The new robotic system HUGO RAS for gynecologic surgery: First European experience from Gemelli Hospital.

OBJECTIVE: To evaluate the safety and feasibility of the new surgical robot HUGO robotic assisted surgery (RAS) in a series of gynecologic surgical procedures. METHODS: Between March and October 2022, 138 patients treated at Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy were enrolled in the study. All patients suitable for a minimally-invasive approach were prospectively included and divided into two groups: Group 1 (78 patients) made up of patients operated on for uterine and/or adnexal pathologies, and Group 2 (60 patients) made up of patients treated for pelvic organ prolapse. RESULTS: In Group 1, median docking time (DT) was 5 min and median console time (CT) was 90 min. In two patients (2.6%) redocking was necessary. In two patients (2.6%), the surgeon continued the surgery laparoscopically. Intraoperative complications occurred in two surgeries (2.6%). In Group 2, median DT was 4 min and median CT was 134.5 min. In three patients (5%), redocking was necessary. In all patients, the surgery was successfully completed robotically without intraoperative complications. CONCLUSIONS: The present study demonstrates that the new HUGO RAS system for gynecologic surgery is safe with good results in terms of surgical efficacy and perioperative outcomes. Further studies are needed to investigate its use in other technical and surgical aspects.

Robotic docking time with the Hugo™ RAS system in gynecologic surgery: a procedure independent learning curve using the cumulative summation analysis (CUSUM).

Robot-assisted surgery has been proven to offer improvements in term of surgical learning curve and feasibility of minimally invasive surgery, but has often been criticized for its longer operative times compared to conventional laparoscopy. Additional times can be split into time required for system set-up, robotic arms docking and calibration of robotic instruments; secondly, surgeon's learning curve. One of the newest systems recently launched on the market is the Hugo™ RAS (MEDTRONIC Inc, United States). As some of the earliest adopters of the Hugo™ RAS system technology, we present our data on robotic docking learning curve for the first 192 gynecologic robotic cases performed at our institution. Our data indicates that robotic set-up and docking with the new Hugo™ RAS robotic surgical system can be performed time-effectively and that the specific robotic docking learning curve is comparable to preexisting data for other platforms. This preliminary insights into this recently released system may be worthwhile for other centers which may soon adopt this new technology and may need some relevant information on topics such as OR times. Further studies are necessary to assess the different features of the Hugo™ RAS considering other technical and surgical aspects, to fully become familiar with this novel technology.

Clinical, anatomical and perioperative outcomes of abdominal sacral colpopexy using autologous fascia: A systematic review of the literature.

OBJECTIVES: Although sacral colpopexy is considered the gold standard for the treatment of advanced apical prolapse, several warnings and restrictions has been delivered to urogynecological surgeons in order to avoid the implants of prosthetics meshes. The purpose of this systematic review is to investigate the role of sacral colpopexy performed with autologous tissue in literature. METHODS: a systematic review according to PRISMA guidelines was performed in June 2022 through the Medline, Web of Science and Scopus databases. Quality assessment of each article was performed according to Critical Appraisal tool of Oxford center for EBM, LoE according to SORT standards, ROBINS-I tool for methodological assessment in non-randomized trials. From 236 screened records, 7 articles were considered eligible for this systematic review. RESULTS: Collected data showed objective cure rate ranging from 94.7% to 100% in medium term follow up. Subjective cure rate was specifically investigated in 2 studies with high satisfaction rates. Complication rate ranged from 0 to 36.8%, with 90.1% graded ≤2 according to Clavien-Dindo classification. CONCLUSIONS: sacral colpopexy with autologous fascia shows satisfying outcomes in terms of safety and efficacy and may be taken in account in particular clinical situations.

Sacrocolpopexy after sub-total hysterectomy vs. sacral hysteropexy for advanced urogenital prolapse: A propensity-matched study.

