Uterine displacement as fertility sparing technique for pelvic malignancies: Demonstration of the surgical options on a human cadaver.

Preservation of fertility without compromising oncological outcomes is a major objective in young patients at the time of cancer treatment (Azaïs et al., 2018, Bizzarri et al., 2022). Radio(chemo)therapy is often required in pelvic malignancies (anus, rectum, sarcoma). Direct irradiation results in a damage to ovarian (Bizzarri et al., 2023) and endometrial function (Lohynska et al., 2021), compromising the fertility of female patients of reproductive age. While ovarian transposition is an established method to move the ovaries away from the radiation field (Morice et al., 2022, Pavone et al., 2023), corresponding surgical procedures displacing the uterus are investigational (Pavone et al., 2023, Querleu et al., 2010, Ribeiro et al., 2017, Ribeiro et al., 2024). In a human female cadaver model, the reported laparoscopic techniques of uterine displacement were carried out to demonstrate their feasibility and the step-by-step surgical techniques. The surgeries were performed in a hybrid operating room which enables to perform CT-scan and evaluate the uterine positions according to anatomical landmarks. The following procedures were performed in the same cadaveric model and were described in the video: 1. Uterine suspension of the round ligaments to the abdominal wall 2. Uterine ventrofixation of the fundus at the level of the umbilical line 3. Uterine transposition according to the technique reported by Ribeiro et al. All procedures were completed without technical complications. All of these uterine displacement procedures are technically feasible. Uterine transposition is the most technically complex procedure, and its effectiveness in protecting the endometrium should be evaluated in comparison to the simpler techniques (Table 1). Future studies incorporating radiotherapy simulations are needed to define which technique represents the best compromise between surgical complexity and positioning the uterus at a level that receives the lowest possible radiation dose.

Modified Oxford technique of colpopexy for the treatment of uterine and vaginal vault prolapse: a retrospective pilot cohort study.

Introduction: Pelvic organ prolapse is a common health issue that affects 30.8% of women. Laparoscopic sacrocolpopexy and colpopectopexy are two of the most common procedures to restore the pelvic anatomy. Mesh application on the other hand carries an increased complications risk over the short and long terms. The aim of this study is to provide a basis for meshless sacrocolpopexy and colpopectopexy. Methods: This study is a retrospective cohort pilot study that analyzed the data of patients with a pelvic organ prolapse according to the pelvic organ prolapse quantification system and underwent the modified technique for sacrocolpopexy and colpopectopexy. Descriptive statistics were used to express the different variables. Results: A total of 36 patients met the inclusion criteria and provided consent for the participation in this study. The majority of patients were postmenopausal. 22 out of 36 patients received a previous prolapse surgery. All patients presented with reducible vaginal lump. Dyspareunia and sexual dysfunction were the most commonly reported symptoms. The intraoperative complications rate was 0%. Only one patient had a postoperative persistent urinary retention that was managed medically. Discussion: Sacrocolpopexy and colpopectopexy seems to be a safe alternative to the mesh-based pelvic surgeries with a very low rate of intraoperative complications and favorable follow up outcomes.

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.

A comparison of modified laparoscopic uterine suspension and vaginal hysterectomy with sacrospinous ligament fixation for treating pelvic organ prolapse.

OBJECTIVES: To compare the efficacy and adverse events between modified laparoscopic uterine suspension and vaginal hysterectomy and sacrospinous ligament fixation. METHODS: The study reviewed the clinical data of 50 postmenopausal patients who underwent modified laparoscopic uterine suspension (the hysteropexy group) and 50 patients who underwent vaginal hysterectomy with sacrospinous ligament fixation (the hysterectomy group) conducted by the same group of surgeons (2018.1-2019.6) retrospectively. We compared the two groups' baseline characteristics, perioperative details, complications, and POP-Q values before the operations and at 12 months after the operations. The effects on quality of life according to valid questionnaires (PFIQ-7 and PFDI-20) were compared. The patients were followed up for 12 months. RESULTS: There were no significant differences in the perioperative details or baseline characteristics, except that more cases of concurrent vaginal wall (anterior and posterior) and concurrent perineal repair were observed in the hysteropexy group than in the hysterectomy group (9 versus 0, P=0.02; 33 versus 6, P < 0.001). The anatomical measures of points Ba, Bp, and C (P < 0.001), and the quality of life measures (P < 0.001 for PFIQ-7 and PFDI-20) after the operations exhibited significant improvements in the two groups. The total vaginal lengths (TVL) were dramatically decreased after the surgery in the hysterectomy group, but no differences were observed in the hysteropexy group. The two groups didn't show a significant difference in the recurrence of prolapse anatomically or symptomatically, but a dramatically higher number of patients in the hysterectomy group were found to have experienced postoperative vaginal bleeding, excessive granulation tissue and right buttock pain. CONCLUSIONS: The postoperative outcomes, anatomical results, and improvement of function and symptoms of modified laparoscopic uterine suspension were similar to those of vaginal hysterectomy with sacrospinous ligament fixation. Moreover, modified laparoscopic uterine suspension had fewer postoperative complications, so it could be used as an additional choice for POP, although the long-term outcomes haven't been determined yet.

