Nerve preserving vs standard laparoscopic sacropexy: Postoperative bowel function

Pelvic anatomy in laparoscopic surgery for pelvic organ prolapse: dissect your success

Background

Laparoscopic surgery for pelvic organ prolapse is a complex procedure, requiring high technical skills and great knowledge of the anatomy to perform a safe dissection and achieve the best clinical and surgical outcomes.

Objectives

To highlight the anatomical landmarks during dissection in this procedure and give tips for a safer and more effective performance.

Materials and Methods

Surgical videos of the dissection involved in laparoscopic surgery for pelvic organ prolapse in a stepwise approach.

Main outcome measures

Identification of the most important anatomical landmarks involved in the dissection of the promontory, the para-rectal space, the recto-vaginal space, and the vesico-vaginal space. Advice for acquiring better exposure and the right cleavage planes. Presentation of some difficult cases during dissection.

Results

Step-by-step overview of the different steps of dissection involved in laparoscopic surgery for pelvic organ prolapse, specifying the most important anatomical landmarks for reference and at risk of damage and presenting tips to correctly perform the dissection.

Conclusion

Besides the great surgical technical skills required, deep knowledge of pelvic anatomy is key for performing laparoscopic surgery for pelvic organ prolapse safely, minimising complications and recurrence and improving quality of life and the overall success of surgery.

Robot-assisted sacro(hystero)colpopexy with anterior and posterior mesh placement: impact on lower bowel tract function and clinical outcomes at mid-term follow-up

Background:

Robotic sacrocolpopexy (RSCP) is an established option for the treatment of apical, anterior, and proximal posterior compartment pelvic organ prolapses (POP). However, there is lack of evidence investigating how lower bowel tract symptoms (LBTS) may change after RSCP.

Methods:

Data from consecutive patients treated with RSCP for stage 3 or higher POP from 2012 to 2019 at a single tertiary referral center with at least 1 year of follow-up were prospectively collected and retrospectively analyzed. RSCP was performed following a standardized technique which always employed both anterior and posterior hand-shaped meshes. Outcomes were collected at follow-up and analyzed. LBTS were evaluated through the Wexner questionnaire.

Results:

Overall, 114 women underwent RSCP. Eleven were excluded for missing data, whereas 12 had insufficient follow-up. Thus, 91 (79.8%) patients were included in this cohort. Median follow-up was 42 [interquartile range (IQR), 19–62] months. Mean age was 65 ± 10 years. In our series, RSCP was mainly performed for anterior and apical/medium stage 3 POP (in 95.6% of patients). Anatomic success rate of RSCP was 97.8%, with 89 patients with POP stage 0–1 at 12-month follow-up. Two patients (2.2%) experienced POP recurrence and were treated with redo-SCP. No patient experienced clinically significant posterior vaginal wall prolapse after RSCP. When analyzing LBTS, there was no significant change in postoperative total Wexner’s score as compared to the preoperative value ( p > 0.05). However, the manual assistance subscore was statistically significantly lower within the first-year follow-up ( p = 0.04), but it spontaneously improved during the follow-up ( p = 0.12).

Conclusion:

RSCP with simultaneous placement of both anterior and posterior mesh is safe and successful to treat high-stage POP in carefully selected patients. Of note, LBTS appear unaffected by posterior mesh placement, supporting its routine use to prevent posterior POP recurrence. Larger prospective studies are needed to confirm our results.

Medium term anatomical and functional outcomes following modified laparoscopic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

We evaluated the anatomical and functional outcomes following modified laparoscopic sacrocolpopexy (LSC) utilizing deep dissection of the vaginal walls and distal mesh fixation at the anterior and posterior compartments. We hypothesized that anatomical and functional outcomes improve after this modified LSC technique.

METHODS

This was a retrospective study of all women (n = 240) who underwent LSC for pelvic organ prolapse (POP) from January to December 2017 in a tertiary center. POP-Q staging, validated questionnaires (International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF] and Pelvic Floor Distress Inventory Questionnaire-Short Form), and uroflowmetry were used to evaluate the anatomical and functional outcomes. Statistical analyses were performed using McNemar test and repeated measures analysis of variance with Fisher's least significant difference post hoc (p < 0.05).