OBJECTIVE: To compare objective and subjective outcomes of laparoscopic sacral colpopexy with supracervical hysterectomy (L-SCP) and robotic sacral hysteropexy (R-SHP). METHODS: This is a multicenter retrospective propensity score matched study. In the period between January 2014 and December 2018, we enrolled 161 patients with apical prolapse stage 2 or above, alone or with multicompartment descensus. RESULTS: After propensity-match analysis, there were 44 women for each group. Patients of the two groups had similar preoperative characteristics. No difference was found in terms of estimated blood loss, hospital stay, operative time, and intraoperative or postoperative complications. Subjective success rate, 12 months after surgery, was statistically better in the L-SCP group (P = 0.034): 81.8% and 97.8% women had Patient Global Impression of Improvement scores less than 3, in R-SHP and L-SCP, respectively. The objective cure rate was high in both groups without any significant differences in recurrence rate (P = 0.266). CONCLUSION: Both procedures are safe and effective in pelvic organ prolapse treatment. Patients who no longer desire uterine preservation could be encouraged to consider L-SCP. R-SHP is an alternative in women who are strongly motivated to preserve their uterus in the absence of abnormal uterine findings.

The first 60 cases of robotic sacrocolpopexy with the novel HUGO RAS system: feasibility, setting and perioperative outcomes.

Introduction: We present the preliminary report of the first 60 cases of robotic sacrocolpopexy (RSCP) performed with a minimally invasive approach by using the new HUGO RAS system (Medtronic) with the aim of assessing its feasibility, safety and efficacy. Methods: Results in terms of operative time, intraoperative blood loss, post-operative pain, length of hospitalisation, intra and post-operative complications were comparable to previously described laparoscopic and robotic techniques. Results: Urogynecological assessment at three months follow up showed surgical anatomic success in 96.7% of patients (<2 POP-Q stage), while subjective cure rate was 98.3%. Conclusions: This is the first series analyzing RSCP outcomes for POP using the new Hugo RAS system. Our results suggest effectiveness both in objective and subjective outcomes, with minimal intra and post-operative complications. Larger series as well as longer follow-up are needed to better define advantages and possible disadvantages of this novel system. Our work may represent the basis of future studies to confirm its safety, efficacy and feasibility, and may provide technical notes for other centres that wish to perform RSCP through this innovative system.

Is There a Role for Bladder Biopsy in the Diagnosis of Non-Hunner Lesions Interstitial Cystitis?

INTRODUCTION: Bladder pain syndrome/interstitial cystitis (BPS/IC) is either Hunner lesion interstitial cystitis (HL IC) or non-Hunner lesion interstitial cystitis (N-HL IC), differing in the presence of HLs on cystoscopy. Cystoscopy is essential in diagnosing HL but are bladder biopsies useful in N-HL IC patients? Our objective was to assess bladder biopsy in patients with N-HL IC, evaluating whether the count of mast cells (MCs) and percentage of activated MCs could measure severity. MATERIALS AND METHODS: This is a single-centre retrospective study. INCLUSION CRITERIA: diagnosis of BPS/IC by ESSIC definition; absence of HLs. Each patient had three bladder biopsies. STATISTICAL ANALYSIS: χ2/Fischer's exact test; Wilcoxon signed-ranks test/Mann-Whitney U test. Statistical significance: p < 0.05. RESULTS: We separated 48 women into Group 1 with <50% of MCs activated and Group 2 with >50%. We compared the results of the O'Leary-Sant questionnaire between the two groups and did not find any correlation between the severity of the pathology and either the MC count in the detrusor or the percentage of activated MCs in the lamina propria or detrusor. DISCUSSION/CONCLUSION: These findings cast doubt on the usefulness of bladder biopsy for the evaluation of severity in N-HL IC.

Laparoscopic posterior vaginal plication plus sacral colpopexy for severe posterior vaginal prolapse: A randomized clinical trial.

