Pregnancy after laparoscopic hysteropexy: Is there a prolapse recurrence?

Laparoscopic hysteropexy is a surgery of choice for woman with pelvic organ prolapse wishing to retain fertility. There are few cases of pregnancies after this surgery as standard practice recommends to fulfil their family project before undergoing laparoscopic prolapse surgery. Our operative technique involves the use of 2 polypropylene meshes, one placed anteriorly and one posteriorly, they are attached to the cervix and together through the cervix. There is no compression on the uterine arteries as we do not encircle the cervix and there is no concern on blood flow to the uterus. The patient had a gestational diabetes with an oversize baby in breech position. A caesarean section was planned due to the babies' position and weight. The patient delivered a healthy baby and 10 months after the surgery the patient did not have recurrence of pelvic organ prolapse.

The impact of laparoscopic gynecological surgery training on the technicity index of a developing country center.

PURPOSE: To compare laparoscopic gynecological surgery training between a developed country's reference center (host center) and a public reference service in a developing country (home center), and use the technicity index (TI) to compare outcomes and to determine the impact of laparoscopic gynecological surgery fellowship training on the home center's TI. METHODS: The impact of training on the home center was assessed by comparing surgical performance before and after training. TI was assessed in 2017 in the host center, and before and after training in the home center. Epidemiological and clinical data, and information on reason for surgery, preoperative images, estimated intraoperative bleeding, operative time, surgical specimen weight, hospital stay length, complication and reintervention rates were collected from both institutions. Home center pre-training data were retrospectively collected between 2010 and 2013, while post-training data were prospectively collected between 2015 and 2017. A two-tail Z-score was used for TI comparison. RESULTS: The analysis included 366 hysterectomies performed at the host center in 2017, and 663 hysterectomies performed at the home center between 2015 and 2017. TI in the host center was 82.5%, while in the home center it was 6% before training and 22% after training. There were no statistical differences in length of hospital stay, preoperative uterine volume, surgical specimen weight and complication rate between centers. However, significantly shorter mean operative time and lower blood loss during surgery were observed in the host center. CONCLUSIONS: High-quality laparoscopic training in a world-renowned specialized center allowed standardizing laparoscopic hysterectomy procedures and helped to significantly improve TI in the recipient's center with comparable surgical outcomes.

Laparoscopic TOT-like Burch Colposuspension: Back to the Future?

OBJECTIVE: To demonstrate a modification of the classic Burch procedure, called "laparoscopic transobturator tape (TOT)-like Burch colposuspension." The technique does not involve any type of prosthesis placement, and it is an alternative for patients with stress urinary incontinence in a future without meshes. Describing and standardizing the procedure in different steps makes the surgery reproducible for gynecologists and safe for the patients. DESIGN: Step-by-step educational video, underlining and focusing on the main anatomical landmarks. SETTING: A university tertiary care hospital. INTERVENTIONS: The patient is set under general anesthesia and in lithotomy position. The distinct steps of the procedure are performed as followed: Step 1: Installation. Two 10-mm trocars are positioned in the midline and 2 5-mm trocars in the suprapubic region. The recommended intra-abdominal pressure is 6 to 8 mm Hg, and excessive Trendelenburg is not needed. Step 2: Entry in the Retzius space. The median umbilical ligament and the vesicoumbilical fascia are transected. Step 3: Exposure of the Retzius space and the anatomical structures. The dissection is continued consecutively toward the pubic bone and the Cooper's ligament, laterally toward the external iliac vessels and the corona mortis and medially toward the bladder neck. Step 4: Vaginal dissection. The pubocervical is dissected at the level of the pubourethral ligaments. Step 5: Suspension of the vagina to the Cooper's ligament. In contrast to the standard technique, with the TOT-like Burch, the sutures on the pubocervical fascia are placed at the level of the attachment of the arcus tendinous fascia pelvis and the pubourethral ligament. This way of suspension ensures a lateral traction on the bladder neck, resembling the effect of the TOT, which leads to lower incidence of dysuric symptoms. Step 6: Peritoneal closure. CONCLUSION: The classic colposuspension was created in 1961 for the treatment of stress urinary incontinence prolapse [1]. In the following years, vaginal meshes gained popularity as a treatment option for prolapse and for incontinence owing to their ease of use and satisfying results, which led to a decreased use of the Burch procedure [2,3]. In 2019, the Food and Drug Administration forbid the production of the transvaginal meshes for prolapse [4], an interdiction that could influence the use of synthetic meshes for incontinence in the future [5]. Owing to these recent events, searching for an effective way of management for patients with stress urinary incontinence without any synthetic prostheses, gynecologists have turned back to the 60-year-old Burch colposuspension. One of the drawbacks of the original technique is the high incidence of voiding difficulties-up to 22% [6]. Owing to the knowledge of the exact course of traction with the TOT, in our modified technique, the lateral direction of the suspension provides a tension-free support on the urethra and the bladder neck. The laparoscopic TOT-like Burch colposuspension is a safe and effective treatment for patients with stress urinary incontinence with low rates of dysuric symptoms and represents a valuable alternative for gynecologists in a future without meshes.

