Laparoscopic Sacrohysteropexy for Pelvic Organ Prolapse and the Technique Used for Uterine Preservation: A Case Report.

Pelvic organ prolapse (POP) is prevalent among middle-aged and older women, and its prevalence is expected to increase in Japan in the future. Laparoscopic surgery for POP is covered by insurance and is currently a minimally invasive procedure. There are multiple treatment approaches for the uterus, especially sacrohysteropexy, for patients who wish to preserve their uterus. This approach requires an understanding of its anatomical characteristics, including how the arm is threaded. However, specific techniques for uterine preservation have not yet been thoroughly investigated or reported. Here, we discuss the innovative operative techniques for uterine preservation and mesh application achieved by laparoscopic sacrohysteropexy performed at our hospital. A 34-year-old woman presented at our hospital with a uterine prolapse in the hope of undergoing laparoscopic sacrohysteropexy. The anterior vaginal wall was dissected, the mesh fixed, and the right and left intrauterine foramina next to the cervix were deployed and released. The anterior vaginal wall mesh penetrated the released mesentery and was integrated with the mesh of the posterior vaginal wall. It was fixed to the anterior aspect of the cape angle by using a subperitoneal tunnel. This surgical case is currently under follow-up, with no recurrence to date. We elaborate upon the ingenious insertion site of the port for the preservation of the uterus, the secure fixation of the mesh to the uterus, and the traction method. Unlike laparoscopic sacrocolpopexy and sacrocervicopexy, laparoscopic sacrohysteropexy necessitates at least the aforementioned techniques. At our institution, we perform sacrohysteropexy following the method outlined in this case. A more efficient technique is expected to emerge as larger-scale studies accumulate additional cases, ultimately leading to widespread acceptance and standardization of the approach.

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.

Laparoscopic sacrohysteropexy versus vaginal hysterectomy and apical suspension: 7-year follow-up of a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Laparoscopic mesh sacrohysteropexy offers a uterine-sparing alternative to vaginal hysterectomy with apical suspension, although randomised comparative data are lacking. This study was aimed at comparing the long-term efficacy of laparoscopic mesh sacrohysteropexy and vaginal hysterectomy with apical suspension for the treatment of uterine prolapse. METHODS: A randomised controlled trial comparing laparoscopic mesh sacrohysteropexy and vaginal hysterectomy with apical suspension for the treatment of uterine prolapse was performed, with a minimum follow-up of 7 years. The primary outcome was reoperation for apical prolapse. Secondary outcomes included patient-reported mesh complications, Pelvic Organ Prolapse Quantification, Patient Global Impression of Improvement in prolapse symptoms and the International Consultation on Incontinence Questionnaire Vaginal Symptoms, Female Lower Urinary Tract Symptoms (ICIQ-FLUTS) and PISQ-12 questionnaires. RESULTS: A total of 101 women were randomised and 62 women attended for follow-up at a mean of 100 months postoperatively (range 84-119 months). None reported a mesh-associated complication. The risk of reoperation for apical prolapse was 17.2% following vaginal hysterectomy (VH) and 6.1% following laparoscopic mesh sacrohysteropexy (LSH; relative risk 0.34, 95% CI 0.07-1.68, p = 0.17). Laparoscopic sacrohysteropexy was associated with a statistically significantly higher apical suspension (POP-Q point C -5 vs -4.25, p = 0.02) and longer total vaginal length (9 cm vs 6 cm, p < 0.001). There was no difference in the change in ICIQ-VS scores between the two groups (ICIQ-VS change -22 vs -25, p = 0.59). CONCLUSION: Laparoscopic sacrohysteropexy and vaginal hysterectomy with apical suspension have comparable reoperation rates and subjective outcomes. Potential advantages of laparoscopic sacrohysteropexy include a lower risk of apical reoperation, greater apical support and increased total vaginal length.

Successful Pregnancy Outcome After Laparoscopic Sacrohysteropexy for Pelvic Organ Prolapse.

