Laparoscopic sacral hysteropexy versus laparoscopic sacral colpopexy plus supracervical hysterectomy in patients with pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The choice of whether or not to preserve the uterus in the case of patients with urogenital prolapse who undergo sacral colpopexy is still debated. We compared objective and subjective outcomes of laparoscopic sacral hysteropexy (LSHP) and laparoscopic sacral colpopexy with concomitant supracervical hysterectomy (LSCP/SCH) in patients with symptomatic pelvic organ prolapse. METHODS: This is a multicenter retrospective cohort study conducted at the Urogynecology Department of the Fondazione Policlinico Universitario A. Gemelli IRCCS of Rome and at the Diaconesses Croix Saint Simon Hospital of Paris. We collected data of 136 patients; 78 underwent LSHP and 58 underwent LSCP/SCH for pelvic organ prolapse between January 2016 and December 2017. RESULTS: Patients of the two groups had similar preoperative characteristics. All patients completed 24-month follow-up evaluation. Overall, anatomical cure rate was 84.6% and 87.9% in the LSHP group and LSCP/SCH group, respectively, without statistically significant differences. In particular, in the LSHP group the anatomical success rate was 94.9%, 92.3% and 92.3% for the apical, anterior and posterior vaginal compartment whereas in the LSHP group LSCP/SCH was 100%, 91.4% and 94.8%, respectively. Subjective success rate was 89.7% among patients who underwent LSHP and 93.1% among women who underwent LSCP/SCH (p = 0.494). The median operative time (OT) was significantly shorter in LSHP. There were no significant differences between the groups in terms of estimated blood loss, conversion to laparotomy and intra- and postoperative complications. Patients' satisfaction was high in both groups without statistical differences. CONCLUSIONS: Both laparoscopic procedures are safe and effective in the treatment of pelvic organ prolapse. LSHP can be offered as an alternative in women who are strongly motivated to preserve the uterus in the absence of abnormal uterine findings.

Comparison of different surgical techniques for pelvic floor repair in elderly women: a multi-institutional study.

PURPOSE: The prevalence of pelvic organ prolapse (POP) is increasing. The number of women aged 70-80 years requiring surgical management for POP is also increasing. The purpose of this study was to compare the complications associated with three pelvic organ prolapse repair methods, sacrocolpopexy (SCP), native tissue repair (NTR), and vaginal mesh repair (VMR), in women aged 70-80 years. METHODS: We performed a multi-institutional retrospective analysis of 213 women who underwent POP surgical repairs between December 2012 and December 2017. Treatment-related complications were classified using the ClavienDindo grading system and compared among the three groups. Perioperative data, anatomical success rates, patient satisfaction, and postoperative complication data were collected during the follow-up period, which lasted up to 12 months. RESULTS: Of 213 patients, 70 (33%) underwent SCP, 85 (40%) underwent NTR, and 58 (28%) underwent VMR. By postoperative day 30, the all-inclusive complication rate was lower in the SCP group than in the NTR or VMR group; however, there was no between-group difference in complication grade. The VMR group underwent fewer concomitant hysterectomies than the other groups, and operative time was the longest for SCP. Overall, recovery time, anatomical success rate, and patient satisfaction were comparable for all three repairs. CONCLUSIONS: All three surgical techniques were equivalent in patient satisfaction, anatomical success rate, and complication rate. SCP should be recommended to elderly women who meet criteria for prolonged general anesthesia, as it was associated with fewer perioperative complications than NTR and VMR.

Vaginal mesh repair SYSTEMS for pelvic organ prolapse: Anatomical study comparing transobturator/trangluteal versus single incision techniques.

