From 3D to 2D-4K laparoscopic sacral colpopexy: are we addicted to technology?

OBJECTIVE: A study analyzing perioperative outcomes related to a sudden switch from 3D to 2D-4K technology for laparoscopic sacral colpopexy by expert pelvic surgeons: are we addicted to technology? MATERIAL AND METHODS: After a sudden transition from 3D to 2D-4K laparoscopic technology, a total of 115 consecutive pelvic prolapse patients who underwent sacral colpopexy from June 2020 to September 2021 were retrospectively assessed from our database. Perioperative parameters, operative times (OT), and intraoperative difficulty scales were assessed. One-year follow-ups were analyzed for the study. Primary endpoints were OT; secondary endpoint was the evaluation of complications linked to this procedure. RESULTS: We found statistical differences in OT and intraoperative difficulty scales between medians of the last 3D procedures and the first ten 2D-4K surgeries, without differences between operators. Only after more than 20 surgeries, we observed no significant differences between 3D and 2D-4K sacral colpopexy. We observed no statistical differences in terms of anatomic failure, PGI-I, and intra-postoperative complications. CONCLUSION: The transition of urogynecology from an exclusive vaginal approach to 2D-3D-4K laparoscopy significantly increased the level of technology necessary for surgical treatment of prolapse. This could, as a result, lead to pelvic surgeons becoming increasingly dependent on technology.

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.

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).

Abdominal versus robotic sacral colpopexy: A detailed analysis of outcomes.

AIMS: Although abdominal sacrocolpopexy (ASC) is considered the gold standard for surgical repair of vaginal vault prolapse, the open surgical approach has significant morbidity. We aim to compare anatomic and functional outcomes in women receiving either robotic-assisted sacral colpopexy (RSC) or ASC for post-hysterectomy prolapse. METHODS: We present a retrospective chart review of all women who underwent ASC and RSC at our institution and had 12-month follow-up (FU). Pelvic organ prolapse quantification (POP-Q) staging was assessed both preoperatively and postoperatively. Perioperative and demographic details were collected from the medical records. RESULTS: One hundred twenty four women underwent RSC (mean age 63, median FU 16 months). Those in the ASC group (n = 144) were statistically younger (mean age 60) and had longer FU (median 60 months). Both median day of successful voiding trial and discharge day significantly favored RSC. There were no Clavien Grade IV/V complications for either procedure and three RSC procedures were converted to ASC. Both approaches were associated with a significant improvement in POP-Q stage at FU, with few women requiring additional surgery. Overall, 76% of women in each group were dry from stress urinary incontinence. Improvement in storage and emptying indices, dyspareunia, and quality of life measures was observed after both approaches. CONCLUSION: RSC demonstrates good support of significant vaginal vault prolapse at medium term FU, with shorter hospital stays and low complication rates. Close FU after RSC over a longer period will be needed to fully assess durability of both functional and anatomic outcomes.

Assessing pelvic organ prolapse recurrence after minimally invasive sacrocolpopexy: does mesh weight matter?

INTRODUCTION AND HYPOTHESIS: There has been a trend toward the use of ultra-lightweight mesh types for minimally invasive sacrocolpopexy. We hypothesized that ultra-lightweight mesh would have a greater proportion of composite anatomical pelvic organ prolapse recurrence than lightweight mesh. METHODS: Retrospective cohort study of minimally invasive sacrocolpopexies at two academic institutions from 2009 to 2016. Our primary outcome was composite anatomical prolapse recurrence, defined as prolapse beyond the hymen or retreatment with pessary or surgery, compared between ultra-lightweight (≤21 g/m2 [range 19-21]) and lightweight (>21 g/m2 [range 35-50]) mesh types. We assessed time to prolapse recurrence using Kaplan-Meier and Cox regression. RESULTS: The cohort consisted of 1,272 laparoscopic (n = 530, 41.7%) and robotic-assisted sacrocolpopexies (n = 742, 58.4%). Lightweight mesh was used in 745 procedures (58.6%) and ultra-lightweight mesh in 527 (41.4%). The lightweight mesh had longer median follow-up than the ultra-lightweight group (344 [IQR 50-670] vs 143 days [IQR 44-379], p < 0.01). There was no difference in composite anatomical prolapse recurrence between lightweight and ultra-lightweight mesh (54 [7.2%] vs 35 [6.6%], p = 0.68). Ultra-lightweight mesh demonstrated a shorter time to prolapse recurrence (p < 0.01), which remained significant on multivariate Cox regression (HR 2.38 [95% CI 1.47-3.87]). The lightweight mesh had significantly more mesh complications (43 [5.8%] vs 7 [1.3%], p < 0.01). CONCLUSIONS: Ultra-lightweight mesh for minimally invasive sacrocolpopexy was not associated with a higher proportion of composite anatomical prolapse recurrence; however, it was associated with a shorter time to recurrence. Longer follow-up is needed to assess the clinical importance of this finding, particularly given the trade-off of more complications with lightweight mesh.