The protrusion of pelvic organs and their associated vaginal segments into or through the vagina is called pelvic organ prolapse (POP). In recent times, a larger number of women of reproductive age group are presenting with complaints of POP, seeking treatment for POP along with the preservation of the uterus. These groups of patients may plan for pregnancy in the future. There is limited data on successful pregnancy, delivery and long-term outcome after sacrohysteropexy. We present here the management of a case of pelvic organ prolapse quantification (POP-Q) stage-III uterovaginal prolapse who underwent laparoscopic sacrohysteropexy and later on conceived and delivered by cesarean section. The uterus remained well-supported at follow up of one year after delivery.

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.

Safety and effectiveness of laparoscopic sacrocolpopexy as the treatment of choice for pelvic organ prolapse.

Objective: To evaluate the safety and effectiveness of laparoscopic sacrocolpopexy (LSC)/laparoscopic sacrohysteropexy (LSH) at 1-year follow-up for female pelvic-organ prolapse (POP). Patients and methods: In all, 52 patients were included and underwent LSC/LSH in the Eldemerdash Hospital, Ain Shams University, Cairo, Egypt. All patients with POP, with Grade ≥II of any anatomical site (anterior, posterior or combined) who were medically fit for general anaesthesia, were included in the study. Patients with previous major abdominal surgery, a body mass index (BMI) of >40 kg/m2 or un-correctable bleeding diatheses, were excluded. Preoperative data, peri- and postoperative functional and anatomical outcomes were assessed. The patients were followed-up at 3, 6 and 12 months postoperatively. Results: Pre- and postoperative data were available for the 52 patients operated on for POP. The subjective cure rate was 92.3% and the objective cure rate was 98.1%. Failure was defined as recurrence of Grade ≥II POP. Conclusion: LSC/LSH is a safe and effective procedure for the treatment of female POP due to its durable results and low rates of complications with high objective and subjective cure rates. Abbreviations: BMI: body mass index; (RA)LSC: (robot-assisted) laparoscopic sacrocolpopexy; LSH: laparoscopic sacrohysteropexy; PFDI-20: Pelvic Floor Distress Inventory; PFIQ-7: Pelvic Floor Impact Questionnaire; POP: pelvic-organ prolapse; QoL: quality of life; SUI: stress urinary incontinence; TVM: total transvaginal mesh; VVP: vaginal vault prolapse.

Laparoscopic inguinal ligament suspension versus laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse: study protocol for a randomized controlled trial.

BACKGROUND: Pelvic organ prolapse (POP) is a common health problem. The lifetime risk of undergoing surgery for prolapse is 11%. POP significantly affects the effects on quality of life and activities of daily living. Laparoscopic sacrocolpopexy (LSC) has been viewed as the gold standard treatment for women with POP who desire reconstructive surgery. However, LSC is associated with technical difficulties, resulting in a long learning curve and operative time. Recently, our team introduced a new laparoscopic technique of inguinal ligament suspension (LILS) and had confirmed its safety and efficacy in treating vaginal vault prolapse. As a new surgical technique for POP, a prospective randomized controlled trial comparing the LILS with the standard technique of LSC is necessary. Therefore, we will conduct a trial. METHODS: The trial is a randomized controlled trial. It compares LILS with LSC in women with stage 2 or higher uterine prolapse. The primary outcomes of this study are perioperative parameters, including surgical time, blood loss, intraoperative complications, and hospital stay as well as surgical anatomical results using the pelvic organ prolapse questionnaire (POP-Q) classification at 6 weeks, 6 months, 12 months, and annually till 5 years after surgery. Secondary outcomes are subjective improvement in urogenital symptoms and quality of life, postoperative complications, postoperative recovery, sexual functioning, and cost-effectiveness at each follow-up point. Validated questionnaires will be used and the data will be analyzed according to the intention-to-treat principle. Based on an objective success rate of 90%, a noninferiority margin of 15%, and a dropout of 20%, 107 patients are needed in each arm to prove the hypothesis with a 95% confidence interval. DISCUSSION: The trial is a randomized controlled, multicenter, noninferiority trial that will provide evidence whether the efficacy and safety of LILS is noninferior to LSC in women with symptomatic stage 2 or higher uterine prolapse. TRIAL REGISTRATION: China Trial Register (CTR): ChiCTR-INR-15007408 . Registered on 9 November 2015.

Laparoscopic Sacrohysteropexy in a Woman at 12 Weeks' Gestation.