INTRODUCTION: The present study aim to compare the anatomic landmarks of two pelvic floor repair systems, in order to identify the potential neurovascular lesions related to different mesh fixation techniques. METHODS: Abdominal and perineal dissections of 10 fresh cadavers after prolapse surgery using transobturator/transgluteal versus single incision techniques. Neuro-vascular structures of obturator region and perineum were isolated. Distances between needles and anatomical structures were measured. RESULTS: During transobturator anterior repair, the superficial cannula passed 2.5 ± 0.6 cm medially to the obturator canal. The distance of superficial arm to the anterior obturator vessels was 2.2 ± 0.4 cm. The distance of deep cannula to the posterior obturator vessels branches was 1.3 ± 0.5 cm. In two of these cases we observed a lesion of posterior obturator vessels. During single incision repair the distance between the obturator canal and the superficial arms was 2.3 ± 0.7. The mean distances of superficial arms to the anterior and posterior obturator vessels were, respectively, 2.3 ± 0.5 cm and 3.2 ± 0.7 cm. During transgluteal posterior repair the distance between the cannula guide and the ischial spine was 1.7 ± 0.5 cm while it measured 2.3 ± 0.4 cm when single incision posterior device was placed. CONCLUSIONS: Anterior transobturator system presents an increased risk of posterior obturator vessels branches injury. During posterior transgluteal repair the distance of the ischio-anal fossa to sacrospinous ligament represents a way that could rule against the correct needle positioning with increased risk of pudendal lesions. Single incision approach offers an easier access to the sacrospinous ligament with lower risk of pudendal lesions.

Laparoscopic sacral colpopexy: how to place the posterior mesh into rectovaginal space?

AIMS: Laparoscopic sacral colpopexy (LSC) for pelvic prolapse is a complex procedure, characterized by an anterior mesh suspension to the sacral promontory and a posterior tension-free mesh fixation. METHODS: Totals of 150 age-BMI and parity matched consecutive POP patients were selected from our Diaconesses Hospital database among women who underwent a laparoscopic supracervical hysterectomy (LSH) plus sacral colpopexy (LSC) from June 2005 to March 2010. We analyzed two group of LSC populations, according to different tension-free apical fixation of the posterior mesh: Promontory (P) group and Utero-Sacral (US) group. Studied endpoints were the anatomical and functional results linked to these different tension-free posterior mesh placements. RESULTS: Baseline characteristics were similar between the groups. No differences in terms of anatomical and functional outcomes were observed between the groups. Pelvic organ mobility at rest versus under Valsalva highlighted a significant reduction of median differential vaginal apex only in the P population (preoperative: 30 mm and 32 mm; postoperative: 8 mm and 24 mm; for P and US, respectively; P < 0.01). No differences were found in terms of intra- or post-operative complications. CONCLUSIONS: Uterosacral tension-free fixation of posterior mesh during LSC could be considered a simple procedure and guarantees a more physiological movement of the pelvic organs if compared with promontory suspension.

[From the open approach to laparoscopy. Background, rationale, technique]. / La promontofixation: de la voie ouverte a la coelioscopie. Historique, rationnel, technique.

Genital prolapse is a frequent functional pathology in women. Its surgical treatment depends specially upon the suspension and fixation of the vaginal vault. Thus, sacrocolpopexy has become a gold standard technique to correct genital prolapse. Laparoscopy is a procedure resulting in less bleeding and decreased hospital stay than open sacrocolpopexy and is presently the approach of choice. Its objective and subjective correction rates are > 90%. Some authors proposed a dual abdominal and perineal approach to help fixing the posterior mesh and repairing the perineal body. Robotics is the actual surgeons' gadget.Its results are similar to laparoscopic sacrocolpopexy albeit a higher cost and a longer operating time. The ideal mesh is monofilamentous with large pores. Sacrocolpopexy consists in fixing two meshes, one on the anterior vaginal wall and one on the posterior vaginal wall, on the anterior sacral ligament, without tension for the posterior mesh, with or without subtotal hysterectomy, and with closure of the peritoneum at the end. In the case of associated stress urinary incontinence, proved on the clinical exam or urodynamical exam, appropriate surgical treatment is done with sacrocolpopexy. In the near future, robotics will replace laparoscopy when costs will be reduced and medical staff well trained to perform robotic or robot-assisted sacrocolpopexy.

Pregnancy after laparoscopic sacral colpopexy: a case report.

