uterovaginal prolapse in 65% and vault prolapse in 35%. Patient follow-up was at 6 weeks, 6 months, 1 year and annually thereafter.

RESULTS

In addition to posterior IVS, hysterectomy was performed in 22 patients, anterior colporrhaphy in 63 patients and transobturator mid-urethral tape insertion in eight patients. The mean operating time was 46 +/- 18.5 min and for posterior IVS alone was 27.4 +/- 10 min, and the mean peri-operative drop in haemoglobin level was 1.4 +/- 0.75 gm/dL. There were no rectal, vesical or ureteric injuries. After a mean follow-up of 14 months (range 2-26 months), upper genital support was maintained in 88%, cystocele formation occurred in 8% and recurrent rectocele was seen in 11%. There was a 17% risk of tape erosion (21/127) and a re-operation rate of 24% (30/127). The risk of tape erosion was related to patient age above 60 years (RR = 1.6, 95% CI 1.02-2.5) and current treatment for diabetes (RR = 4, 95% CI 1.7-9.2). Parity, body mass index, menopausal status, HRT use, hysterectomy and surgeon's experience were not found to influence tape erosion rate.

CONCLUSION

Posterior intravaginal slingplasty is a minimally invasive procedure for upper genital prolapse with an acceptable success rate. However, the operation is associated with high vaginal erosion and re-operation rates.

Posterior intra-vaginal slingplasty for the treatment of vaginal apex prolapse: Medium-term results of 140 operations with a novel procedure

OBJECTIVES

Urogynecologists are constantly looking for simple, safe and effective ways to cure vaginal apex prolapse. A novel surgical technique, posterior intra-vaginal slingplasty (PIVS), was reported recently to include both a high therapeutic rate and a low complication rate. The present study was aimed at evaluating the preliminary data of a series of PIVS-treated patients.

STUDY DESIGN

A total of 140 patients with vaginal apex prolapse underwent the PIVS operation in a daycare setting. Pre-operative demographics, operative details and post-operative follow-up data were prospectively collected for all patients.

RESULTS

The PIVS procedure dose requires neither laparotomy nor deep transvaginal dissection as previously required for operative intervention. No intra-operative complications were recorded. The hospitalization period was relatively short. Three patients (2.1%) presented with surgical failure, whereas 137 (97.8%) of the operated patients reported satisfaction with the therapeutic results. One patient had post-operative unilateral gluteal skin infection. She was treated by surgical removal of the infected hemi-tape. Twelve (8.6%) patients had vaginal tape protrusion, of which 11 underwent segmental tape resection at the outpatient clinic. Two patients had spontaneous rejection of the tape while the vaginal apex remained well suspended. One patient suffered from post-operative fever of unknown origin, which was effectively treated with oral antibiotics.

CONCLUSIONS

The novel PIVS operation reduces the complication rate and shortens the rehabilitation period previously reported for the types of operation designed in the past to cure vaginal apex prolapse. The current list of results supports the previously reported efficacy, safety and simplicity of this procedure. However, more long-term data are required to be able to draw solid conclusions concerning the superiority of the discussed operative technique.

Conservation of the prolapsed uterus is a valid option: medium term results of a prospective comparative study with the posterior intravaginal slingoplasty operation

It has been reported that, by the age of 80, the risk of women to undergo surgery for the treatment of pelvic organ prolapse (POP) exceeds 10%, a percentage expected to increase with the rise in life expectancy. The vaginal approach for POP reconstructive operations is associated with fewer complications and results in a shorter rehabilitation period than the abdominal route, whereas hysterectomy is widely performed concomitantly whenever the uterus is significantly prolapsed. However, there is no clear evidence supporting the role of hysterectomy in improving surgery outcome. We present our experience with a new minimally invasive procedure--the posterior intravaginal slingplasty (PIVS) for correction of advanced uterine prolapse--at the same time, comparing additive vaginal hysterectomy to uterine preservation, to evaluate the therapeutic significance of hysterectomy when vaginal apical prolapse is reconstructed with PIVS. Seventy-nine women presenting with moderate to severe uterine prolapse were enrolled into the current PIVS study. Vaginal hysterectomy was concomitantly performed upon patient's request (44 patients), whereas those wishing to preserve their uterus underwent reconstructive surgery only (35 patients). No intraoperative or postoperative major complications were recorded during an average follow-up of 29.8 months: One patient (1.3%) presented with surgical failure, whereas 71 (89.9%) of the operated patients reported satisfaction with the therapeutic results. Bladder overactivity symptoms declined from three thirds of the patients preoperatively to below 10% postoperatively. Ten (12.7%) patients had vaginal tape protrusion; all underwent segmental tape resection at the out-patient clinic. Because the PIVS procedure does not require either laparotomy or deep transvaginal dissection, as previously required for operative intervention, the hospitalization period was relatively short: 4.2 days for the hysterectomy group and 1.5 for the non-hysterectomy group. Other statistically significant differences between the hysterectomy and non-hysterectomy groups were the average ages (63.5 vs 51.0 years, respectively) and concomitant surgery (87% vs 69%, respectively, the higher percentage due to additive amputation of elongated uterine cervices). No other significant differences were recorded. The current results support the previously reported efficacy, safety, and simplicity of the PIVS procedure as well as the legitimacy of uterine preservation. Moreover, unstable bladder symptoms were found to be improved after this operation. However, long-term data are required to be able to draw solid conclusions concerning the superiority of the discussed operation.

