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.

Is the Presence of Levator Ani Muscle Avulsion Relevant for the Diagnosis of Uterine Prolapse?

OBJECTIVE: To determine if the addition of the assessment of levator ani muscle (LAM) avulsion to the measurement of the difference in the pubis-uterine fundus distance between rest and with the Valsalva maneuver could increase the diagnostic capacity of ultrasound for uterine prolapse (UP). METHODS: This multicenter, observational and prospective study included 145 patients. Ultrasound assessment was performed, establishing the diagnosis of UP as a difference between the pubic-uterine fundus distance at rest and during the Valsalva maneuver ≥15 mm (standard technique), while LAM avulsion was defined as an abnormal LAM insertion in three central slices using multislice ultrasound. A binary multivariate logistic regression model was made using nonautomated methods to predict surgical UP (general population, premenopausal, and postmenopausal patients), including the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver as well as LAM avulsion. RESULTS: A total of 143 patients completed the study. The addition of LAM avulsion criteria to the standard dynamic distance-based protocol for the diagnosis of UP resulted in a higher sensitivity for the general population (79.7 vs 68.1%) as well as for premenopausal (89.3 vs 79.9%) and postmenopausal patients (76 vs 66.1%). In contrast, the standard technique showed a higher specificity than the model based on the standard technique associated with LAM avulsion for the general population (89.2 vs 74.3%) and premenopausal women (91.7 vs 63.2%). For postmenopausal patients, the model based on the standard technique associated with LAM avulsion had a higher sensitivity (76 vs 66.1%) and specificity (91.7 vs 86.8%) than the ultrasound diagnosis of UP. CONCLUSION: The implementation of the assessment of LAM avulsion in the ultrasound diagnosis of UP is useful in postmenopausal patients, increasing sensitivity and specificity relative to the ultrasound assessment based only on the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver.

Fortifying the foundation: assessing the role of uterine ligament integrity in uterine prolapse and beyond.

BACKGROUND: Pelvic floor stability is influenced by various biomechanical, anatomical, and physiological factors. Understanding these dynamics is crucial for improving the treatment of pelvic organ prolapse (POP) and related conditions. OBJECTIVE: To analyze the key factors affecting pelvic floor integrity and explore both non-surgical and surgical interventions to enhance stability and treatment outcomes. METHODS: This review draws from biomechanical research to assess the role of the uterosacral ligament in pelvic support, while also examining the potential of both traditional and emerging therapeutic approaches, including non-surgical interventions like vitamin C supplementation. RESULTS: - The uterosacral ligament demonstrates superior strength and stiffness, making it essential for structural support of pelvic organs. - Non-surgical interventions, such as vitamin C supplementation, show potential in improving ligament integrity and preventing pelvic floor disorders. - Emerging surgical techniques, including tendon-based procedures and injectable fibrous hydrogel composites, offer promising improvements in outcomes for patients with pelvic organ prolapse. - Additional factors such as muscle strength and neural deficiencies contribute to the complexity of pelvic floor biomechanics, indicating the need for multifaceted treatment approaches. CONCLUSION: This analysis provides a comprehensive framework for understanding and managing pelvic floor stability by integrating biomechanical, physiological, and anatomical insights. The findings highlight the potential for personalized treatment strategies to improve patient outcomes in pelvic floor disorders.

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 review of vaginal hysterectomies in the gynaecology department of a tertiary care hospital.

This retrospective cohort study analysed the trends and complications of vaginal hysterectomy conducted at Services Hospital, Lahore, from January 1, 2015 to December 31, 2020. Demographics, indications, surgery duration, complications (haemorrhage, urological or rectal problems, infection), and hospital stay were recorded. Out of 819 hysterectomies performed for benign gynaecological conditions, 112 (13.68%) were vaginal hysterectomies. Non-descent vaginal hysterectomy (NDVH) accounted for 33(29.46%) and uterine prolapse for 79(70.53%) of the cases. Mean age was 52.35±8.74 years, parity was 5.01±1.32, intraoperative haemorrhage was 796.87±450.1 ml, surgery duration was 48.61±12.28 minutes, and hospital stay was 2.58±0.41 days. Complications occurred in 19(16.97%) of the cases, while 93(83.03%) cases had no complications. Outcomes were comparable between NDVH and vaginal hysterectomy for prolapse (p=0.552). This indicates that vaginal hysterectomy is a safe procedure with minimal complications and quick recovery for uterine prolapse and non-descent uterus. However, a declining trend was observed over the study period.