Uterus-Sparing Surgery: Outcomes of Transvaginal Uterosacral Ligament Hysteropexy.

STUDY OBJECTIVE: Recently, there has been a paradigm shift toward uterine conservation during the surgical management of pelvic organ prolapse (POP), specifically uterine prolapse. There are few reports on transvaginal uterosacral ligament hysteropexy (TULH). This study aimed to describe our surgical technique and outcomes. DESIGN: Retrospective review and description of surgical technique. Anatomic outcome has been reported using the POP quantification system. Complications were segregated. A comparison of parametric continuous variables was performed using paired t test. Categoric variables were evaluated using the Pearson χ2 test and the Fisher exact test. A p-value <.05 was considered significant. SETTING: Teaching hospital. PATIENTS: Forty patients who underwent TULH from 2009 to 2017. INTERVENTIONS: TULH. MEASUREMENTS AND MAIN RESULTS: A total of 40 patients met the inclusion criteria. Of these, 56.1% had preoperative stage 3 prolapse. The median operative time was 116 minutes. The mean estimated blood loss was 158.5 mL. Transient ureteral obstruction occurred in 2 patients. The mean follow-up time was 17.2 months, and all patients had significant improvement of prolapse (p <.001). There was also an improvement in urinary incontinence and bladder storage symptoms (p <.001). None of the patients were reoperated on for recurrent POP. CONCLUSION: TULH is an effective uterus-preserving surgical alternative for the treatment of uterovaginal prolapse and provides good apical support. It is also associated with a low short-term recurrence and incidence of reoperation. TULH is a viable option for suitable patients with uterovaginal prolapse who desire uterine conservation.

Hysteropexy in the treatment of uterine prolapse stage 2 or higher: laparoscopic sacrohysteropexy versus sacrospinous hysteropexy-a multicentre randomised controlled trial (LAVA trial).

OBJECTIVE: To investigate whether laparoscopic sacrohysteropexy (LSH) is non-inferior to vaginal sacrospinous hysteropexy (SSHP) in the surgical treatment of uterine prolapse. DESIGN: Multicentre randomised controlled, non-blinded non-inferiority trial. SETTING: Five non-university teaching hospitals in the Netherlands, one university hospital in Belgium. POPULATION: 126 women with uterine prolapse stage 2 or higher undergoing surgery without previous pelvic floor surgery. METHODS: Randomisation in a 1:1 ratio to LSH or SSHP, stratified per centre and severity of the uterine prolapse. The predefined inferiority margin was an increase in surgical failure rate of 10%. MAIN OUTCOME MEASURES: Primary outcome was surgical failure, defined as recurrence of uterine prolapse (POP-Q ≥ 2) with bothersome bulging/protrusion symptoms and/or repeat surgery or pessary at 12 months postoperatively. Secondary outcomes were anatomical recurrence (any compartment), functional outcome and quality of life. RESULTS: Laparoscopic sacrohysteropexy was non-inferior for surgical failure (n = 1, 1.6%) compared with SSHP (n = 2, 3.3%, difference -1.7%, 95% CI: -7.1 to 3.7) 12 months postoperatively. Overall, anatomical recurrences and quality of life did not differ. More bothersome symptoms of overactive bladder (OAB) and faecal incontinence were reported after LSH. Dyspareunia was more frequently reported after SSHP. CONCLUSION: Laparoscopic sacrohysteropexy was non-inferior to SSHP for surgical failure of the apical compartment at 12 months' follow up. Following LSH, bothersome OAB and faecal incontinence were more frequent, but dyspareunia was less frequent. TWEETABLE ABSTRACT: Laparoscopic sacrohysteropexy and vaginal sacrospinous hysteropexy have equally good short-term outcomes.