Should we perform subtotal hysterectomy associated with sacral colpopexy for genital prolapse to prevent the risk of endometrial cancer?

OBJECTIVE: In a menopausal woman scheduled for curative surgery for pelvic organ prolapse (POP) by sacral colpopexy (SC), the question of concomitant hysterectomy is frequently considered by the surgeon. The risk of endometrial cancer (EC) exists in this population, and increases with age and body mass index. The French college of gynecologists and obstetricians (CNGOF) decided to issue good practice guidelines on subtotal hysterectomy (SH) for postmenopausal women scheduled for SC for POP. METHODS: The CNGOF has decided to adopt the AGREE II and GRADE systems for grading scientific evidence. Each recommendation for practice was allocated a grade, which depends on the quality of evidence (QE) (clinical practice guidelines). RESULTS: The prevalence of occult endometrial cancer (EC) found on pathological analysis after SH in this context (concomitant SH associated with SC) is low (<1%) (QE: high). Few studies have assessed the value of preoperative uterine exploration. Performing SH during SC is associated with its own risks, which may diminish the potential "carcinological prevention benefit". Uterine morcellation, performed by laparoscopy or a robot-assisted procedure, is associated with a low risk (<0.6%) of dissemination of an unknown sarcoma/EC (QE: moderate) A risk of dissemination of parasitic myomas (<0.5%) is also possible (QE: moderate). CONCLUSION: It is not recommended to perform a subtotal hysterectomy associated with sacral colpopexy for the sole purpose of reducing the occurrence of endometrial cancer (Recommendation: STRONG [GRADE 1-]; the level of evidence was considered to be low and the risk-benefit balance was considered not to be favorable).

Laparoscopic sacral colpopexy with polyester fiber suture: Ozerkan modification.

INTRODUCTION AND HYPOTHESIS: Mesh-related problems are significant complications of laparoscopic sacral colpopexy. The conventional technique precludes performing laparoscopic sacral colpopexy without using a mesh. We describe the Ozerkan modification for laparoscopic sacral colpopexy using a polyester fiber suture instead of a standard mesh and report 1-year objective and subjective outcomes. METHODS: Women diagnosed with stage ≥ 2 vaginal vault prolapse were prospectively recruited for the Ozerkan modification between 2015 and 2017. The primary outcome was the anatomic success of the repair, defined by objective parameters using the pelvic organ prolapse quantification system (stage 0 or 1). Secondary outcomes were subjective outcomes assessed with the quality of life scores. RESULTS: Twenty-two women underwent the Ozerkan modified laparoscopic sacrocolpopexy. Mean operation time was 85.6 min. Mean estimated blood loss was 71 ml. One patient was lost during the clinical follow-up in the outpatient clinic up to 1 year. Nineteen of 21 patients had stage 0 or 1 prolapse at the end of 1 year. Two patients were not satisfied with their pelvic floor after 1 year. Both the objective and subjective cure rates were 90.4%. There were no bladder or bowel complications during the peri- or postoperative period. CONCLUSIONS: The new modification of laparoscopic sacral colpopexy seems a feasible and safe option to avoid mesh complications in the treatment of vaginal vault prolapse.

Laparoscopic Mesh Repair for Perineal Hernia after En Bloc Resection of an Aggressive Angiomyxoma Using a Modified Sacral Colpopexy Technique.