AIM: A randomized clinical trial proposing a new laparoscopic prosthetic and fascial approach to severe posterior vaginal prolapse. The primary endpoint was to evaluate the objective and subjective outcomes of our laparoscopic posterior plication (LPP) combined to "two-mesh" sacral colpopexy (laparoscopic sacral colpopexy [LSC]) in severe posterior vaginal prolapse, with a 1-year follow-up. The secondary endpoint was to evaluate the safety of this surgical procedure. METHODS: This is single-center prospective randomized double-blinded clinical trial. A total of 130 consecutive patients with anterior and/or apical pelvic organ prolapse (POP) (POP-Q stage ≥II) and severe posterior vaginal prolapse (posterior POP-Q stage ≥III) were prospectively assessed for inclusion into the study from November 2018 to January 2020. Patients underwent "two-meshes" LSC and were randomized in Group A (LSC plus LPP) and Group A (LSC alone). Of the 130 included subjects, 8 were excluded, not meeting inclusion criteria. Cure rate was evaluated objectively, using POP-Q study, and subjectively using PGI-I, POPDI-6, and FSDS questionnaires. Complications were assessed intra-, peri-, and postoperatively. Twelve-month follow-ups were analyzed for the study. RESULTS: We found in LSC plus LPP Group a significant improvement of Ap and genital hiatus POP-Q points. Our subjective study showed, at 12 months, a statistical difference in PGI-I successful outcomes rate in favor of LPP. Also the FSDS resulted significantly much more improved in Group A. We observed no statistical differences in terms of postoperative complications. CONCLUSIONS: Our LPP approach to LSC could be considered an effective and safe technique to POP patients with severe posterior prolapse.

Transobturator tape versus single incision sling: how are they different? Clinical outcomes and ultrasonographic features of two mid-urethral slings.

PURPOSE: Stress urinary incontinence (SUI) is usually treated with mid-urethral slings. The best approach is still debated and the relationship between slings and pelvic structures is not completely understood. The aim of this study is to identify any difference between trans-obturator tape (TOT) and single incision sling (minisling). METHODS: Patients submitted to TOT or minisling were included in the study. Q-tip and stress test, ICIQ-SF questionnaire, PGI-I validated score, and 2D/3D transvaginal ultrasound parameters were collected at 1- and 6-month follow-up. Correlations between ultrasound parameters and clinical outcomes, PGI-I and ICIq-SF, were performed. RESULTS: 61 patients were included in the study. PGI-I score was significantly lower in the minisling group than in TOT group at 1-month (p = 0.016) and 6-month follow-up (p = 0.076). The median distance between the sling and the lumen of urethra was significantly higher and the angle between the branches of the sling was significantly narrower in the minisling group. There were significant differences in distances between the sling and the bladder neck at 1-month and 6-month follow-up. An inverse correlation between angle of the branches and the Q-tip test was observed (p = 0.059 Pearson's Rho - 0.578). PGI-I correlated also with angle of the branches (p = 0.009, Pearson's Rho 0.503). CONCLUSION: Patients undergoing TOT or minisling are similarly satisfied but show differences at ultrasound exam at 1- and 6-month follow-up. Pelvic floor ultrasound could be used in a short-term follow-up to visualize the sling position and to plan the most appropriate follow-up strategy.

Laparoscopic uterosacral ligament suspension: a comprehensive, systematic literature review.

OBJECTIVES: Laparoscopic uterosacral ligament suspension (LUSLS) of the vaginal apex for the treatment of pelvic organ prolapse (POP) has gained popularity. The aim of this systematic review is to investigate perioperative outcomes and complications, subjective and objective success rates and recurrence rates in women undergoing this surgical procedure. STUDY DESIGN: A systematic literature search was performed in December 2021. The critical appraisal skills program (CASP) was used to assess the methodological quality of the selected studies. The Clavien-Dindo (CD) scale and the Satava scale were used to classify periprocedural complications. Continuous variables were described as means and standard deviations while categorical were expressed as percentages of the whole group. Statistical significance was set at p < 0.05. RESULTS: 26 articles were selected and analysed, with a total population of 1401 patients. Anatomical and subjective success rates after LUSLS ranged from 79% and 100% and from 76.2% to 100% respectively. The re-operation rate varied from 2% to 4.5% in the largest cohorts. The overall complication rate was 13.6%, however grade III CD complications occurred only in 1% of patients. Ureteral complications were described in only 2 cases. CONCLUSIONS: LUSLS represent a safe and effective technique for vaginal apex resuspension in women with POP. Further larger prospective randomized studies are required to confirm these data.

Redo laparoscopic sacrocolpopexy for POP recurrence: Is it the right call?