Laparoscopic extraperitoneal uterine suspension with suture line instead of mesh.

OBJECTIVE: To compare the safety and effectiveness of two different materials (mesh and suture line) used in laparoscopic extraperitoneal uterine suspension. DESIGN: A retrospective observational study. SETTING: Gynaecology departments in two hospitals in China. POPULATION: Women with symptomatic pelvic organ prolapse (POP) of stage II or higher. METHODS: The women were divided into two groups according to the two different materials for laparoscopic extraperitoneal uterine suspension: mesh or suture line. The baseline characteristics, perioperative details, complications, objective and subjective indexes of the two groups were compared. MAIN OUTCOME MEASURES: The primary outcome was subjective satisfaction rate based upon validated questionnaires. The secondary outcome was objective anatomic assessment with the POP-Q system. RESULTS: No difference was found in baseline characteristics and perioperative details except that there were more cases of cardiovascular disease (CVD) and associated other surgeries in the Line than the Mesh group (36 versus 19, P < 0.05; 12 versus 2, P < 0.05). Statistically significant improvements were found in anatomical measures of points Aa, Ba, Ap, Bp, C and TVL (P < 0.01), as well as functional and quality-of-life measures (P < 0.01 for PFDI-20 and PFIQ-7) between both groups. The postoperative PFDI-20, PFIQ-7 and PGI-I scores were not different between two groups (P > 0.05). Two cases of deep wound infection were observed in Mesh group at 3-month follow up. CONCLUSIONS: Laparoscopic extraperitoneal linear uterine suspension is easy to perform and is associated with fewer mesh-related complications. It is more secure, especially in elderly women and in those with physical complications. TWEETABLE ABSTRACT: Laparoscopic extraperitoneal linear uterine suspension is safe, with fewer mesh-related complications.

Clinical outcomes in women undergoing laparoscopic hysteropexy: A systematic review.

OBJECTIVES: To systematically review the current evidence on the anatomic and functional outcomes in women undergoing laparoscopic hysteropexy. STUDY DESIGN: An electronic database search was undertaken (2000-2016). Keywords were: "laparoscopy", "hysteropexy", "cervicopexy", "uterine suspension", "uterosacral plication". References of identified studies as well as abstracts from conferences were considered. We restricted the search to humans, female patients and currently used surgical procedures. Studies with ≥5 cases in English language and published in 2000 or later, were included. After the initial yield, studies were selected following title screening, abstract and full text scrutiny. RESULTS: A total of 17 studies were deemed suitable for inclusion in the review. A total of 770 patients in 17 studies received the intervention being studied (laparoscopic hysteropexy) and were assessed post-operatively with pooled success rates of 85.32% (95%CI: ±2.5). Laparoscopic suture hysteropexy has pooled success of 70.5% (95%CI:±5.33) whereas the pooled success of the suspension to the sacral promontory using mesh or tape is 92% (95%CI: ±2.53). One small study on suspension to the anterior abdominal wall (28 cases) and one to the pectineal ligament (18 cases) have shown 96.4% (95%CI:±6.9) and 94.5% (95%CI:±10.53) objective success rates respectively. CONCLUSION: Laparoscopic hysteropexy was associated with good anatomic cure rates of greater than 90% in majority of the studies. There was an improvement in symptoms, and good subjective cure rates in 73%-100% of the patients. Reoperation rates were low in most studies ranging from around 0%-28%. Complications rates were generally low. Laparoscopic hysteropexy is a feasible alternative for women needing surgical correction of uterovaginal prolapse and who desire conservation of the uterus.

Uterine Suspension With Adjustable Sutures for Difficult Laparoscopic Myomectomy.