Effects of Low Intraperitoneal Pressure on Quality of Postoperative Recovery after Laparoscopic Surgery for Genital Prolapse in Elderly Patients Aged 75 Years or Older.

STUDY OBJECTIVE: Previous clinical trials for laparoscopic surgery have included few elderly patients aged ≥75 years. We aimed to evaluate the quality of postoperative recovery after laparoscopic surgery using low intraperitoneal pressure (IPP) (6 mm Hg) and warmed, humidified carbon dioxide gas for genital prolapse in elderly patients aged ≥75 years. DESIGN: Prospective consecutive case series. SETTING: University hospital. PATIENTS: Consecutive patients (n = 30) aged ≥75 years planning to undergo laparoscopic surgery for genital prolapse by the same surgeon were recruited from October 2016 through December 2019. INTERVENTIONS: Laparoscopic promontofixation for the treatment of genital prolapse was performed using low IPP and warmed, humidified carbon dioxide gas. When a promontory could not be easily identified, laparoscopic pectopexy was alternatively performed. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the Quality of Recovery-40 (QoR-40) score at 24 hours postoperatively. The secondary outcomes were postoperative pain using a 100-mm visual analog scale and the length of hospital stay after surgery (LHSS). For the global QoR-40 score and for 4 dimensions of the QoR-40, "emotional state," "physical comfort," "psychologic support," and "pain," no differences were observed between the baseline score and the score at 24 hours. The score for the "physical independence" dimension at 24 hours was significantly lower than the baseline score (p <.001). No patient had visual analog scale pain scores >30 out of 100 at 12 hours or later. LHSS was <48 hours in 22 patients (73.3%) and <72 hours in 8 patients (26.7%). Multivariable analysis showed that the odds of an LHSS >48 hours were more than 8 times higher in patients who were discharged from the operating room in the afternoon compared with those with a morning discharge. CONCLUSION: The use of a low IPP is feasible, safe, and has clinical benefits for elderly patients aged ≥75 years who undergo laparoscopic surgery for genital prolapse.

Which Knots Are Recommended in Laparoscopic Surgery and How to Avoid Insecure Knots.