We report a case of a pregnancy and follow the delivery of a young woman who previously underwent a laparoscopic sacral colpopexy (LSC) for pelvic organ prolapse (POP). A 38-year-old woman with POP desires pregnancy who after unsuccessful medical treatment with pessary underwent a laparoscopic uterine ventrosuspension (LUV). However, this procedure also failed and there was an immediate relapse. Thus, LSC was then performed. After which, she became pregnant culminating in elective caesarean delivery. The LUV failure was documented by a POP-Q classification and dynamic pelvic magnetic resonance (PMR) which was carried out 1 month after the surgery. When the same assessment was conducted after the LSC, it showed an optimal POP correction. The short-term post-delivery follow-up exhibited a small prolapse relapse, which remained stable 48 months after surgery as confirmed by a new PMR. Surgical correction of POP is possible in women with pregnancy desires. The result is variable and links to the POP stage and other surgical interventions.

Laparoscopic sacrocolpopexy for management of pelvic organ prolapse enhances quality of life at one year: a prospective observational study.

STUDY OBJECTIVE: Assessment of 1-year quality of life outcome of patients treated with laparoscopic sacrocolpopexy. DESIGN: A prospective multicenter observational study (Canadian Task Force classification II-3). SETTING: Four French medical centers. PATIENTS: A total of 94 women who underwent laparoscopic sacrocolpopexy for pelvic organ prolapse between June 2006 and May 2007 were included in the study. MEASUREMENTS AND MAIN RESULTS: Women attended a research clinic where they completed validated quality of life questionnaires and were examined. Women were assessed before and 1 year after surgery for the degree and impact of vaginal, urinary, and bowel symptoms with validated quality of life questionnaires, evaluation of sexual function with a validated questionnaire, and pelvic organ support was assessed by a Pelvic Organ Prolapse Quantification score. Mean age of the women was 58.8 years. Anatomic success occurred in 94% of women. Concomitant urinary continence surgery was performed in 39% of cases. All the scores of quality of life and sexuality were significantly improved at 1 year. CONCLUSIONS: Laparoscopic sacrocolpopexy for pelvic floor prolapse is a safe and effective treatment that has a positive impact on every aspect of quality of life (symptoms, social impact, sexual function) in the medium term.

Anterior/Apical single incision mesh (Elevate™): Surgical experience, anatomical and functional results, and long-term complications.

OBJECTIVE: Pelvic organ prolapse is a common condition among post-menopausal women, and surgery is often the standard treatment proposed. Native tissue vaginal surgery is burdened by a high rate of recurrence, and mesh vaginal surgery has become current practice. The purpose of this study was to evaluate the safety and the effectiveness of the vaginal kit Anterior/Apical single incision mesh Elevate™ for the correction of anterior and apical compartment prolapse. STUDY DESIGN: Data of patients with symptomatic anterior vaginal prolapse stage ≥ II, receiving mesh repair with the Anterior/Apical Elevate single incision system between January 2010 and January 2015 were retrieved. Prolapse was classified according to the POP-Q system. The main outcome measure was anatomical success, while subjective and safety outcomes were secondary outcomes. RESULTS: Anatomical success rate was 87.2 % for anterior compartment prolapse and 84.6 % for combined anterior and apical prolapse, while overall functional success rate was 96.2 % after a median follow-up of 33.6 months. The most frequent short-term complications were urinary bladder injury (3.0 %) and transient urinary retention (6.9 %). The most common long-term complications were de novo or persistent symptomatic stress urinary incontinence (10.8 %) and vaginal mesh extrusion (3.8 %). CONCLUSION: Mesh vaginal surgery with Anterior/Apical single incision mesh Elevate™ is a well-tolerated procedure with a very high anatomical and functional success rate. Short and long-term complications rate seem to be acceptable, and in most of cases, solvable. Further studies are needed to confirm our promising data.

[Descending perineum in women]. / Le périnée descendant de la femme.

Physiopathological and clinical interpretation of the descending perineum as described by A. Parks in 1970 remains difficult. This review is based on the literature between 1966 and 2004. The observed symptoms are more often due to associated lesions. The descending perineum on X-ray is not always symptomatic. Colpocystography shows the descent of the perineum and pelvic disorders from the anterior and middle parts of the perineum whereas defecography seems to provide a better diagnosis of dyschesia due to posterior damage (such as rectocele or endo-anal intussusception). The first step of treatment is reeducation and medical treatment because there is no consensus for surgical therapy. Soft sacrocolpopexy by the abdominal approach with three meshes, one under the bladder, one in front of and one behind the rectum can be proposed for complete descending perineum. Transanal rectal resection by staple could be useful when the descending perineum is only associated with a rectocele and/or an intra-anal intussusception.