STUDY OBJECTIVE: To assess whether transabdominal uterine suspension with adjustable sutures (USAS) is beneficial when performed concomitantly with laparoscopic myomectomy in patients with unfavorably localized leiomyomas in whom uterine manipulators are not an option. DESIGN: A retrospective cohort study (Canadian Task Force classification II-2). SETTING: A university teaching hospital. PATIENTS: Patients (N = 158) with posterior deep intramural, intraligamental, or cervical leiomyomas; 81 patients underwent USAS (suspension group), and 77 patients did not (control group) concomitantly with laparoscopic myomectomy. INTERVENTIONS: Transabdominal USAS was performed for all eligible patients undergoing laparoscopic myomectomy using a 2-0 synthetic, monofilament, nonabsorbable polypropylene suture. One end of the double-headed straight needles of the polypropylene suture was inserted into the pelvic cavity through the abdomen to "lift" or "retract" the uterus to allow for the main tumor to be completely exposed and excised. MEASUREMENTS AND MAIN RESULTS: The average time to create USAS was 2.5 minutes. For the suspension and control groups, the average number of abdominal ports was 3 and 4.4 (p < .001), the average blood loss was 96.3 and 201.5 mL (p < .001), and the average operative time was 50.8 and 91.2 minutes (p < .001), respectively. There was no significant difference in complications (4.9% vs 9.1%, p = .303), but there was a significant difference in conversion to laparotomy (1.2% vs 10.4%, p = .009). At the 3-year follow-up, there were no significant differences in gynecologic and reproductive outcomes, including leiomyoma recurrence, uterine rupture, and pregnancy and live birth rates. The ratio of conversion to laparotomy (odds ratio = 0.108; 95% confidence interval, 0.013-0.884) was much lower in the suspension group. CONCLUSION: USAS is an easy, safe, and feasible alternative to uterine manipulation when performed concomitantly with laparoscopic myomectomy for unfavorably localized uterine leiomyomas.

Laparoscopic hysteropexy versus vaginal hysterectomy for the treatment of uterovaginal prolapse: a prospective randomized pilot study.

INTRODUCTION AND HYPOTHESIS: We have previously reported on laparoscopic hysteropexy for uterine prolapse. We now report a pilot randomized study comparing laparoscopic hysteropexy (LH) with vaginal hysterectomy (VH) for the surgical management of uterine prolapse. METHODS: Women with symptomatic uterine prolapse requiring surgery for uterine prolapse were recruited. The data were analyzed for those who had completed a 1-year follow-up. As this is a pilot randomized study, no power calculation was available. The main primary outcome measure was repeat apical prolapse. Secondary outcomes included operation data, complications, recovery time, functional and QoL outcomes, and anatomical outcomes. Wilcoxon signed rank and Mann-Whitney tests compared pre-operative with post-operative data and the difference between the two groups respectively. RESULTS: One hundred and thirty-two women were recruited. Of these, 101 were randomized. Eighty percent of the 31 women who dropped out preferred LH. One-year follow-up data were analyzed for 37 women in the LH and 35 women in the VH group. Time before return to normal activity was significantly shorter, estimated blood loss was significantly less, pain score 24 h post-operatively was significantly lower, and hospital stay was significantly shorter in the hysteropexy group compared with the vaginal hysterectomy group. Operation time was significantly longer in the hysteropexy group. Both procedures showed significant improvement in prolapse symptoms. Hysteropexy was associated with better apical support; point C and total vaginal length were significantly improved. More vaginal repairs were subsequently required post-hysteropexy. CONCLUSIONS: Laparoscopic hysteropexy is a safe surgical alternative to vaginal hysterectomy with a similar risk of repeat apical surgery at 1 year. Longer follow-up data from larger studies are required.

Modified cervicopexy: a novel, less-invasive technique for Stages III and IV uterine prolapse.

OBJECTIVE: To evaluate modified anterior abdominal wall cervicopexy (AWC) as a less invasive (via 3-cm minilaparotomy) and more augmented (via securing posterior vaginal wall to uterosacral ligaments) technique. METHODS: Case series of 30 women with Stages III and IV apical uterine prolapse assessed by the pelvic organ prolapse quantification system. RESULTS: The modified AWC procedure was performed successfully for 17 cases with Stage III uterovaginal prolapse and 13 cases with Stage IV uterovaginal prolapse. The procedure was conducted safely with no operative or postoperative complications, apart from two cases with postoperative urinary retention. Operative time ranged from 45 to 70min. Follow-up was available for 1-3 years. Overall, 27 cases were satisfied with the procedure, and three cases developed recurrence after caesarean section due to cutting the supporting sutures. CONCLUSIONS: The modified AWC procedure is less invasive, simple and effective for Stages III and IV uterine prolapse.