STUDY OBJECTIVE: To demonstrate laparoscopic mesh repair of perineal hernia (PH) by a modified sacral colpopexy technique. DESIGN: Step-by-step demonstration of the technique used for the surgical repair of PH after gynecologic surgery. SETTING: PH is defined as a pelvic floor defect through which the intra-abdominal viscera may protrude [1]. The reported incidence of PH ranges from 0.6% to 3%, and it generally occurs after rectal or prostate surgery [2]. Owing to its low incidence, there is no standard procedure to treat PH [3]. Herein, we demonstrate a successful case of PH treatment with a composite mesh (Dual Mesh; W. L. Gore & Associates, Newark, DE) after gynecologic surgery by a modified laparoscopic sacral colpopexy technique, which was approved by our institutional review board. INTERVENTIONS: The patient had undergone extralevator abdominoperineal excision for an aggressive angiomyxoma and developed a sigmoid colon-protrudent PH after the surgery [4]. The patient suffered from defecatory dysfunction and dysmenorrhea. A total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and mesh repair of the PH were performed at 2 years after the primary surgery, and they were successful without any intra- or postoperative complications. Because the pelvic floor defect was too large to secure the mesh by a simple placement, we applied the modified sacral colpopexy technique using 2-0 proline (ETHICON, Tokyo, Japan) to cover and support this defect. At 12 months after the second surgery, there was no sign of recurrence of PH and aggressive angiomyxoma, and the preoperative symptoms had diminished. CONCLUSION: Laparoscopic mesh repair by the modified sacral colpopexy technique is safe and effective to manage PH.

Robot-assisted surgery for the management of apical prolapse: a bi-centre prospective cohort study.

OBJECTIVE: Robot-assisted surgery is a recognised treatment for pelvic-organ prolapse. Many of the surgical subgroup outcomes for apical prolapse are reported together, leading to a paucity of homogenous data. DESIGN: Prospective observational cohort study (NCT01598467, clinicaltrials.gov) assessing outcomes for homogeneous subgroups of robot-assisted apical prolapse surgery. SETTING: Two European tertiary referral hospitals. POPULATION: Consecutive patients undergoing robot-assisted sacrocolpopexy (RASC) and supracervical hysterectomy with sacrocervicopexy (RSHS). METHODS: Anatomical cure (simplified Pelvic Organ Prolapse Quantification, sPOPQ, stage 1), subjective cure (symptoms of bulge), and quality of life (Pelvic Floor Impact Questionnaire, PFIQ-7). MAIN OUTCOME MEASURES: Primary outcome: anatomical and subjective cure. SECONDARY OUTCOMES: surgical safety and intraoperative variables. RESULTS: A total of 305 patients were included (RASC n = 188; RSHS n = 117). Twelve months follow-up was available for 144 (RASC 76.6%) and 109 (RSHS 93.2%) women. Anatomical success of the apical compartment occurred for 91% (RASC) and in 99% (RSHS) of the women. In all compartments, the success percentages were 67 and 65%, respectively. Most recurrences were in the anterior compartment [15.7% RASC (symptomatic 12.1%); 22.9% RSHS (symptomatic 4.8%)]. Symptoms of bulge improved from 97.4 to 17.4% (P < 0.0005). PFIQ-7 scores improved from 76.7 ± 62.3 to 13.5 ± 31.1 (P < 0.0005). The duration of surgery increased significantly for RSHS [183.1 ± 38.2 versus 145.3 ± 29.8 (P < 0.0005)]. Intraoperative complications and conversion rates were low (RASC, 5.3 and 4.3%; RSHS, 0.0 and 0.0%). Four severe postoperative complications occurred after RASC (2.1%) and one occurred after RSHS (1.6%). CONCLUSIONS: This is the largest reported prospective cohort study on robot-assisted apical prolapse surgery. Both procedures are safe, with durable results. TWEETABLE ABSTRACT: European bi-centre trial concludes that robot-assisted surgery is a viable approach to managing apical prolapse.

Intraocular pressure change during laparoscopic sacral colpopexy in patients with normal tension glaucoma.

INTRODUCTION AND HYPOTHESIS: The steep Trendelenburg position, high pneumoperitoneum pressure, and longer surgical time may lead to significantly increased intraocular pressure (IOP), which could result in unexpected eye disease complications, including perioperative visual loss (POVL). We monitored IOP to induce early laparoscopic sacral colpopexy (LSC) safely. METHODS: This prospective study enrolled 39 patients with pelvic organ prolapse (POP), including 10 with eye diseases (6 with normal tension glaucoma and 4 with a narrow anterior chamber and normal range IOP). Enrolled patients underwent LSC under the same surgical settings involving a pneumoperitoneum of 10 mmHg and a Trendelenburg position of 15°. We measured IOP at seven time points during surgery and estimated IOP changes with time in patients with or without eye diseases. RESULTS: All patients, with or without eye diseases, experienced significantly elevated IOP during LSC. There were no significant differences between these groups. The average maximal IOP reached 20 mmHg at the end of surgery, and recovered to baseline values with the patient in the supine position at the end of anesthesia. No patient had an IOP of >40 mmHg as a critical threshold during surgery, and no substantial clinical eye symptoms were seen after LSC. CONCLUSIONS: Laparoscopic sacral colpopexy using an pneumoperitoneum of 10 mmHg and a Trendelenburg position of 15° during a 3-h surgical period could be performed within a safe range of IOP.