STUDY OBJECTIVE: To investigate why security of identical knot sequences is variable and how to avoid occasionally insecure knots. DESIGN: A factorial design was used to assess factors affecting the security of half knot (H) and half-hitch (S) knot combinations. The effect of tying forces and the risk factors to transform H knots into S knots were investigated. The risk factors evaluated were as follows: starting with an H1 or H2 instead of an H3 knot, inexperience, short sutures, and monomanual knot tying. Security of transformed knots, S2S1 and S2S2 knots, and their recuperation with 2 additional half hitches, SSb or SbSb, were evaluated. SETTING: Training center for laparoscopic suturing. PATIENTS: Not applicable. INTERVENTIONS: Security of knots was evaluated in vitro. MEASUREMENTS AND MAIN RESULTS: The forces that caused knot combinations to open before breaking of the suture were used to calculate the risk of opening with low forces. Tying more strongly increased the security of half knots (H2H1sH1s) (p <.02) and half hitches (p <.001). The forces needed to transform an H3 into an S3 are higher than those for an H2 (p <.001), and the risk increases when the surgeon is inexperienced (p <.001), when sutures are short (p <.001), and when monomanual knot tying (p <.001) is used. Inadvertently made S2S1 and S2S2 knots are dangerous, with the exception of the symmetric S2S2, which is stable. Unstable knots such as S2S1a and S2S2a knot combinations improve with 2 additional blocking half hitches (SbSb), but S2S2aSbSb remains occasionally insecure. CONCLUSION: To reduce the risk of accidentally transforming a first H into an S knot, it is recommended to start with an H3, tie with force, avoid short sutures, and use bimanual suturing. This permits the recommendation to use preferentially H3H2 knots or 5 half hitches (SSSbSbSb). When in doubt, half knot combinations should be secured with at least 2 blocking half hitches.

What Is a Good Teaching Video? Results of an Online International Survey.

STUDY OBJECTIVE: To analyze surgeon views on criteria for a good teaching video with the aim of determining guidelines. DESIGN: An online international survey using a self-developed questionnaire. SETTING: A French university tertiary care hospital. PATIENTS: Three hundred eighty-eight participants answered an online questionnaire (154 women [40.53%] and 226 men [59.47%]). INTERVENTIONS: A questionnaire on the criteria for a good quality teaching surgery video was developed by our team and communicated via an online link. MEASUREMENTS AND MAIN RESULTS: The responses of 388 respondents were analyzed and highlighted the pedagogical benefits of teaching videos. The video duration may vary according to the type of media or surgical procedure but should not exceed 10 to 15 minutes for complex procedures. Providing information on the surgical setup (body mass index of the patient, Trendelenburg position degree, pressure of pneumoperitoneum, etc.) is essential. Surgical videos should be reviewed and divided into clearly defined steps with continued access to the entire nonmodified video for reviewers and be accessible on both educational and open platforms. Patient consent and relevant information should be made available. Reviews should include "bad procedure" videos, which are highly appreciated, especially by young surgeons. CONCLUSION: The many advantages of the video format, including availability and rising popularity, provide an opportunity to reinforce and complement current surgical teaching. To optimize use of this surgical teaching tool, standardization, updating, and ease of access of surgical videos should be promoted.

Minilaparoscopic Total Hysterectomy in Current Practice Feasibility and Benefits: A Unicentric, Randomized Controlled Trial.

STUDY OBJECTIVE: To investigate whether mini-instrumentation may be used for hysterectomy (HT) by all surgeons (assistants and seniors) without increasing the operative time or altering surgeon working conditions. DESIGN: A unicenter, randomized controlled, single blind, parallel, noninferiority trial comparing 2 surgical techniques. SETTING: A tertiary referral center. PATIENTS: Thirty-two patients undergoing HT for a benign gynecologic disease were enrolled in this study in our center between April 2, 2015, and June 1, 2018. Sixteen patients were randomized in group A and 16 patients in group B. INTERVENTIONS: HT with bilateral annexectomy or ovarian conservation using 3-mm instruments (group A) or conventional 5-mm instruments (group B). MEASUREMENTS AND MAIN RESULTS: Concerning the primary outcome, the operative time for the HT 3-mm group was 128 minutes (range, 122-150 minutes) versus 111 minutes (range, 92-143 minutes) for the HT 5-mm group (i.e., δ = 17 [90% confidence interval, -6 to 39]), with rejection of the noninferiority threshold at 35 minutes. Thirty-one percent of HTs initially performed using 3-mm instruments were completed with conventional instruments. HTs performed with mini-instruments required more concentration (p = .02) with surgeons reporting higher levels of frustration (p = .009) and sense of failure (p = .006). Patients tend to experience greater satisfaction regarding scars with a significant difference noted during the postoperative visit both for scar pain (1 vs 4 patients with moderate pain [30-50 mm on the Patient Scar Assessment Scale) in the HT 3-mm group and the HT 5-mm group, respectively) and scar firmness (p = .021; 3 vs 7 patients with moderate firmness [30-50 mm on the Patient Scar Assessment Scale] in the HT 3-mm group and the HT 5-mm group, respectively). CONCLUSION: Total minilaparoscopic HT appears inferior to standard laparoscopy in terms of operative time and surgeon working conditions; only the short-term cosmetic appearance was in favor of the 3-mm approach.