OBJECTIVES: As Laparoscopic Sacrocolpopexy (LSCP) has proven to be the gold-standard for treating Pelvic Organ Prolapse, management of recurrence after its failure is a challenge with upcoming interest. In these patients, repeat LSCP might represent a suitable surgical choice. STUDY DESIGN: We present a retrospective observational study analysing safety, feasibility and outcomes of Redo LSCP. Data of 20 patients with POP recurrence who underwent previous sacrocolpopexy were recruited, and all successfully underwent a repeat LSCP. RESULTS: Median 24-months follow-up demonstrated a statistically significant improvement of objective and subjective outcome. No intra and postoperative complications were noted. Anatomical cure rate was 95%. Subjective cure rate was 100%, with a statistically significant POP symptoms resolution and improvement of voiding and storage symptoms. We compared perioperative data and outcome of Redo patients to a population who underwent LSCP for a first-time diagnosed POP. The findings demonstrated that surgery did not differ from standard procedure in terms of intra/postoperative complications, hospital stay, blood loss, except for operative time. CONCLUSIONS: Minimally invasive Redo LSCP appears to be a safe and effective procedure in treating recurrent and symptomatic Pelvic Organ Prolapse. Our series shows low recurrence rates, comparable to data from patients who underwent their primary surgery for POP.

Laparoscopic ventral rectopexy plus sacral colpopexy: continuous locked suture for mesh fixation. A randomized clinical trial.

PURPOSE: Laparoscopic ventral rectopexy (LVR) plus sacral colpopexy (LSC) is a high-complexity surgical procedure. The aim of the present study was to evaluate a new approach to rectal-mesh fixation during LVR with continuous locked suture. METHODS: This is a prospective randomized double-blinded clinical trial enrolling 80 patients with severe POP and obstructed defecation syndrome (ODS) from November 2016 to January 2021. Patients underwent a "two-meshes" LSC plus LVR and were randomized, regarding rectal mesh fixation, in Group A (extracorporeal interrupted 0 delayed absorbable sutures) and Group B ("U-shaped" running locked 0 delayed absorbable suture). Our primary endpoints were the operative times (OT); the secondary endpoints were the incidence of anatomical failures, vaginal mesh erosions and surgical complications. RESULTS: A total of 75 patients completed the study. Baseline characteristics were similar between the groups. Overall OT (156 vs 138 min; p < 0.05; treatment reduction of 11.5%) and LVR mesh fixation time (29 vs 16 min; p < 0.05; treatment reduction of 44%), resulted in significantly lower in Group B. No differences were found in terms of anatomic failure, vaginal mesh erosion or intra- or post-operative complications. PGI-I, FSDS and Wexner questionnaires resulted significantly improved after surgery, without statistical differences between the studied surgical procedures. CONCLUSION: Laparoscopic continuous locked 0 absorbable suture for LVR mesh fixation guaranteed a faster and effective alternative to multiple interrupted sutures. The significant OT reduction linked to this technique should be considered even more helpful when performing a highly complex surgery such as LVR. CLINICAL TRIAL REGISTRATION: NCT05254860 (13/02/2017).

Altis® Adjustable Single Incision Sling System for Treatment of Intrinsic Sphincteric Deficiency: A 3-Year Follow-up Observational Study.

IMPORTANCE: This article is a long-term follow-up study on the Altis adjustable single incision sling (Coloplast Corp.) in patients with isolated intrinsic sphincteric deficiency (ISD). OBJECTIVES: The primary end-points were to evaluate the subjective and objective outcomes of the Altis for the treatment of ISD, with a 3-year follow-up. The secondary end-point was to evaluate the safety of this surgical procedure. STUDY DESIGN: This is a retrospective single-arm study. A total of 123 consecutive patients with ISD were selected from our database among women who underwent an Altis implantation for ISD from March 2015 to June 2017, after unsuccessful previous conservative treatment. Of the 123 included patients, 16 were excluded, not meeting inclusion criteria. Cure rate was evaluated objectively, using a standardized cough stress test and urodynamics, and subjectively using the Patient Global Impression of Improvement. Complications were assessed intraoperatively, perioperatively, and postoperatively. Six, 12, and 36 months of follow-ups were analyzed for the study. RESULTS: The 3-year objective cure rate was 86.9%, and the subjective cure rate was 81.5%. We observed no intraoperative complications. No women were obstructed. Ten patients reported postoperative complications, although most of them were Clavien-Dindo grade I and self-limited. CONCLUSIONS: Altis system could be considered an effective and safe alternative to traditional midurethral slings as treatment for women with ISD.

