Laparoscopic Mesh-Less Cervicosacropexy for Uterovaginal Prolapse

Novel Vaginal Cerclage Assisted Laparoscopic Cervico-Sacropexy Technique for Uterovaginal Prolapse

AIM

Laparoscopic hysteropexy is a complicated procedure that requires specialized surgical skills, including precise dissection and suturing. The aim is to describe the technical considerations for performing a new, feasible, and minimally invasive technique to correct apical and concurrent apical and anterior vaginal wall defects.

METHOD

A retrospective analysis was conducted on 70 consecutive women who underwent surgery for stage ≥3 uterovaginal prolapse. As a part of the technique, an anterior 2-cm long transverse incision was made at the anterior cervicovaginal junction, and the bladder was dissected through blunt and sharp dissection to the level of the isthmus. A posterior colpotomy was performed. A polypropylene tape was inserted into the cervical connective tissue, and the free arms of the tape were inserted into the peritoneum via the posterior colpotomy. Two arms of the tape were passed from the tunnel parallel and medial to a right sacrouterine fold, then fixed to the anterior longitudinal ligament via the laparoscopic route.

RESULTS

The tape can be inserted into the cervix in a median of 15 min, and the laparoscopy procedure can be completed in 24 min. No mesh erosion or long-term complications occurred. At a 1-year control, there were no cases of recurrence.

CONCLUSIONS

This novel cervico-sacrocolpopexy technique is a feasible and safe, minimally invasive way to correct apical or multicompartment defects, with a short operation time and an anatomical result that mimics the normal sacrouterine ligament.

A Randomised Trial on the Effects of the Addition of Uterosacral Ligament Plication to Pectopexy Operation on Anatomical Restoration and Female Sexual Functions

INTRODUCTION AND HYPOTHESIS

The objective was to determine whether the addition of uterosacral ligament plication to pectopexy for pelvic organ prolapse increases anatomical improvement and female sexual functioning.

METHODS

This is a prospective randomised study. Forty patients who underwent laparoscopic pectopexy (LP) and laparoscopic pectopexy with uterosacral ligament plication (LPUSL) were included in the study. A total of 38 patients were evaluated in the study. Patients were assessed by the Pelvic Organ Prolapse Quantification (POP-Q) system and the patients who had symptomatic apical prolapse POP-Q ≥ II were included in the study. Patients were evaluated preoperatively and postoperatively at the 3rd, 6th and 12th month, with respect to anatomical changes as well as sexual function.

RESULTS

A statistically significant difference was found when the preoperative C points was compared with the C points postoperatively, at 3rd, 6th and 12th months in both the LP and LPUSL groups (p < 0.001). Additionally, there were statistically significant difference between the LP and LPUSL groups in terms of C and Aa points at the 6th and 12th postoperative months in favour of the LPUSL group (p = 0.007, p = 0.005 respectively). There was also a statistically significant difference when Ba points were compared between the two groups at the 12th postoperative month, in favour of the LPUSL group (p = 0.002). There were no statistically significant differences between the groups with respect to the variables of the Female Sexual Function Index. Additionally, all parameters were significantly better in both groups at the 3rd and 12th months than the preoperative values in post hoc analysis; only desire also had a significant improvement between the 3rd and 12th months in the LPUSL group in post hoc analysis.

CONCLUSION

Pectopexy operation seems to be a successful surgical approach as an alternative to sacrocolpopexy. The addition of uterosacral ligament plication to pectopexy operation improves the anatomical restoration more drastically than with LP on its own. Moreover, either LP or LPUSL has improved the majority of sexual function indices.

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.

Quality of Sexual Life after Native Tissue versus Polypropylene Mesh Augmented Pelvic Floor Reconstructive Surgery

There are still controversies around reconstructive surgeries used in POP treatment. The aim of this study was to compare the QoSL after VNTR vs. TVM surgery due to POP via the use of PISQ-12 and FSFI questionnaires. The study included a group of 121 sexually active patients qualified for reconstructive surgery due to symptomatic POP, and 50 control. The average results of PISQ-12 before and after surgery were compared using the t-test. The significance of the mean differences in demographic groups was measured using the t-test for independent samples and one-way ANOVA. The results in the demographic groups were compared using the Mann–Whitney U test and the Kruskal–Wallis test. Fifty-eight women had VNTR, while 63 had TVM. Results of PISQ-12 revealed significant improvement in the sexual life after reconstructive surgery (27.24 vs. 32.43; p < 0.001, t = 8.48) both after VNTR and TVM. There were no significant differences in the assessment of the QoSL according to PISQ-12 and FSFI results between both analyzed groups of patients (PISQ-12: VNTR vs. TVM; t-test p = 0.19 and FSFI: VNTR vs. TVM; Mann–Whitney U test p = 0.54). VNTR is the treatment of choice in the case of uncomplicated primary POP.