Laparoscopic Myomectomy in 10 Steps.

STUDY OBJECTIVE: Laparoscopic myomectomy has the advantages of a minimally invasive approach for the surgical treatment of myomas. The standardization and description of the technique are the main objectives of this video. We described laparoscopic myomectomy in 10 steps, which could help make this procedure easier and safer [1]. SETTING: A French university tertiary care hospital. PATIENTS: Patients with indication for laparoscopic myomectomy. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. INTERVENTION: Standardized laparoscopic myomectomies were recorded to realize the video. MEASUREMENTS AND MAIN RESULTS: This video presents a systematic approach to myomectomy clearly divided into 10 steps: (1) prepare your surgery, make selection and prehabilitation of patient [2], provide a good cartography of the myoma(s), and plan the surgery [3,4]; (2) ergonomy and material; (3) preventive hemostasis: triple occlusion; (4) hysterotomy; (5) enucleation by fast dissection and traction; (6) bipolar hemostasis; (7) check for missing myomas; (8) suture; (9) extraction/morcellation; and (10) prevent adhesions [5]. CONCLUSION: Standardization of laparoscopic myomectomy could make this procedure easier and safer to perform. The 10 steps presented help to perform each part of surgery in logical sequence making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve.

Laparoscopic Promontofixation in 10 Steps.

STUDY OBJECTIVE: Laparoscopic promontofixation has all the advantages of a minimally invasive approach for the treatment of urogenital prolapse. The standardization and description of the technique was the main objective of this video. We describe the complete procedure in 10 steps, which could help to understand and perform this procedure simply, easily, and safely. DESIGN: Step-by-step video demonstration of the technique. SETTING: A university tertiary care hospital. PATIENTS: Patients with indication for the laparoscopic treatment of urogenital prolapse. The local institutional review board ruled that approval was not required for this video article. MEASUREMENTS AND MAIN RESULTS: Ten main steps were identified and described in detail during laparoscopic promontofixation: step 1, exposition of the operating field; step 2, dissection of the promontory; step 3, pararectal dissection; step 4, rectovaginal dissection; step 5, vesicovaginal dissection; step 6, supracervical hysterectomy; step 7, fixation of the prosthesis; step 8, peritonization; step 9, fixing the prosthesis to the promontory; and step 10, uterine morcellation. CONCLUSION: Laparoscopic promontofixation is an effective technique for prolapse surgery. The 10 steps help to perform each part of the surgery in logical sequences, making the procedure faster to adopt and easy to learn. Standardization of laparoscopic techniques could help to reduce learning curve.

Effects of low intraperitoneal pressure and a warmed, humidified carbon dioxide gas in laparoscopic surgery: a randomized clinical trial.