Relationship of the uterosacral ligament to the sacral plexus and to the pudendal nerve

We describe the anatomy of the uterosacral ligament with respect to the sacral plexus. In six adult female embalmed cadavers, we identified the uterosacral ligament and its lateral nerve relations. Using the ischial spine as the starting point and measuring along the axis of the uterosacral ligament, we noted that the S1 trunk of the sacral plexus passes under the ligament 3.9 cm [95% confidence interval (CI), 2.1-5.8 cm] superior to the ischial spine. The S2 trunk passes under the ligament at 2.6 cm (95% CI; 1.5, 3.6 cm), the S3 trunk passes under the ligament at 1.5 cm (95% CI; 0.7, 2.4 cm), and the S4 trunk passes under the ligament at 0.9 cm (95% CI; 0.3, 1.5 cm) superior to the ischial spine. The pudendal nerve forms lateral to the uterosacral ligament. Our data demonstrate that the S1-S4 trunks of the sacral plexus, not the pudendal nerve, are vulnerable to injury during uterosacral ligament suspension.

[Application of transvaginal sacrospinous colpopexy in the treatment of pelvic organs prolapse]

INTRODUCTION

The incidence of uterovaginal and vaginal vault prolapse appears to be higher due to the increased longevity of women. Sacrospinous ligament colpopexy is a surgery procedure which suspends the vagina up to the sacrospinous ligament and brings upper vagina over the levator plate. This technique is very useful for the primary treatment of uterovaginal prolapse in young women who want to preserve their fertility. The main aim of our study was to present the effectiveness of the us of this technique at our clinic, to investigate the possible intraoperative and postoperative complications of this technique, and to find out its effectiveness in the prevention of repeated vaginal vault prolapse.

METHODS

Patients were treated with sacrospinous colpopexy with uterine conservation, vaginal hysterectomy with simultaneous sacrospinous colpopexy or obliteration of the enterocele sac, and sacrospinous colpopexy. Follow-up examinations of the patients we performed at 4 weeks, 6 months and 12 months after the surgery and yearly thereafter.

RESULTS

Thirty-seven women were treated with sacrospinous ligament suspension of vaginal vault. The 5 women had vault prolapse following the hysterectomy (the 3 of then had abdominal, and the 2 vaginal hysterectomy), and another 32 women had the various degrees of uterovaginal prolapse. We obtained satisfactory results in 33 patients, in the 3 we noticed asymptomatic cystocele, and the 1 (2.7%) had partial vaginal vault prolapse six months after the surgery. With regard to postoperative complications, 3 patients had Urination disturbance, 3 patients had urinary tract infection, 2 patients had febrile temperature, and the 2 patients had low back pain.

DISCUSSION

We performed sacrospinous fixation on the right side, and the postoperative results demonstrated no disturbance in vaginal axis and vault prolapse except in 1 patient. We had no intraoperative complications noted related to sacrospinous ligament colpopexy, such as the damage to the pudendal vessels and nerve, the sciatic nerve and rectum. The possibility of injury to the vessels and nearby nerves was preventid with the careful placement of suture through the sacrospinous ligament in the two fingerbreadths medial to its insertion in the ischial spine. In our series, we had 3 patients with conservation of the uterus. The 3 asymptomatic cystocele in our series were diagnosed 6 months after the operation. Our results were satisfactory, since we hade only one postoperative vault prolapse (2.7%).

CONCLUSION

The results of numerous studies, as well as the results of our study, showed that transvaginal sacrospinous colpopexy could be performed along with vaginal hysterectomy and the anterior and posterior vaginal wall repair in the patients with uterovaginal prolapse because of its high success in the prevention of postoperative vaginal vault prolapse and the low intra- and postoperative complication rates. This operative technique is successful in prevention of repeated vaginal vault prolapse.