Laparoscopic High Uterosacral Ligament Suspension vs. Laparoscopic Sacral Colpopexy for Pelvic Organ Prolapse: A Case-Control Study.

Introduction: Laparoscopic sacral colpopexy is the gold standard technique for apical prolapse correction but it is a technically challenging procedure with rare but severe morbidity. Laparoscopic high uterosacral ligament suspension could be a valid technically easier alternative using native tissue. Material and Methods: In the period from 2015 to 2018, 600 women were submitted to laparoscopic sacral colpopexy while 150 to laparoscopic high uterosacral ligament suspension in three Italian urogynecology referral centers. We enrolled women with apical prolapse stage ≥2 alone or multicompartment descensus. To reduce allocation bias, we performed a propensity matched analysis. Women undergoing laparoscopic high uterosacral ligament suspension surgery were matched 1:2 to women undergoing laparoscopic sacral colpopexy. The cumulative proportion of relapse-free women in time was analyzed by the Kaplan-Meier method. The primary objective of this multicenter case-control retrospective study was to compare the recurrence rate while the secondary objectives were to compare feasibility, safety, and efficacy of laparoscopic sacral colpopexy and laparoscopic high uterosacral ligament suspension in surgical treatment of pelvic organ prolapse. Results: Three hundred and nine women were enrolled (103 laparoscopic high uterosacral ligament suspension; 206 laparoscopic sacral colpopexy). Median operatory time was significantly shorter in the laparoscopic high uterosacral ligament suspension group (P = 0.0001). No statistically significative difference was found in terms of estimated blood loss, admission time, intraoperative, and major early postoperative complications, postoperative pelvic pain, dyspareunia and de novo stress urinary incontinence. Surgical approach was the only independent risk factor for prolapse recurrence (RR = 6.013 [2.965-12.193], P = 0.0001). The objective cure rate was higher in the laparoscopic sacral colpopexy group (93.7 vs. 68%, 193/206 vs. 70/103, P = 0.0001) with a highly reduced risk of recurrence (RR = 5.430 [1.660-17.765]). Median follow up was 22 months. Conclusion: Both techniques are safe, feasible, and effective. Laparoscopic sacral colpopexy remains the best choice in treatment of multicompartment and advanced pelvic organ prolapse while laparoscopic high uterosacral ligament suspension could be appropriate for moderate and isolated apical prolapse when laparoscopic sacral colpopexy is not suitable for the patient or to prevent prolapse in women at high risk at the time of the hysterectomy.

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.

Laparoscopic lateral suspension for pelvic organ prolapse: A systematic literature review.

BACKGROUND: Abdominal lateral suspension with mesh represents an alternative treatment to suspend the vaginal apex. OBJECTIVES: The aim of this study was to summarize literature data regarding the anatomical and functional outcomes, and intra- and postoperative complications of this technique with minimally invasive approach (laparoscopic/robotic). SEARCH STRATEGY: Systematic literature search using MEDLINE/PubMed, SCOPUS, Web of Science. DATA COLLECTION AND ANALYSIS: Two authors extracted data on baseline characteristics (age, BMI, prior pelvic reconstructive surgery, preoperative POP stage), perioperative outcomes (operative time, estimated blood loss, intraoperative and postoperative complications, admission time), objective and subjective success rate, surgical failure, time of follow-up. Data were presented descriptively. MAIN RESULTS: Thirteen studies were included in the review. The overall number of patients for our analysis was 1066. Patients referred for laparoscopic/robotic lateral suspension were most frequently postmenopausal, aged 50 to 65 years, BMI ≥ 25 kg/m2; 22.2% were already hysterectomized, while 17% had already a previous POP surgery. Operative time ranged from 78.4 ± 29.7 to 254 ± 45 min. The overall anatomic success was more than 90% in the apical compartment and more than 88% in the anterior compartment. Subjective cure rate varies from 78.4% to 100% in medium-term follow-up. Post-operative complication grade >= 3 according to Claiven-Dindo Scale was 1.03%. Mesh erosion rate varied between 0% and 13%. CONCLUSIONS: Results coming from our systematic review suggest safety, efficacy and feasibility of minimally invasive lateral suspension with optimal anatomical and functional outcomes. Well-designed, randomized, controlled trials are required to confirm this data.