Laparoscopic surgery technology continues to advance. However, much less attention has been focused on how alteration of the laparoscopic surgical environment might improve clinical outcomes. We conducted a randomized, 2 × 2 factorial trial to evaluate whether low intraperitoneal pressure (IPP) (8 mmHg) and/or warmed, humidified CO2 (WH) gas are better for minimizing the adverse impact of a CO2 pneumoperitoneum on the peritoneal environment during laparoscopic surgery and for improving clinical outcomes compared to the standard IPP (12 mmHg) and/or cool and dry CO2 (CD) gas. Herein we show that low IPP and WH gas may decrease inflammation in the laparoscopic surgical environment, resulting in better clinical outcomes. Low IPP and/or WH gas significantly lowered expression of inflammation-related genes in peritoneal tissues compared to the standard IPP and/or CD gas. The odds ratios of a visual analogue scale (VAS) pain score >30 in the ward was 0.18 (95% CI: 0.06, 0.52) at 12 hours and 0.06 (95% CI: 0.01, 0.26) at 24 hours in the low IPP group versus the standard IPP group, and 0.16 (95% CI: 0.05, 0.49) at 0 hours and 0.29 (95% CI: 0.10, 0.79) at 12 hours in the WH gas group versus the CD gas group.

Transrectal Mesh Erosion Requiring Bowel Resection.

STUDY OBJECTIVE: To report a case of a transrectal mesh erosion as complication of laparoscopic promontofixation with mesh repair, necessitating bowel resection and subsequent surgical interventions. INTRODUCTION: Sacrocolpopexy has become a standard procedure for vaginal vault prolapse [1], and the laparoscopic approach has gained popularity owing to more rapid recovery and less morbidity [2,3]. Mesh erosion is a well-known complication of surgical treatment for prolapse as reported in several negative evaluations, including a report from the US Food and Drug Administration in 2011 [4]. Mesh complications are more common after surgeries via the vaginal approach [5]; nonetheless, the incidence of vaginal mesh erosion after laparoscopic procedures is as high as 9% [6]. The incidence of transrectal mesh exposure after laparoscopic ventral rectopexy is roughly 1% [7]. The diagnosis may be delayed because of its rarity and variable presentation. In addition, polyester meshes, such as the mesh used in this case, carry a higher risk of exposure [8]. CASE REPORT: A 57-year-old woman experiencing genital prolapse, with the cervix classified as +3 according to the Pelvic Organ Prolapse Quantification system, underwent laparoscopic standard sacrocolpopexy using polyester mesh. Subtotal hysterectomy and bilateral adnexectomy were performed concomitantly. A 3-year follow-up consultation demonstrated no signs or symptoms of erosion of any type. At 7 years after the surgery, however, the patient presented with rectal discharge, diagnosed as infectious rectocolitis with the isolation of Clostridium difficile. She underwent a total of 5 repair surgeries in a period of 4 months, including transrectal resection of exposed mesh, laparoscopic ablation of mesh with digestive resection, exploratory laparoscopy with abscess drainage, and exploratory laparoscopy with ablation of residual mesh and transverse colostomy. She recovered well after the last intervention, exhibiting no signs of vaginal or rectal fistula and no recurrence of pelvic floor descent. Her intestinal transit was reestablished, and she was satisfied with the treatment. CONCLUSION: None of the studies that represent the specific female population submitted to laparoscopic promontofixation with transrectal mesh erosion describe the need for more than one intervention or digestive resection [9-12]. Physicians dealing with patients submitted to pelvic reconstructive surgeries with mesh placement should be aware of transrectal and other nonvaginal erosions of mesh, even being rare events. Moreover, they should perform an active search for unusual gynecologic and anorectal signs and symptoms. Most importantly, patients undergoing mesh repair procedures must be warned of the risks of the surgery, including the possibility of several subsequent interventions.

Sampling in Atypical Endometrial Hyperplasia: Which Method Results in the Lowest Underestimation of Endometrial Cancer? A Systematic Review and Meta-analysis.