International Urogynecology Consultation Chapter 1 Committee 5: relationship of pelvic organ prolapse to associated pelvic floor dysfunction symptoms: lower urinary tract, bowel, sexual dysfunction and abdominopelvic pain

INTRODUCTION AND HYPOTHESIS

This article from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) establishes the prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP.

METHODS

An international group of nine urogynecologists/urologists and one medical student performed a search of the literature using pre-specified search terms in Ovid, MEDLINE, Embase and CINAHL from January 2000 to March 2019. Publications were eliminated if not relevant or they did not include clear definitions of POP or the symptoms associated with POP. Definitions of POP needed to include both a physical examination finding using a validated examination technique and the complaint of a bothersome vaginal bulge. Symptoms were categorized into symptom groups for ease of evaluation. The Specialist Unit for Review Evidence (SURE) was used to evaluate for quality of the included articles. The resulting list of articles was used to determine the prevalence of various symptoms in women with POP. Cohort studies were used to evaluate for possible causation of POP as either causing or worsening the symptom category.

RESULTS

The original search yielded over 12,000 references, of which 50 were used. More than 50% of women with POP report lower urinary tract symptoms. Cohort studies suggest that women with POP have more obstructive lower urinary tract symptoms than women without POP. Pain described in various ways is frequently reported in women with POP, with low back pain being the most common pain symptom reported in 45% of women with POP. In cohort studies those with POP had more pain complaints than those without POP. Sexual dysfunction is reported by over half of women with POP and obstructed intercourse in 37-100% of women with POP. Approximately 40% of women have complaints of bowel symptoms. There was no difference in the median prevalence of bowel symptoms in those with and without POP in cohort studies.

CONCLUSIONS

The prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP are common but inconsistently reported. There are few data on incidence of associated symptoms with POP, and cohort studies evaluating causality are rare or inconsistent. Obstructive voiding, lower abdominal and pelvic pain, and sexual dysfunction are most frequently associated with POP.

Laparoscopic cervicopexy for correction of apical genital prolapse in 10 steps: a pilot study

INTRODUCTION

Surgical repair of pelvic organ prolapse is one of the most frequent gynecological procedures, and its frequency is expected to increase as the population is gradually aging. Mesh use in urogynecological surgery should be limited because of important and life-treating complications. Sacral mesh-less and lateral procedures have been described as safe and effective to treat apical compartment prolapse. In this video, we describe a new laparoscopic mesh-less cervicopexy in women with symptomatic uterovaginal prolapse who did not desire uterine preservation.

METHODS

Eleven women with symptomatic uterovaginal prolapse [stage 2 or higher according to the Pelvic Organ Prolapse Quantitative (POP-Q) classification system] underwent laparoscopic mesh-less cervicopexy to the sacrum and transverse fascia between May 2018 and June 2019. We performed application of the right uterosacral ligament starting from the sacrum and two semicontinous sutures including the transverse fascia, round ligament, prevescical peritoneum, pubocervical fascia and cervix that were subsequently knotted.

RESULTS

At 6-month follow-up, the objective success rate for apical prolapse (POP-Q score C > -1) was 90.9% (10/11 women). Only one woman presented stage 3 apical prolapse recurrence with vaginal buldge.

CONCLUSION

Laparoscopic mesh-less cervicopexy for uterovaginal prolapse seems to be a feasible surgical technique at 6-month follow-up.

A Meshless Practical Laparoscopic Sacrohysteropexy Modification and Long-term Outcomes

STUDY OBJECTIVE

To describe a new modification of laparoscopic sacrohysteropexy without using a mesh and report the 3-year outcomes.

DESIGN

A prospective cohort study.

SETTING

Minimally Invasive Gynecology Unit, Bursa Uludag University Hospital, Turkey.

PATIENTS

Women who were diagnosed with ≥ stage 2 uterine prolapse.

INTERVENTIONS

A laparoscopic sacrohysteropexy modification using a polyester fiber suture instead of a standard polypropylene mesh.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the anatomic success of the repair, with success defined as objective parameters using the pelvic organ prolapse quantification system. The secondary outcomes were subjective outcomes, which were assessed using the quality-of-life scales. Forty-seven women who underwent the procedure were followed up for a minimum of 3 years. Forty-four of the 47 patients had stage 0 or 1 prolapse at the end of the second year, according to the primary outcomes. The anatomic success rate was 93.6%. In the secondary outcomes, 2 patients were not satisfied with their pelvic floor after the second year. The subjective cure rate was 95.7%. There was a statistically significant improvement in both pelvic organ prolapse quantification and quality-of-life scores in the third postoperative year. The mean operating time was 84.6 minutes, and the mean estimated blood loss was 21.3 mL. There were no bladder or bowel complications in the perioperative or postoperative period.

CONCLUSION

Laparoscopic sacrohysteropexy can be performed safely with this meshless modification in uterine prolapse as an alternative.