Outcomes of stress urinary incontinence in women undergoing TOT versus Burch colposuspension with abdominal sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: To compare postoperative rates of stress urinary incontinence (SUI) in patients with pelvic organ prolapse and SUI undergoing abdominal sacrocolpopexy (ASC) with Burch colposuspension or a transobturator tape (TOT) sling. METHODS: In this retrospective cohort study, medical records of 117 patients who underwent ASC with Burch (n = 60) or TOT (n = 57) between 2008 and 2010 at NYU Winthrop Hospital were assessed. Preoperative evaluation included history, physical examination, cough stress test (CST), and multichannel urodynamic studies (MUDS). Primary outcomes were postoperative continence at follow-up up to 12 weeks. Patients considered incontinent reported symptoms of SUI and had a positive CST or MUDS. Secondary outcomes included intra- and postoperative complications. Associations were analyzed by Fisher's exact, McNemar's and Wilcoxon-Mann-Whitney tests. RESULTS: The groups were similar regarding age, BMI, parity, Valsalva leak point pressure (VLPP), and prior abdominal surgery (p = 0.07-0.76). They differed regarding preoperative SUI diagnosed by self-reported symptoms, CST, or MUDS (TOT 89.5-94.7%, Burch 60.7-76.3%, p < 0.0001-0.007). The TOT group had lower rates of postoperative SUI (TOT 12.5%, Burch 30%, OR = 0.15, 95% CI 0.04, 0.62). Relative risk reduction (RRR) in postoperative SUI for the TOT group compared with the Burch group was 79%-86%. There were no differences concerning intra- and postoperative complications. The Burch group had a higher rate of reoperation for persistent/recurrent SUI (Burch 25%, TOT 12% p = 0.078). CONCLUSIONS: The TOT group experienced a greater reduction in postoperative incontinence, and the Burch group underwent more repeat surgeries. The TOT sling may be superior in patients undergoing concomitant ASC.

Anatomical outcomes 1 year after pelvic organ prolapse surgery in patients with and without a uterus at a high risk of recurrence: a randomised controlled trial comparing laparoscopic sacrocolpopexy/cervicopexy and anterior vaginal mesh.

INTRODUCTION AND HYPOTHESIS: Few studies have compared the different approaches of mesh surgery in patients with severe pelvic organ prolapse (POP). In addition to laparoscopic sacrocolpopexy/cervicopexy (LSC-Cx), anterior vaginal mesh (AVM) may be an effective approach for correcting anterior vaginal wall associated with apical POP in women with advanced POP. METHODS: A randomised controlled trial (RCT; January 2011 to March 2016) including 120 patients (60/group) with advanced symptomatic POP, with a predominant anterior vaginal wall descent stage III or greater in combination with a stage II or III apical defect (uterus or vaginal vault). Patients underwent four visits: baseline, 3, 6 and12 months after surgery. The main outcome was anatomical success defined as anterior and posterior vaginal wall not descending beyond the hymen and vaginal apex descent no more than one third into the vagina. Secondary variables: PFDI, ICIQ-UI-SF, intraoperative variables, postoperative morbidity and complications. RESULTS: Anatomical success was achieved with LSC-Cx in 79% and with AVM in 76% (NS). No statistically significant differences were found among POP-Q anterior vaginal wall points between groups, whereas better results were obtained with LSC-Cx in posterior vaginal wall points and total vaginal length. Intraoperative outcomes were similar in the two groups, except for operating time (78.05 min LSC-Cx vs 44.28 min AVM). There were no statistically significant differences related to de novo stress urinary incontinence and dyspareunia. Worse results were found in the CRADI-8 in the LSC-Cx group, owing to constipation. Late postoperative complications and reinterventions were similar in the two groups. CONCLUSIONS: No differences were found in the anatomical correction of anterior and apical POP. The LSC-Cx group presented better correction of posterior vaginal wall defects and a longer total vaginal length.

Comparison between laparoscopic uterus/sacrocolpopexy and total pelvic floor reconstruction with vaginal mesh for the treatment of pelvic organ prolapse.