Laparoscopic techniques for the repair of vaginal vault prolapse: determining if less is more

Repair of vaginal vault prolapse remains a surgical challenge. Abdominal, vaginal, and combined procedures have been described. The ideal operation remains elusive with regard to outcomes, morbidity, and economics. As an extension of the abdominal approach, laparoscopy continues to gain favor as an access method and as a surgical advancement. Recent studies highlight a number of laparoscopic techniques for restoration of apical support that demonstrate feasibility and encouraging results. Further study is necessary to determine if the minimally invasive nature of laparoscopy can duplicate or surpass standard abdominal and vaginal approaches to the repair of pelvic organ prolapse.

Improved surgical outcome by modification of porcine dermal collagen implant in abdominal wall reconstruction in rats

AIM

We earlier showed in rats that fascial repair with Pelvicol, a porcine dermal collagen implant, was associated with a lesser inflammatory response but lower tensile strength in the early postoperative period as compared to Prolene. Herein we wanted to evaluate whether creation of pores in Pelvicol, facilitating ingrowth of fibrous tissue and vessels, would result in a higher tensile strength at d30 without compromising longer term results.

METHODS

First tensile strength of Pelvicol modified with different pore sizes was evaluated ex vivo. In a second step, Pelvicol implants with pores were used to cover full-thickness abdominal wall defects in 36 rats. Implants were either Pelvicol (non-porous) or with pores of Phi : 0.7, 1.2, or 2.0 mm (n=6 each). Animals were sacrificed on d30 and 90 to evaluate the presence of herniation, infection, adhesions, change in thickness and tensile strength. Histopathology was performed to assess inflammatory response and collagen deposition. Data were compared to available data on Prolene implanted animals at same time points.

RESULTS

Pelvicol with pore diameter of 2.5 mm was significantly weaker ex vivo. Animals repaired with non-porous material did develop seroma (2/6) or clinical infection (1/6) whereas none in the other groups did. There was a trend for increasing tensile strength at 30 d with increasing pore diameter, being significant in the 2.0-mm pore size group. This difference disappeared by 90 d, where all materials were equally strong as Prolene. The foreign body reaction was less intense in a pore-size dependent manner, with more abundant neo-vascularization and collagen deposition passing through the pores.

CONCLUSION

Creation of pores in Pelvicol promotes neo-vascularization, collagen deposition, and fibrous tissue ingrowth, and at pore size 2.0 mm tensile strength was increased at d30 whereafter all materials had comparable strength.

Surgical techniques for vault prolapse: a review of the literature

We searched MEDLINE for articles indexed between 1972 and 2002 and dealing on operative techniques for vault prolapse. We found 149 articles describing, variously, abdominal sacrocolpopexy with mesh (2008 patients), other transabdominal methods (387 patients), sacrospinous ligament fixation (2390 patients), other transvaginal repairs (1556 patients), laparoscopic procedures (128 patients), intravaginal sling (168 patients) and vaginal obliteration techniques (157 patients). For each of these procedures there is a short presentation of the operative technique and a summary of all published data on concomitant surgery, complications and follow-up results relating to anatomical and functional outcome. Two procedures are more frequently used than the others: abdominal sacrocolpopexy and transvaginal sacrospinous ligament fixation. We were unable to detect any differences in the complication and/or cure rates, but did find a slightly better long-term anatomical outcome after the abdominal technique. Since no standardized outcome measure is available it is difficult to compare the functional results. Only in more recent studies have subjective cure rates (patient satisfaction with the outcome) also been evaluated as well as the objective cure rates determined by the investigators, and the objective and subjective rates are not necessarily the same. The subjective cure rate is probably more strongly influenced by the functional outcome in terms of micturition, defaecation and sexual activity than by the anatomical result.

Fortentwickelte Konzepte zur weiblichen (In-)Kontinenz

The integral theory postulates that defect ligaments and fascias, which impair the supporting function of the vaginal wall, can cause stress urinary incontinence as well as urgency and voiding dysfunction. The anatomical and pathophysiologic basis for these dysfunctions are presented. Voiding dysfunctions can be treated by the substitution of defect structures using the principle of "restoration of structure leads to restoration of function". Essential elements of this therapeutic algorithm are suburethral vaginal slings (retropubic or transobturatoric), further a posterior sling, which runs through the fossa ischiorectalis and suspends the vaginal vault near the sacrospinal ligaments, thus reconstructing defect uterosacral ligaments. In cystoceles, lateral and medial defects can be restored by ventral meshes, which are fixed at the arcus tendineus fasciae pelvis by lateral transobturatoric slings. The use of polypropylene slings and meshes is well-founded because they are well tolerated in the tissues and through the development of scar tissue lead to neoligaments with long-lasting therapeutic effects.