Effect of different surgical techniques on postoperative wound infection in patients with uterine prolapse: A meta-analysis.

The assumption is that a number of controlled trials have been conducted to assess the impact of uterus retaining or hysterectomy on wound and haemorrhage, but there is no indication as to which method would be more beneficial for wound healing. This research is intended to provide a comprehensive overview of the availability of wound healing in case studies of both operative methods. From inception to October 2023, four databases were reviewed. The odds ratio (OR) and the mean difference (MD) for both groups were computed with a random effect model, as well as the corresponding 95% confidence intervals. A total of five studies were carried out in the overall design and enrolled 16 972 patients. No statistical significance was found in the rate of postoperative wound infection among the two treatments (OR,1.46; 95% CI,0.66,3.22 p = 0.35); The rates of bleeding after surgery did not differ significantly from one procedure to another (OR,1.41; 95% CI,0.91,2.17 p = 0.12); two studies demonstrated no statistical significance for the rate of incisional hernia after surgery (OR,2.58; 95% CI,0.37,18.05 p = 0.34). Our findings indicate that there is a similar risk between uterine preservation and hysterectomies for the incidence of wound infection, haemorrhage and protrusion of incision.

Patient's preference for sacrospinous hysteropexy or modified Manchester operation: A discrete choice experiment.

OBJECTIVE: To investigate women's preference for modified Manchester (MM) or sacrospinous hysteropexy (SH) as surgery for uterine prolapse. DESIGN: Labelled discrete choice experiment (DCE). SETTING: Eight Dutch hospitals. POPULATION: Women with uterine prolapse, eligible for primary surgery and preference for uterus preservation. METHODS: DCEs are attribute-based surveys. The two treatment options were labelled as MM and SH. Attributes in this survey were treatment success ( levels SH: 84%, 89%, 94%; levels MM: 89%, 93%, 96%), dyspareunia (levels: 0%, 5%, 10%), cervical stenosis (levels: 1%, 6%, 11%) and severe buttock pain (levels: 0%, 1%). A different combination of attribute levels was used in each choice set. Women completed nine choice sets, making a choice based on attribute levels. Data were analysed in multinomial logit models. MAIN OUTCOME MEASURES: Women's preference for MM or SH. RESULTS: 137 DCEs were completed (1233 choice sets). SH was chosen in 49% of the choice sets, MM in 51%. Of all women, 39 (28%) always chose the same surgery. After exclusion of this group, 882 choice sets were analysed, in which women preferred MM, likely associated with a labelling effect, i.e. description of the procedure, rather than the tested attributes. In that group, MM was chosen in 53% of the choice sets and SH in 47%. When choosing MM, next to the label, dyspareunia was relevant for decision-making. For SH, all attributes were relevant for decision-making. CONCLUSIONS: The preference of women for MM or SH seems almost equally divided. The variety in preference supports the importance of individualised healthcare.

Laparoscopic and robot-assisted suture versus mesh hysteropexy: a retrospective comparison.

INTRODUCTION AND HYPOTHESIS: Our study was aimed at comparing the outcomes of laparoscopic and robot-assisted laparoscopic suture-based hysteropexy (SutureH) versus sacral hysteropexy using mesh (MeshH) for bothersome uterine prolapse. Our hypothesis is that MeshH is more successful and provides better uterine support than SutureH. METHODS: A retrospective cohort study of 228 consecutive women who underwent re-suspension of the uterus using uterosacral ligaments (SutureH n=97) or a "U-shaped" mesh from the sacral promontory (MeshH, n=132). Surgery was performed by laparoscopy or robot-assisted laparoscopy. Subjects were assessed at baseline, 1 year, and beyond 1 year. The null hypothesis, that SutureH and MeshH have similar success, was based on a composite outcome ("composite success"), and that they provide the same level of uterine support, was based on POP-Q point C at 1 year. "Composite success" was defined as: POP-Q point C above the hymen; absence of a vaginal bulge; no repeat uterine prolapse surgery or pessary placement. Other outcomes included improvement in symptomology using Patient Global Impression of Improvement, POP-Q point C change and complications. RESULTS: Follow-up data were available for 191 out of 228 women. "Composite success" was not significantly different between MeshH and SutureH groups (81.7% vs 84.5%, p=0.616). MeshH provided better elevation of the uterus than SutureH (point C change: -7.38cm vs -6.99cm; p<0.001). Similar symptom improvement and low complications occurred in both groups. CONCLUSIONS: Laparoscopic and robot-assisted laparoscopic suture hysteropexy and mesh sacral hysteropexy provide women with minimally invasive, durable surgical options for uterine preservation. "Composite success" was similar in the two groups, but MeshH provided better uterine support than SutureH. However, SutureH gives women an effective mesh-free option.