Terminologia Anatomica versus unofficial descriptions and nomenclature of the fasciae and ligaments of the female pelvis: a dissection-based comparative study.

OBJECTIVE: The aims of this study were: (1) to define and classify those connective structures of the female pelvis that are of potential clinical interest, (2) to evaluate the adequacy of the Terminologia Anatomica (official nomenclature) and (3) to establish a correspondence between the official nomenclature and the most commonly used terms. STUDY DESIGN: The results of 30 macroscopic and laparoscopic dissections of fresh cadavers with and without vessel injection of colored latex solutions were compared with the descriptions and definitions in the Terminologia Anatomica and the most frequently cited English and non-English literature from 1890 to 2003. RESULTS: We identified 3 groups of fasciae, parietal pelvic fascia, visceral pelvic fascia, and extraserosal pelvic fascia, which could be divided into diverse clinically relevant anatomical structures characterized by different locations, spatial orientation, and consistency. These structures differed considerably with regard to number and nomenclature from those described in the Terminologia Anatomica and part of the literature. CONCLUSION: Our results suggest that the official terminology applied to the connective structures of the female pelvis could be profitably revised and expanded. We offer a complete description of these structures and suggest a classification that may be useful for teaching and clinical purposes.

[Treatment of stress urinary incontinence with tension-free vaginal tape (TVT). Mid-term results of a prospective study of 124 cases]. / Traitement de l'incontinence urinaire d'effort pure par bandelette sous-urétrale sans tension (TVT). Résultats à moyen terme d'une étude prospective sur 124 cas.

OBJECTIVES: The role of urethral support in continence has been stressed since 1994, resulting in a new technique for repair of stress urinary incontinence: Tension-free Vaginal Tape (TVT). This technique has been performed in France since 1996 and we analyse the results of this technique in 124 consecutive patients treated for stress urinary incontinence. MATERIAL AND METHOD: The 124 patients did not present any prolapse requiring surgical repair and presented clinical urine leaks on effort after filling the bladder with 250 ml of physiological saline (stress test). 29 patients had already been operated for a disorder of pelvic tone, combined with an urological procedure in 22 cases; all patients completed an urodynamic assessment. 54 patients presented clinical signs of urgency in addition to stress urinary incontinence and 6 of them had cystomanometric signs of urgency. The mean maximum urethral closure pressure was 47 cm H2O (range: 12-120). All patients were operated under local anaesthesia (0.25% Xylocaine with adrenaline) according to the same standardized protocol. The mean follow-up was 35.2 months (range: 19-54). The operative and postoperative morbidity, the results demonstrated by stress test, the subjective result assessed by a patient satisfaction questionnaire and long-term complications were analysed. RESULTS: 110 patients (98.7%) were totally continent, 10 (8%) were improved and 4 (3.3%) were failures. 117 patients (94.3%) were satisfied. Signs of urgency resolved in 38 out of 54 patients (63%). The result was not influenced by closure pressure. Complications consisted of 11 bladder perforations (8.9%) and 3 haematomas, none of which required reoperation. Micturition was easily resumed in 122 patients, while acute retention was observed in 2 cases, on D2 and D3. In 76 patients (61.3%), the first residual urine was less than 100 ml. Long-term follow-up did not reveal any cases of rejection of the TVT, but 3 vaginal erosions were treated by simple plasty. CONCLUSION: With a follow-up of three years and an experience of 5 years, this series demonstrates the value of the TVT technique for treatment of female stress urinary incontinence based on the good results (objective: 89%; subjective: 95%), reproducibility, simplicity and low morbidity.

Endorectal ultrasonography in predicting rectal wall infiltration in patients with deep pelvic endometriosis: a modern tool for an ancient disease.