Our objective was to identify the most accurate method of endometrial sampling for the diagnosis of complex atypical hyperplasia (CAH), and the related risk of underestimation of endometrial cancer. We conducted a systematic literature search in PubMed and EMBASE (January 1999-September 2013) to identify all registered articles on this subject. Studies were selected with a 2-step method. First, titles and abstracts were analyzed by 2 reviewers, and 69 relevant articles were selected for full reading. Then, the full articles were evaluated to determine whether full inclusion criteria were met. We selected 27 studies, taking into consideration the comparison between histology of endometrial hyperplasia obtained by diagnostic tests of interest (uterine curettage, hysteroscopically guided biopsy, or hysteroscopic endometrial resection) and subsequent results of hysterectomy. Analysis of the studies reviewed focused on 1106 patients with a preoperative diagnosis of atypical endometrial hyperplasia. The mean risk of finding endometrial cancer at hysterectomy after atypical endometrial hyperplasia diagnosed by uterine curettage was 32.7% (95% confidence interval [CI], 26.2-39.9), with a risk of 45.3% (95% CI, 32.8-58.5) after hysteroscopically guided biopsy and 5.8% (95% CI, 0.8-31.7) after hysteroscopic resection. In total, the risk of underestimation of endometrial cancer reaches a very high rate in patients with CAH using the classic method of evaluation (i.e., uterine curettage or hysteroscopically guided biopsy). This rate of underdiagnosed endometrial cancer leads to the risk of inappropriate surgical procedures (31.7% of tubal conservation in the data available and no abdominal exploration in 24.6% of the cases). Hysteroscopic resection seems to reduce the risk of underdiagnosed endometrial cancer.

Laparoscopic-assisted Retropubic Midurethral Sling Placement: A Technique to Avoid Major Complications.

STUDY OBJECTIVE: To describe a technique for the safe placement of retropubic midurethral slings in patients undergoing concomitant laparoscopic surgery in order to avoid major complications associated with this procedure such as bladder perforation and retropubic hematomas. DESIGN: Step-by-step video demonstration of the technique. SETTING: A university tertiary care hospital. PATIENTS: Patients with an indication for retropubic midurethral sling placement because of recurrent stress urinary incontinence, intrinsic sphincter deficiency, or severe pelvic organ prolapse in whom a concomitant laparoscopic surgery has to be performed for other medical conditions. INTERVENTION: Laparoscopic opening and dissection of the Retzius space and insertion of the sling under a laparoscopic view of this space. MEASUREMENTS AND MAIN RESULTS: This technique has been mainly used in patients undergoing laparoscopic pelvic organ prolapse repair. No complications have been identified so far, even in high-risk patients such as those with previous Burch colposuspension. CONCLUSION: This is a simple and reproducible technique for preventing major complications associated with retropubic sling placement in patients undergoing laparoscopic surgery for other reasons. It also permits the immediate detection and even resolution of complications in case any arise. Even high-risk patients may be safely approached.

Are gynecologists sufficiently trained and educated on electro surgery and basic laparoscopic setting?

BACKGROUND: Basic knowledge of electrosurgery and patient's safety during laparoscopic setup are fundamental, as laparoscopic surgical skills do. The aim of this prospective case-control study was to assess the improvement of such knowledge and skills among gynecologists. METHODS: Gynecologists attending a training course on laparoscopy at the Centre International de Chirurgie Endoscopique (CICE), Clermont Ferrand (France) (December 2013-March 2014) were asked to answer a questionnaire about their own clinical activity and basic surgical knowledge and skills at the beginning and end of the course. The questionnaire included multiple choice questions about technical (four questions) and safety (five questions) aspects of laparoscopic set up and electrosurgery (five questions). RESULTS: Sixty-two residents and 68 graduated gynecologists completed pre- and post-course questionnaires (PrQ and PoQ, respectively). Considering 9 as an arbitrary cut-off score indicating an adequate theoretical knowledge, a total of 70 (51.8 %) and 128 (94.8 %) participants had a sufficient score at the PrQ and PoQ, respectively. Only 9.6 % of participants were able to complete PoQ without making any mistakes, with a mean PrQ score of 9.5. At the beginning, the most difficult steps in laparoscopy in participants' opinion were intra-corporeal suture and insufflation of pneumoperitoneum (both 36.1 %). After the course and the practical training, only 20 % of participants still indicated intra-corporeal suture as the most difficult. CONCLUSION: Education on electro surgery and basic laparoscopic setting and laparoscopic practical training are necessary to improve and maintain laparoscopic surgical skills. The assessment of that knowledge is mandatory to define surgical competence.