[Cystocele repair by vaginal approach with a tension-free transversal polypropylene mesh. Technique and results]

OBJECTIVE

To evaluate mid term results, tolerance and efficiency of interposition of a tension-free polypropylene monofilament mesh by vaginal approach for the repair of cystoceles.

PATIENTS AND METHODS

Fourty consecutive women underwent this new procedure between March 2001 and September 2002. After complete dissection of the cystocele, the polypropylene mesh (Gynemesh), Gynecare, Ethicon, Johnson & Johnson, France), proper cut-out was positioned under the bladder without any fixation. The lateral extensions of the mesh where introduced in the para-vesical spaces in contact with the arcus tendinus fascia pelvis.

RESULTS

Before surgery all patients had cystocele of more or equal than grade II according to the POP-Q classification. Eight had grade II cystocele (20%) and 32 had grade III cystocele (80%). Thirty women had associated posterior or median prolapse (82.5%). Thirty women had urinary incontinence (75%). Mean age was 63.9 years (51-78). The procedure was performed without any difficulty in all cases. Duration of a cystocele cure procedure was 20 min +/- 2.2 (16-24). Mean follow-up is 16.4 months +/- 4.7 (12-24). The early complication rate was 7.5% (two vaginal erosions and one complete exposition of the mesh which requires secondary ablation). There was no mesh infection. The success rate was 95%. The satisfaction index overpasses 80% in 95% of our patients 6 months after the cystocele repair.

DISCUSSION AND CONCLUSIONS

The interposition of a sub-vesical transversal tension-free polypropylene mesh by the vaginal route seems to be an excellent procedure in the definitive surgical treatment of grades II and III anterior vaginal wall prolapse. This new procedure is simple, mini-invasive, reproducible and efficient with low morbidity and good tolerance.

Laparoscopic repair of vaginal vault prolapse

PURPOSE OF REVIEW

Currently, the two laparoscopic techniques available and described in the literature for the treatment of vaginal vault prolapse are uterosacral ligament vault suspension and sacrocolpopexy. These two techniques are opposing each other fundamentally. While the first is reconstructive, the second is essentially palliative.

RECENT FINDINGS

In both methods the surgeon starts with the identification and dissection of the pubocervical and rectovaginal fascia. In the first technique however, the new vaginal vault, made by re approximation of the two fasciae, is attached to the uterosacral complex, while in the second one, each fascia is suspended from the sacral promontorium, using a mesh. In review of the existing literature, it seems that the palliative surgical approach is more successful in the long term, giving a cure rate of approximately 92%, probably as it involves using mesh instead of the native tissue.

SUMMARY

In this article we discuss the laparoscopic techniques available currently, analyse their results, discuss their differences and compare them with other non-laparoscopic techniques. Finally, we discuss the different options described, and offer some guidelines for the future of laparoscopic treatment of pelvic prolapse.

Anatomical correction of vaginal vault prolapse by uterosacral ligament fixation in women who also require a pubovaginal sling

PURPOSE

We describe the anatomical and functional outcome in patients who underwent vaginal vault fixation to the proximal uterosacral ligaments for the treatment of vault prolapse and who also required a concomitant pubovaginal sling for associated stress urinary incontinence as well as the repair of other sector defects.

MATERIALS AND METHODS

We retrospectively analyzed the records of 33 patients who underwent such repairs between November 1998 and December 2001. Endopelvic fascial defects were described using the pelvic organ prolapse quantitative system (POPQ). Outcome measures included anatomical and functional assessment of pelvic floor defects and urinary incontinence.

RESULTS

Preoperatively all patients complained of a vaginal bulge and stress urinary incontinence, while 17 of the 33 had urge incontinence, and 24 and 9 had POPQ stage III or IV and stage II prolapse, respectively. Mean followup was 28 months (range 6 to 43). There was significant improvement in all POPQ measurements (p <0.05). Most notably vaginal cuff support improved by a mean of 7 cm. Stages IIAp (rectocele) and IIC (cuff) prolapse developed in 4 and 2 failed cases, respectively. Stress urinary incontinence was cured in all 33 patients and urge incontinence was cured in 14 of 17, while in 27 vaginal prolapse symptoms resolved and most had improved defecation dysfunction. No patients had urinary obstructive symptoms. There were no ureteral, bladder or rectal complications but 1 patient required blood transfusion.

CONCLUSIONS

Suspension of the vaginal cuff to the proximal uterosacral ligaments with site specific repair of other associated endopelvic fascial defects provides excellent anatomical and functional correction of vault prolapse. Furthermore, a concomitant pubovaginal sling is a compatible repair for associated stress urinary incontinence. It did not compromise vaginal repair and prolapse repair did not jeopardize the outcome of the sling.