Quality of life recovery after laparoscopic high uterosacral ligament suspension: a single centre observational study.

OBJECTIVE: Laparoscopic high uterosacral ligament suspension (l-HUSLS) is a laparoscopic-transposed vaginal technique for the treatment of pelvic organ prolapse. Nowadays data regarding quality of life and sexual functions in patients who underwent l-HUSLS for pelvic organ prolapse are few and generic with most of the study investigating the anatomical outcome. For these reasons, the aim of our study is to evaluate these subjective outcomes in women undergoing this surgical procedure with the support of validated questionnaires. STUDY DESIGN: This is a retrospective study with the primary aim of analysing the quality of life, sexual function, patient satisfaction rates and anatomical outcome among patients who underwent l-HUSLS in our institution. The SPSS Version 26.0 for Windows (Statistical package for the social studies, Chicago, IL, USA) was used for the statistical analysis. RESULTS: A total of 60 patients underwent l-HUSLS between 2016 and 2018. All patients had a high grade of apical prolapse. No intraoperative and major postoperative complications were registered. The median follow-up was 24 months (24-48). PGI-I score was 1-2 in 55 (91.6 %) women. We observed a significant improvement of EQ-5D index and VAS scores from the baseline to the 2 years follow-up: from 0.72 (0.67-1) to 0.91 (0.79-1) and from 50 (30-90) to 70 (50-100) respectively (p = 0.000). All women showed a statistically significant amelioration of FSDS and ICIQ-SF scores. Anatomical success rate after 24 months was 83.7 %. CONCLUSIONS: l-HUSLS appears to be a safe, feasible and effective treatment for advanced pelvic organ prolapse with high rates of patient self-reported cure.

Minimally invasive surgery in urogynecology: a comparison of standard laparoscopic, minilaparoscopic, percutaneous surgical system, and robotic sacral colpopexy.

BACKGROUND: We compared surgical outcome of sacral colpopexy (SCP) performed with the most recent minimally invasive surgery such as 3-mm laparoscopy (Mini-LPS), percutaneous system (PSS), standard laparoscopy (LPS), and robotic surgery. METHODS: This is a multicenter retrospective cohort study conducted at Urogynecological Department of the IRCCS A. Gemelli University Polyclinic Foundation in Rome and at the Gynecological Clinic of Maggiore della Carità Hospital in Novara, and of the Polyclinic of Abano. We collected data of 115 patients who underwent laparoscopic SCP for pelvic organ prolapse between June 2017 and June 2018 using PSS, Mini-LPS, standard LPS, and da Vinci Si. RESULTS: Patients of all four groups had similar characteristics. The median operative time (OT) was significantly longer in robotic procedure compared to all other groups There were no significant differences between the four groups in terms of estimated blood loss, conversion to laparotomy, intraoperative complications and median postoperative ileus. Visual Analogue Scale (VAS) at 4 hours was significantly less for Mini-LPS compared to the other techniques. VAS at 24 hours was higher for robotic procedures than other techniques. CONCLUSIONS: Results rule out that minimize surgical invasiveness of laparoscopic techniques could bring improvements in SCP not only from a cosmetic point of view but also from a functional one without requiring longer OT and maintaining the same standard laparoscopic configuration. Even if robotic SCP is useful and safe because of its guarantee of efficiency, it cannot be considered the first choice for many women.

Laparoscopic high uterosacral ligament suspension (modified Shull technique): A case series and a step by step description of surgical procedure.