RESULTS

The anatomical success rate is 96%, with a prolapse recurrence rate of 3.8% at 3-year follow-up. Bulge symptoms and anatomical compartments were significantly improved after LSC. Clinically, there were significant improvements after LSC in voiding dysfunction and bowel symptoms. Also, there was a significant increase in stress urinary incontinence and non-significant decrease in mixed urinary incontinence and urge urinary incontinence. ICIQ-SF and Colorectal-Anal Distress Inventory 8 scores were significantly lower after LSC, signifying improvement in incontinence and bowel symptoms.

CONCLUSION

Our modified LSC technique is safe and effective in restoring level 1 and level 2 supports, without adverse effects on urinary and bowel function. Bladder and bowel symptoms have also been found to keep improving over time.

An Anatomical Clue for Minimizing Iliac Vein Injury During the Anterolateral Approach at L5-S1 Level: A Cadaveric Study

Objective

The injury to the common iliac vein (CIV) seems to be the most important concern during the anterior approach to the spine at L5–S1 level. We investigated the anatomy of the L5–S1 vertebral structures related to the CIV through a cadaveric study to find an anatomical clue for safe dissection of CIV.

Methods

Ten cadavers were prepared for this study. After removing the peritoneum and the presacral fascia, the section from the lower part of the L5 to the upper part of the S1 vertebral body was removed with the CIV attached. After decalcification, 2 sections in the vertical and horizontal directions were made for histological study.

Results

An adipose tissue layer was present between the intervertebral disc and CIV. The adipose tissue layer in 6 cadavers was thin, and in 3 of these cadavers, the CIV was attached to the vertebral body and the disc. In the other 4 cadavers, the CIV was clearly separated from the vertebral body and the disc by the intervening adipose tissue layer (IATL). Under the microscope, a thin layer surrounding the anterior longitudinal ligament, periosteum, and disc was observed, and we named this structure the ‘perivertebral membrane.’ The perivertebral membrane was attached to the CIV when there was no IATL, but a potential space was detected under the membrane.

Conclusion

There was a thin membrane, perivertebral membrane, between the CIV and L5–S1 disc. In cases with CIV adhesion to the disc due to the absence of IATL, the CIV may be mobilized indirectly through the perivertebral membrane.

Nerve-sparing in Gynecologic Surgery: A Perspective

OBJECTIVE

To provide a perspective on nerve-sparing (NS) surgery in gynecology.

DATA SOURCES

Literature review, English language.

METHODS OF STUDY SELECTION

Systematic reviews and meta-analyses studies were selected for review for oncology; comparative studies were selected for endometriosis, and 1 comparative and 1 prospective study were chosen for sacrocolpopexy.

TABULATION, INTEGRATION, AND RESULTS

Two tables summarize the results of systematic reviews and meta-analyses in oncology. Oncology, endometriosis, and urogynecology sections. Primary benefit of NS technique is decreased bladder dysfunction, and, to a lesser degree, vaginal and rectal dysfunc.

CONCLUSION

NS is preferable to conventional surgery for benign and malignant conditions to reduce postoperative bladder, rectal, and vaginal dysfunction.

A simplified fascial model of pelvic anatomical surgery: going beyond parametrium-centered surgical anatomy