What to Do With Recurrent Prolapse After Vaginal Mesh Failure?

STUDY OBJECTIVE: To show that in selected cases laparoscopic sacrocolpopexy can be used for the treatment of recurrent pelvic organ prolapse after vaginal mesh surgery. METHODS: Step-by-step examination of the technique using an educative video. Institutional review board approval was obtained. SETTING: The authors describe two clinical cases of treatment of recurrent pelvic organ prolapse, after a vaginal mesh surgery, using laparoscopic sacrocolpopexy. PATIENTS: A 56-year old patient (para 3, gravida 2) presented with the sentation of bulging in the vagina. On physical examination, the patient had a grade 2-3 vaginal apical prolapse and a stage 4 rectocele. She had a slight mesh contraction but no vaginal extrusion and no pain were reported. Eleven years before, she had a vaginal total hysterectomy for pelvic organ prolapse correction and one year before she had a vaginal prolapse repair using a synthetic mesh. A laparoscopic sacrocolpopexy with bilateral ooforectomy was performed. The second case is of a 54-year old patient (para 2, gravida 2) that presented stress urinary incontinence. On physical examination, the patient had a grade 3 uterine prolapse and grade 2 cystocele. Eleven years before she had a vaginal prolapse repair using a synthetic mesh and a miduretral sling for stress urinary incontinence. Two years before, she had the miduretal sling removed for recurrent urinary infections and dysuria. A laparoscopic sub-total hysterectomy with salpingectomy and ovarian conservation, sacrocolpopexy and a Burch colposuspension was performed. MEASUREMENTS AND MAIN RESULTS: The procedures and postoperative recovery were uneventful. No minor or major complications occurred. The patients were discharged three days after surgery. CONCLUSION: Laparoscopic sacrocolpopexy is a promising approach for the treatment of recurrent pelvic organ prolapse after vaginal mesh surgery. It appears to be feasible, safe, and effective.

Laparoscopic Ureteroneocystostomy: Be Prepared!

STUDY OBJECTIVE: To assess the outcomes and complications of laparoscopic ureteroneocystotomy in gynecologic surgery. DESIGN: We retrospectively reviewed all medical records of patients who underwent ureteroneocystostomy between April 2008 and May 2012. DESIGN CLASSIFICATION: Retrospective case series study. SETTING: A university tertiary care hospital. PATIENTS: Nine patients underwent ureteroneocystostomy: 3 patients had ureteral endometriosis stenoses; and 6 patients had iatrogenic ureter injuries. INTERVENTIONS: All procedures were performed laparoscopically. The ureterovesical re-implantation was unilateral in 8 cases and bilateral for 1 patient. MEASUREMENTS AND MAIN RESULTS: The mean operating time was 226.7 min (range, 120-480). Average blood loss was 114.4 mL (range, 30-400). The mean duration of the in-dwelling catheter was 10.4 days (range, 7-21); the average hospital stay was 12.6 days (range, 6-26). The mean duration of the ureteral double J stent was 7.8 weeks (range, 6-16). One patient was re-operated for vaginal and laparoscopic drainage of a pelvic abscess on the sixth postoperative day. The median follow-up time was 20.8 months (range, 9-36), No patient had stenosis or breakdown of a suture line. CONCLUSIONS: Our series confirms the feasibility and the effectiveness of laparoscopic ureteroneocystostomy. This minimally invasive approach, which avoids laparotomy, requires a multidisciplinary team.