Laparoscopic management of incontinence and pelvic organ prolapse

Mini-laparoscopic sacrocolpopexy for apical and posterior female pelvic organ prolapse

AIM OF THE VIDEO

Mini-laparoscopic surgery is the future for most laparoscopic procedures. Although already applied in some gynaecological surgical interventions, this video is to our knowledge the first publication on the use of the mini-laparoscopic approach to sacrocolpopexy for apical and posterior pelvic organ prolapse following total hysterectomy.

METHODS

The concept of mini-laparoscopic sacrocolpopexy presented in this video article was performed on 12 women with post-hysterectomy apical and posterior pelvic organ prolapse using mini-laparoscopic instruments and ports of 3 mm in diameter combined with a 12-mm umbilical port. Surgery was performed with the same principles as for the conventional laparoscopic procedure.

RESULTS

The mean operating time was 70 min (SD ± 12). The tensile strength of the mini-laparoscopic instruments allowed appropriate manipulation of tissue consistent with that of conventional instruments. No difficulties or complications were experienced in comparison to a conventional technique. All patients were discharged from hospital on day 1 postoperatively.

CONCLUSIONS

The effectiveness, safety and feasibility of the mini-laparoscopic surgical technique was applied to sacrocolpopexy. Because of the initial favourable experience, the mini-laparoscopic sacrocolpopexy could become more widely used in the future.

Bilateral isolated Epididymal Agenesis in a 32 year old man

Laparoscopy began to be used widely since the second half of 1990s as an alternative to laparotomy or vaginal approaches in incontinence and pelvic diseases in women, based on its claimed better success rates. Injuries were reported in the bladder, gastrointestinal system and the entry of the Verress cannula in early and late laparoscopic applications. De-novo urging, voiding dysfunctions, marked recurrences and surgical inefficiencies were observed in 5-year follow-ups after laparoscopic incontinence surgery. Although tension-free midurethral sling operations replaced open laparoscopic colposuspensions nowadays, laparoscopic colposuspension is still preferred in cases where simultaneous laparoscopic paravaginal repair or sacrocolpopexy is considered or where synthetic graft implantation is contraindicated. Moreover, meshes and endotackers are still frequently used in many laparoscopic applications in various clinics. The migration of the tacker used in mesh fixation in a patient where retroperitoneal laparoscopic Burch was performed 7 years ago due to stress urinary incontinence and the extraction of the ossified tacker from the bladder will be presented.

Is de novo stress incontinence after sacrocolpopexy related to anatomical changes and surgical approach?

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the relationship between new onset postoperative stress urinary incontinence (SUI) after sacrocolpopexy (SCP) and anatomical change/surgical approach.

METHODS

We analyzed a retrospective cohort of patients with negative preoperative testing for SUI who underwent SCP from 2005 to 2012. Our primary outcome was new onset postoperative SUI. Logistic regression was used to examine the relationship among anatomical change, defined as ΔAa, ΔBa, ΔC, and ΔTVL, and surgical approach, categorized as abdominal (ASCP) for open cases and minimally invasive (MISCP) for laparoscopic and robot-assisted cases, and postoperative SUI.

RESULTS

Of 795 cases, 33 ASCP (43%) and 44 MISCP (57%) met the inclusion criteria for analysis. New onset SUI was demonstrated by 15 patients (45%) of the ASCP group and 7 patients (15%) of the MISCP group (p = 0.005). New onset SUI was significantly associated with route of SCP and ΔAa (p = 0.006 and p = 0.033 respectively). Controlling for ΔAa, the odds of new onset SUI were 4.4 times higher in the ASCP group compared with the MISCP group (OR 4.37, 95% CI 1.42, 13.48). Controlling for route of SCP, the odds of new onset SUI were 2.2 times higher with moderate ΔAa compared with low ΔAa (OR 2.16 95% CI 1.07, 4.38). The odds of new onset SUI was 4.7 times higher in those with high ΔAa than in those with low ΔAa (OR 4.67 95% CI 1.14, 19.22). ΔBa, ΔC, and ΔTVL were not associated with new onset SUI.

CONCLUSIONS

Greater reduction in point Aa and abdominal surgical route are risk factors for new onset postoperative SUI after SCP.

Apical vaginal prolapse surgery: practice patterns and factors guiding route of repair

OBJECTIVES

Describe current trends for repair of primary and recurrent apical vaginal prolapse using 4 different approaches, namely, transvaginal native (TVN) tissue, transvaginal using graft, laparotomy, or laparoscopic/robotic, and to determine which factors influence decision for favored approach.

METHODS

A 15-item survey was distributed to attendees of the 2011 Society of Gynecologic Surgeons meeting. Demographic data and percentages of routes of repair were collected. Twenty factors were graded on the importance for influencing surgical approach.

RESULTS

Transvaginal native tissue was the preferred route for primary repair (mean, 53.0%), and laparoscopic/robotic for recurrent repair (33.8%). Surgeons in academic practices, without formal postresidency training, and with lower surgical volumes were more likely to elect TVN for primary repair than alternatives. Important factors in selection of surgical approach included patient age and severity of medical comorbidities.

CONCLUSIONS

Among the Society of Gynecologic Surgeons meeting attendees, TVN is the preferred primary route for apical prolapse repair. Laparoscopic-assisted repairs are more common for recurrent prolapse.

Combined Burch urethropexy and anterior rectopexy in pelvic organ prolapse: skip the mesh

PURPOSE

Pelvic organ prolapse (POP) is a common accompaniment of advancing age. Current repair techniques incorporate transvaginal and transabdominal approaches with or without prosthetic mesh insertion. In this paper, we present the short- and medium-term results of a unit policy directed at patients with POP of combined abdominal rectopexy and Burch retropubic urethropexy without the use of prosthetic mesh assessing its safety profile in selected cases.

METHODS

Between January 2009 and January 2011, 16 women with tri-compartmental prolapse who had all undergone prior hysterectomy underwent combined surgical pelvic floor repair. Preoperative symptom assessment by validated questionnaires and clinical examination were pre- and postoperatively recorded. Cures were defined as either optimal or satisfactory outcomes based on combined clinical, radiological examinations and reported patient satisfaction.

RESULTS

The mean age of the 16 patients was 57.2 years, and their mean BMI was 28.6 (±5 SD). Pelvic examination revealed a POP-Q stage III prolapse in 12 patients and stage IV in 4 patients. The mean operating time was 57.5 min (range 40-85), with a mean length of hospital stay of 4.5 days. Cystocele and enterocele resolution was noted in every case on dynamic magnetic resonance imaging (MRI).

CONCLUSIONS

Our results in a small patient cohort employing a simple 'all-in-one' repair approach combining a retropubic colposuspension with an anterior rectopexy appear to be satisfactory. Further larger randomized studies are required, incorporating a laparoscopic arm in order to determine the longer-term effectiveness of this approach.

Case report: a novel method for uterine-sparing hysteropexy

OBJECTIVE

The objective of this study was to describe a technique for uterine-sparing hysteropexy.

CASE REPORT

A 50-year-old multiparous woman with pelvic organ prolapse underwent laparoscopic sacrohysteropexy utilizing polypropylene mesh with good clinical result.

CONCLUSIONS

Placement of mesh arms medial to the uterine vessels during a laparoscopic sacrohysteropexy can be facilitated by using blunt needles to introduce the mesh arms.