PURPOSE: This study evaluated the validity of endorectal ultrasonography in predicting rectal infiltration in patients with deep pelvic endometriosis. METHODS: Patients were recruited consecutively in the Department of Surgical Gynecology of Diaconesses Hospital from April 1996 to July 2003. Inclusion criteria were the suspicion of deep pelvic endometriosis on the basis of outpatient history and/or clinical symptoms with a mass palpable on bimanual examination that might infiltrate the rectal wall. There were no exclusion criteria. Endorectal ultrasonography was performed by the same investigator with a 7.5-MHz to 10-MHz rigid probe, producing a 360 degrees view of the rectal wall and adjacent areas. We used surgical and histopathologic findings as the "gold standard" to evaluate the validity of endorectal ultrasonography. RESULTS: This study was based on 37 patients (mean age, 35.8 (range, 26-46) years) who underwent surgery. The time between endorectal ultrasonography and surgery ranged from 4 to 529 (mean, 88.7) days. Eight patients had endometriosis nodules penetrating the rectal wall. Endorectal ultrasonography showed sensitivity, specificity, a positive predictive value, and a negative predictive value of 87.5, 97, 87.5, and 97 percent, respectively, in the diagnosis of infiltration of the rectal wall by endometriosis. CONCLUSIONS: Endorectal ultrasonography is a reliable technique for visualizing rectal infiltration in patients with deep pelvic endometriosis. It should be more widely used by gynecologists because knowing about rectal infiltration before surgery is fundamental to defining the best possible surgical approach.

The use of laparoscopic sacrocolpopexy in the management of pelvic organ prolapse.

PURPOSE OF REVIEW: This paper aims to review and comment on the developments in laparoscopic sacrocolpopexy published during the last year. RECENT FINDINGS: We classified the findings reported recently in the literature for laparoscopic sacrocolpopexy as technical or tactical findings. Technical findings concern the material of the mesh, the methods of mesh fixation, the use of adapted vaginal retractors and the interest in robotic assistance. Tactical findings consist of specific modifications to the standard surgical procedure aimed at reducing the side effects and complications and ameliorating the effectiveness of this intervention. These modifications include the possibility of avoiding the placement of a posterior mesh and the fixation of the posterior mesh to the puborectal muscles or the perineal body instead of the posterior vaginal wall. A specific section has been dedicated to reviewing and commenting on those interventions associated routinely with laparoscopic sacrocolpopexy. SUMMARY: Laparoscopic sacrocolpopexy is a safe surgical procedure in constant evolution which allows excellent results in the treatment of utero-vaginal prolapse. Large prospective, randomized studies comparing the different technical and tactical modifications recently introduced are needed in order to further enhance the effectiveness of this intervention.

Laparoscopic sacrocolpopexy with two separate meshes along the anterior and posterior vaginal walls for multicompartment pelvic organ prolapse.

STUDY OBJECTIVE: To assess the feasibility and results of laparoscopic sacrocolpopexy (LSC) with two separate meshes along the anterior and posterior vaginal walls in correcting multicompartment pelvic organ prolapse (POP). DESIGN: Prospective study (Canadian Task Force classification I). SETTING: Tertiary care university-affiliated teaching hospital. PATIENTS: Forty-six consecutive women with radiologic diagnosis of multicompartment POP with or without genuine stress urinary incontinence and no history of surgery for either disorder. INTERVENTION: LSC with or without laparoscopic Burch colposuspension or tension-free vaginal tape procedure. MEASUREMENTS AND MAIN RESULTS: LSC was performed in 89% of patients. Mean operating and hospitalization times were 171 +/- 37 minutes and 4.0 +/- 2.1 days, respectively. Intraoperative complications were 7% of bladder injuries successfully treated by laparoscopic suture. The success rate for POP was 83%. The main recurrence was rectocele (12%), which occurred only among women undergoing LSC plus laparoscopic Burch colposuspension (P = 0.036). The LSC was effective in treating symptoms in 95% of women. Because of excessive mesh tension, one patient (2%) developed obstructed defecation, and two (5%) had de novo urinary incontinence. In no patient did occlusion or mesh infection and/or erosion in adjacent organs occur. CONCLUSION: LSC appears to be feasible and effective in treatment of multicompartment POP. Performing concomitant Burch colposuspension significantly enhances the risk of rectocele recurrence or development.