Laparoscopic sacrohysteropexy versus vaginal sacrospinous hysteropexy as treatment for uterine descent: comparison of long-term outcomes.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is a frequent occurring health issue, especially concerning elderly women. The objective of this study is to examine the long-term outcomes of laparoscopic sacrohysteropexy (LSH) and vaginal sacrospinous hysteropexy (SSHP) for treatment of uterine prolapse. METHODS: A retrospective study of patients who underwent a LSH or SSHP. Validated questionnaires and an outpatient examination visit were used to investigate the effects of both surgical treatments. The primary outcome was the composite outcome of success for the apical compartment, defined as no recurrence of uterine prolapse (POP-Q measurement C ≤ 0), no subjective recurrence of POP, and/or not requiring therapy for recurrent prolapse. Secondary outcomes were peri- and postoperative data, anatomical failure, prolapse beyond hymen, subjective outcomes, and disease-specific quality of life. RESULTS: We included 105 patients, 53 in the LSH group and 52 in the SSHP group. The overall response rate of the questionnaires was 83% (n = 87) after a mean follow-up time of 4.5 years (54.2 months; 95% CI 44.8-64.2 months) in the LSH group and 2.5 years (30.1 months; 95% CI 29.3-31.5 months) in the SSHP group. There were no clinically relevant differences between the study groups in composite outcome of success (p = 0.073), anatomical failure of the apical compartment (p = 0.711), vaginal bulge symptoms for which patients consulted professionals (p = 0.126), and patient satisfaction (p = 0.741). The operative time was longer in the LSH group (117 min; interquartile range (IQR) 110-123) compared to the SSHP group (67 minutes; IQR 60-73) (p < 0.001). The duration of hospital stay was also longer in the LSH group (4 days) than in the SSHP group (3 days) (p = 0.006). CONCLUSIONS: LSH and SSHP seem to be equally effective after long-term follow-up in treating uterine prolapse in terms of objective and subjective recurrence.

Robotically assisted laparoscopic lateral suspension: a step-by-step approach aiming to standardize a novel procedure.

INTRODUCTION AND HYPOTHESIS: The aim of this video is to show a step-by-step approach to robotically assisted laparoscopic lateral suspension for pelvic organ prolapse aiming to standardize this procedure. METHODS: This video shows a robotically assisted laparoscopic approach to a POP-Q stage 3 prolapse with a combined anterior and apical defect. First, the trocars are positioned, with one 8-mm trocar, two lateral trocars 5 cm above the anterior-superior iliac spine, and a 10-mm assistant trocar either paraumbilically or suprapubically. Second, the uterovesical pouch is dissected up to 2 cm above the level of the bladder neck. The mesh is then fixed to the vesicovaginal fascia and to the isthmus uteri. Next, a laparoscopic forceps is inserted retroperitoneally through the lateral trocars and the lateral arms of the mesh are pulled retroperitoneally. The peritoneum of the uterovesical fold is sutured, including round ligament plication. Finally, the lateral arms of the peritoneum are fixed to the peritoneum of the abdominal wall. CONCLUSIONS: Robotically assisted laparoscopic lateral suspension is a safe alternative to laparoscopic and robotically assisted laparoscopic sacropexy and very well suited for uterine-preserving POP surgery. This video contributes to the standardization of this procedure, and we believe our video to be useful in helping urogynecologists to perform this innovative procedure.