STUDY OBJECTIVE: To demonstrate laparoscopic sacrohysteropexy for a case of uterine prolapse in a 12 weeks, 3 days pregnant woman. To our knowledge this is the first case of laparoscopic sacrohysteropexy performed at 12 weeks of gestation to be reported in literature. DESIGN: A step-by-step explanation of the surgical procedure (Canadian Task Force classification III). SETTING: Maltepe University Hospital. PATIENT: A 37-year-old pregnant woman. INTERVENTION: Laparoscopic sacrohysteropexy. Institutional Review Board ruled that approval was not required for this study. MEASUREMENTS AND MAIN RESULTS: Uterine prolapse is very rare condition, manifesting in an estimated 10 000 to 15 000 pregnancies [1]. The management plan must be individualized, and the obstetrician should aware of possible complications, such as preterm labor, high incidence of abortion, cervical ulceration, and cervical dystocia. In general, bedrest, good genital hygiene, and pessary use is recommended. Alternatively, in cases where conservative solutions have failed, laparoscopic surgery in the pregnant patient may be considered. To date, only 1 case of laparoscopic promontohysteropexy at 10th weeks of gestation was reported by Pirtea et al [2]. A 37-year-old woman, at 12 weeks and 3 days of gestation, with stage III pelvic organ prolapse was referred to our clinic. Conservative management with pessary failed. The patient underwent laparoscopic sacrohysteropexy after written informed consent form was obtained. In exploration, uterine manipulation was difficult because of softness and large size of the uterus. First, the sigmoid colon was suspended at the abdominal wall to gain an adequate surgical field. The promontorium was dissected and the parietal peritoneum incised on the right pelvic side wall after ureter visualization. A polypropylene mesh was fixed to the cervix at the level of the uterosacral ligaments. The other edge of the mesh was fixed at the level of the promontory using the Uplift device (Neomedic International, Barcelona, Spain). Then, the peritoneum was sutured to cover the mesh. The patient was discharged 2 days after surgery. At the examination the pelvic floor was detected to be normal. The patient delivered a healthy baby weighing 3030 g by cesarean section at 38 weeks of gestation. The position of the mesh was controlled during surgery. There was no peritoneal fold detected on the cervical part of mesh; however, no adhesion was observed. CONCLUSION: Laparoscopic sacrohysteropexy may be an alternative and safe approach, if conservative treatment fails, for pelvic organ prolapse during pregnancy.

Simplified Laparoscopic Sacrohysteropexy.

STUDY OBJECTIVE: To demonstrate a simplified technique of performing laparoscopic sacrohysteropexy for uterine prolapse. DESIGN: A technical video demonstrating a simplified method of laparoscopic sacrohysteropexy (Canadian Task force classification level III). SETTING: The benign gynecology department at a university hospital. INTERVENTIONS: A 38-year old woman with grade 3 uterine descent presented requesting surgical management for symptomatic prolapse. CONCLUSION: Laparoscopic sacrohysteropexy is becoming an increasingly popular alternative to hysterectomy to treat uterine prolapse in women. We present a novel approach of performing laparoscopic sacrohysteropexy that differs from previously described methods [1,2]; it is shorter, simpler, and reduces possible complications. Key differences include the mesh type, site of attachment, and dissection of the peritoneum while creating the possibility of future vaginal delivery after pregnancy. Our simplified technique uses a polyvinylidene fluoride mesh woven with a square weave secured to the posterior aspect of the cervix under a layer of visceral peritoneum. Because there is no longitudinal give of the mesh, unlike polypropylene meshes with a diamond weave, a wrap method [2] is not required. No dissection of the broad ligament and bladder is needed, eliminating the risk of bladder perforation and anterior mesh erosion with fewer adhesions and simplifying hysterectomy if required in the future. We also uniquely "tunnel" the peritoneum, reducing the size of defect for suture closure, and reperitonize the mesh. Previous methods restrict cervical dilatation and require women to have cesarean sections. The method described in the video allows women to deliver vaginally and, in the event of late miscarriage, avoid the need for hysterotomy. We have performed 25 cases with 1 mild cystocoele recurrence requiring no surgery, 1 reoperation for posterior compartment repair, and 1 case of cervical elongation requiring Manchester repair. No cases of recurrent uterine prolapse have occurred.