OBJECTIVE: In this series we investigate the safety, feasibility and efficacy of our laparoscopic modified Shull technique describing the fundamental aspects of this surgical procedure in order to add a new feasible abdominal approach for apex resuspension. STUDY DESIGN: A retrospective case series of 10 patients referring to our Urogynecological department for symptomatic apical prolapse, enrolled consecutively between September 2018 and November 2018. All women underwent the presented technique which we described in detail explaining the fundamental tips and tricks of our procedure. We examined perioperative details, postoperative complication- evaluated with Clavien-Dindo's classification-, anatomical outcome and subjective satisfaction, assessed with the Patient Global Impression of Improvement questionnaire. RESULTS: All women presented symptomatic apical prolapse of II-III grade. No perioperative complications including ureteral damages were recorded. There was only one case of de novo stress urinary incontinence. At 1-year follow-up the POP-Q apex was well suspended in all women with only 2 cases of asymptomatic anterior recurrence. All patients reported a complete resolution of pelvic organ prolapse (POP)-related symptoms and were fully satisfied with the treatment received. CONCLUSION: Laparoscopic modified Shull technique suggests safety, feasible and efficacy in the treatment of apical prolapse. In addition, this report represents a useful instrument for surgeon to understand key aspects of this surgical procedure allowing to him to perform the described technique in a safe and timely manner.

Laparoscopic sacral colpopexy for pelvic organ prolapse recurrence after transvaginal mesh surgery.

OBJECTIVE: Pelvic organ prolapse (POP) recurrence in transvaginal mesh surgery patients has become increasingly common, due to widespread mesh use before the FDA alert. The aim was to assess feasibility, effectiveness and safety of laparoscopic sacral colpopexy (LSCP) in recurrent POP after previous vaginal surgery with polypropylene mesh. STUDY DESIGN: Medical records of 20 patients with ≥ stage 2 POP recurrence, who underwent LSCP from January 2015 to July 2018, were retrospectively analyzed in a monocentric observational study. We analyzed operative time, intraoperative complications - defined as bowel, bladder, ureteral, or vascular injuries, post-operative complications - assessed with Clavien-Dindo's classification, and postoperative patient satisfaction - evaluated with the Patient Global Impression of Improvement questionnaire. Pre- and postoperative data were compared using t-test. RESULTS: All women presented apical prolapse recurrence regardless of mesh type implanted and most of them involved the posterior compartment. No perioperative complications or cases of mesh extrusion, de novo urinary stress, urge incontinence, dyspareunia were recorded. At 12-month follow-up the POP-Q examinations demonstrated a statistically significant improvement of all parameters with a complete resolution of bulge, voiding and storage symptoms in all patients. CONCLUSION: LSCP suggests safety, feasible and efficacy in the treatment of recurrent POP after prior transvaginal polypropylene mesh surgery. We suggest to conduct a prospective research with larger sample size to gain further insights.

Titanized polypropylene mesh in laparoscopic sacral colpopexy.

INTRODUCTION: This study investigated perioperative and mid-term clinical outcomes after laparoscopic sacrocolpopexy (LSCP) with light titanium-coated polypropylene (TCP) mesh in a large group of patients affected by International Continence Society stage II-IV pelvic organ prolapse (POP). METHODS: This multicenter retrospective study included 217 patients treated with LSCP using TCP mesh. We aimed to (1) analyze the intra- and postoperative complication rates according to the ICS/IUGA Complication Classification Code guidelines, (2) evaluate the anatomical results and (3) assess postoperative patient satisfaction with the Patient Global Impression Improvement questionnaire. Nonparametric Wilcoxon signed-rank tests, χ2 test and Fisher's exact test were used where appropriate. RESULTS: The intraoperative complications were two (0.9%) cases of hemorrhage, two (0.9%) cases of incidental cystotomy and four (1.8%) cases of incidental colpotomy. During the postoperative follow-up, we recorded mesh exposure in 3 (1.4%) out of 217 patients. These 3 patients were from a group of 22 women who underwent vaginal opening during surgery, while in the remaining 195 patients without incidental colpotomy, no mesh exposure was observed (13.6% vs. 0.0%, p < 0.001). No failure of the apical compartment was observed, while 3 (1.4%) out of 217 patients experienced isolated anterior recurrence, and 1 (0.4%) patient had isolated posterior recurrence. All patients reported PGI-I scores ≥ 3, and 209 patients (96.3%) had a PGI-I score ≥ 2. CONCLUSIONS: The use of light TCP mesh is safe and effective during LSCP for POP repair from both an anatomical and a functional point of view, posing a very low postoperative mesh-related complication risk.