The classical surgical anatomy of the female pelvis is limited by its gynecological oncological focus on the parametrium and burdened by its modeling based on personal techniques of different surgeons. However, surgical treatment of pelvic diseases, spreading beyond the anatomical area of origin, requires extra-regional procedures and a thorough pelvic anatomical knowledge. This study evaluated the feasibility of a comprehensive and simplified model of pelvic retroperitoneal compartmentalization, based on anatomical rather than surgical anatomical structures. Such a model aims at providing an easier, holistic approach useful for clinical, surgical and educational purposes. Six fresh-frozen female pelves were macroscopically and systematically dissected. Three superficial structures, i.e., the obliterated umbilical artery, the ureter and the sacrouterine ligament, were identified as the landmarks of 3 deeper fascial-ligamentous structures, i.e., the umbilicovesical fascia, the urogenital-hypogastric fascia and the sacropubic ligament. The retroperitoneal areolar tissue was then gently teased away, exposing the compartments delimited by these deep fascial structures. Four compartments were identified as a result of the intrapelvic development of the umbilicovesical fascia along the obliterated umbilical artery, the urogenital-hypogastric fascia along the mesoureter and the sacropubic ligaments. The retroperitoneal compartments were named: parietal, laterally to the umbilicovesical fascia; vascular, between the two fasciae; neural, medially to the urogenital-hypogastric fascia and visceral between the sacropubic ligaments. The study provides the scientific rational for a model of pelvic retroperitoneal anatomy based on identifiable anatomical structures and suitable for surgical planning and training.

Outcomes of nerve-sparing laparoscopic sacropexy on one hundred fifteen cases

STUDY OBJECTIVE

To evaluate the postoperative anatomic and functional outcomes of patients who underwent laparoscopic nerve-sparing sacrocolpopexy or sacrocervicopexy for pelvic organ prolapse (POP) POP-Q stage III and IV apical prolapse, and to delineate the contributing factors for recurrence.

STUDY DESIGN AND CLASSIFICATION

The file records of patients who underwent sacropexy in the last five years were reviewed retrospectively and compared in terms of preoperative and postoperative anatomic findings and symptoms.

PATIENTS

Patients who underwent laparoscopic nerve-sparing surgery for treatment of POP-Q Stage III and IV/prolapse of uterine or vaginal cuff were included.

INTERVENTIONS

Postoperative anatomic and functional outcomes were evaluated using POP-Q classification and urinary/anal function by questioning during visits.

RESULTS

The mean follow-up duration was 24.2 ± 17.6 months. Anatomic recovery was achieved in 104 (90.4 %) cases. Advanced age (≥70 years), longer duration of symptoms, and low body mass index were determined as parameters related to recurrence risk.

Functional outcome after laparoscopic nerve-sparing sacrocolpopexy: a prospective cohort study

INTRODUCTION

To date sacrocolpopexy is regarded as the reference standard treatment for primarily apical compartment prolapse and multicompartment prolapse. Most bladder and bowel dysfunction improves postoperatively after sacrocolpopexy; however, de novo bowel or de novo bladder dysfunction can occur. The inferior hypogastric nerve is commonly known among pelvic surgeons. However, the inferior hypogastric nerve and its fine fibers are difficult to identify; iatrogenic lesion is commonly tolerated although this can lead to bladder, bowel and sexual dysfunction. This study was performed to assess the functional outcome after nerve-sparing sacrocolpopexy.

MATERIAL AND METHODS

From 2014 to 2016 all women undergoing a laparoscopic sacrocolpopexy for apical or multicompartment prolapse stage >2 were included in this prospective study. Laparoscopic sacrocolpopexy was performed using the nerve-sparing approach. Objective outcome was assessed by preoperative and postoperative POP-Q changes. De novo bladder and de novo bowel dysfunction were subjectively and objectively evaluated.

RESULTS

In all, 137 women were included. Significant objective improvement for point Aa and C (p < 0.0001) preoperatively to postoperatively was seen. The posterior compartment remained unchanged with point Ba -2. De novo overactive bladder and de novo bladder outlet obstruction with elevated postresidual volume were seen for both in 0.7% (1/137). De novo stress urinary incontinence was seen in 0.7% (5/137). De novo constipation was seen in 5%, bowel incontinence in 0% and resolution of pre-existing obstipation in 14.5%. De novo laxative use (9%) in the first 12 weeks was the most common postoperative problem.

CONCLUSION

We could demonstrate that when a nerve-sparing technique is applied for sacrocolpopexy low de novo bladder (18%) and de novo bowel dysfunction can be seen.