Laparoscopic sacrohysteropexy versus vaginal hysterectomy for uterovaginal prolapse using validated questionnaires: 2-year prospective study.

INTRODUCTION: Surgical options for uterovaginal prolapse can be categorized into uterus conservation-e.g., laparoscopic sacrohysteropexy (LSHP) or vaginal hysterectomy (VH). There is insufficient reliable information on long-term comparative outcomes of these procedures. The primary aim of this study was to compare subjective and objective outcomes of LSHP and VH. The secondary aim was to record adverse events, recurrent prolapse, and new-onset stress urinary incontinence (SUI) up to 2 years. METHODS: Women with symptomatic uterovaginal prolapse who opted for either LSHP or VH were included. Subjective outcomes were compared at 1 and 2 years from baseline using the validated questionnaires. Objective/anatomical outcomes using the Pelvic Organ Prolapse Quantification (POP-Q) system were assessed before and at 3 months after surgery. Adverse events, recurrent prolapse, and new-onset SUI was recorded up to 2 years. RESULTS: The study assessed 226 women with uterovaginal prolapse; 125 opted for surgery (44 LSHP, 81 VH). There was no statistically significant difference in symptom domains between groups at baseline and 1 and 2 years. At 3 months POP-Q, greater improvement was seen in points Ba and Ap in the LSHP group compared to VH group and smaller genital hiatus was seen in the VH group. Adverse events, recurrent prolapse, or new-onset SUI were not significantly different in the two groups. CONCLUSIONS: Both LSHP and VH are effective surgical options for uterovaginal prolapse. At 2 years, both procedures had similar improvement in symptom domains, overall scores, adverse events, recurrent prolapse, and new-onset SUI. Long-term randomized studies are needed.

A new operation technique for uterine prolapse: Vaginally-assisted laparoscopic sacrohysteropexy.

OBJECTIVE: To describe the new surgical technique and report the safety and feasibility of vaginally-assisted laparoscopic sacrohysteropexy (VALSH). MATERIALS AND METHODS: Thirty-three women with stage 3 or more uterine prolapse underwent VALSH operation. Patients were followed up for 12 months for mesh-related complications and improvements of symptoms. The operation had three sections; 1st laparoscopic, 2nd vaginal, 3rd laparoscopic. RESULTS: The mean age, gravidity, and parity of the study population were 46.5 years (range, 25-68 years), 4.3 (1-9), and 2.9 (1-6), respectively. The mean duration of operation was 59.5 min (range, 20-120 min). There were significant differences between the pre- and post-operative values of pelvic organ prolapse quantification parameters, which were favorable in the latter evaluation (p<0.001); total vaginal length was preserved after surgery (p>0.05). CONCLUSION: VALSH is a safe and minimally-invasive procedure in uterovaginal prolapse, with favorable anatomic and functional outcomes at 12 months post-operatively.

Robotic or laparoscopic sacrohysteropexy versus open sacrohysteropexy for uterus preservation in pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to compare robotic or laparoscopic sacrohysteropexy (RLSH) and open sacrohysteropexy (OSH) as a surgical treatment for pelvic organ prolapse (POP). METHODS: Among 111 consecutive patients who had undergone sacrohysteropexy for POP, surgical outcomes and postoperative symptoms were compared between the RLSH (n = 54; robotic 14 cases and laparoscopic 40 cases) and OSH (n = 57). groups The medical records of enrolled patients were reviewed retrospectively. RESULTS: Compared with the OSH group, the RLSH group had shorter operating time (120.2 vs 187.5 min, p < 0.0001), less operative bleeding (median estimated blood loss 50 vs 150 ml; p < 0.0001; mean hemoglobin drop 1.4 vs 2.0 g/dl; p < 0.0001), and fewer postoperative symptoms (13 vs 45.6 %; p < 0.0001). Patients' overall satisfaction (94.4 vs 91.2 %; p = 0.717) and required reoperation due to postoperative complications (3.7 vs 1.8 %; p = 0.611) did not differ between groups. CONCLUSIONS: RLSH could be a feasible and safe procedure in patients with POP and should be considered as a surgical option that allows preservation of the uterus. Prospective randomized trials will permit the evaluation of potential benefits of RLSH as a minimally invasive surgical approach.