AIM: To compare total pelvic floor reconstruction with vaginal mesh (TVM) and laparoscopic uterus/sacrocolpopexy (LSC) for the treatment of pelvic organ prolapse (POP). METHODS: Six hundred and seventy patients with POP stage 3 and 4 underwent LSC (n = 350) or TVM (n = 320) at the West China Second Hospital, Sichuan University between January 2011 and December 2016. Retrospective analysis was done to compare the POP-Q value before operation and 6 months, 5 years after operation, also compare the, patient global impression of change (PGI-C), pelvic floor distress inventory (PFDI-20) and pelvic floor impact questionnaire (PFIQ-7). Patients were followed for a median 36 months. Thirty-five patients in the LSC and 37 in the TVM groups were lost to follow-up. RESULTS: Preoperative POP value and disease course were similar (P = 0.075). The LSC group was younger (52.8 ± 6.8 vs. 63.9 ± 8.7 years, P = 0.037). Intraoperative bleeding was smaller in the LSC group (74.4 ± 33.2 vs. 150.4 ± 80.3 mL, P < 0.01), with longer operation time (130.0 ± 34.1 min vs 100.4 ± 40.4 min, P < 0.035). The patients were followed for 10-60 months (median, 36 months). Postoperative PISQ-12 (P < 0.01) was better in the LSC group. PFDI-20 and PFIQ-7 were improved after operation in both groups. Objective satisfaction (94.9% vs 91.9%, P > 0.05) and recurrence rate (8.4% vs 5.1%, P = 0.064) were similar. No infection or fistula occurred after operation in both groups. The complication rate of intraoperative bladder injury and postoperative perineal pain in LSC group was lower than those in the TVM group (P < 0.05). CONCLUSION: LSC showed no serious adverse events and led to higher postoperative satisfaction than TVM in selected patients. Nevertheless, treatment should be selected in accordance with the willingness and condition of each patient.

Postoperative urinary retention after pelvic organ prolapse repair: Vaginal versus robotic transabdominal approach.

AIMS: Postoperative urinary retention has been reported in 13-32% of patients that undergo pelvic organ prolapse (POP) repair. The purpose of our study was to compare rates of urinary retention between transvaginal and robotic transabdominal approaches and identify risk factors for postoperative urinary retention following POP repair. METHODS: Medical records of patients that underwent POP repair were reviewed. Surgeries included transvaginal high uterosacral ligament suspension (HUSLS) and robotic-assisted sacral colpopexy (RASCP). All patients underwent a retrograde fill voiding trial (RGVT) postoperatively. Demographics, comorbidities, preoperative urodynamic findings, and surgical procedures were compared between women that passed their RGVT and those that did not. RESULTS: Out of 484 patients reviewed, 333 underwent POP repair with a transvaginal HUSLS and 151 underwent RASCP. Postoperative urinary retention was identified in 128 (26.4%) patients where 113 underwent transvaginal HUSLS and 15 underwent RASCP. The odds ratio (OR) of postoperative urinary retention following transvaginal HUSLS was 3.26 (CI 1.72-6.18; P < 0.001) compared to RASCP. Older age was also a risk factor for postoperative urinary retention (OR 1.03, CI 1.01-1.05; P = 0.012). While parity, preoperative post-void residual (PVR), and rates of concomitant transvaginal anterior/posterior repair were significantly higher in patients that developed postoperative urinary retention on univariate analysis, these factors did not demonstrate significance on multivariate analysis. CONCLUSIONS: Transvaginal HUSLS demonstrates a 3.26 OR for postoperative urinary retention compared to the robotic transabdominal approach. Older age is also a significant risk factor whereas parity, preoperative PVR, and rates of concomitant transvaginal anterior/posterior repair were not significant risk factors on multivariate analysis.

Hysteropexy: an Option for the Repair of Pelvic Organ Prolapse.

PURPOSE OF REVIEW: Women have an estimated 12.6% lifetime risk of undergoing surgery for pelvic organ prolapse in the USA (Wu et al. in Obstet Gynecol 123(6): 1201-6, 2014). Surgical repair of uterovaginal prolapse most commonly includes hysterectomy and vaginal vault suspension; however, the value of concomitant hysterectomy is uncertain, and there appears to be growing interest in uterine conservation. Multiple procedures have evolved using a variety of approaches. The aim of this paper is to review uterine sparing (hysteropexy) prolapse repair techniques and outcomes. RECENT FINDINGS: Several randomized controlled trials (RCT) have shown comparable success rates for apical compartment support with sacrospinous hysteropexy as compared to vaginal hysterectomy with uterosacral ligament suspension, with shorter hospitalization and quicker return to work. (Detollenaere et al. in BMJ 351: h3717, 2015); (Dietz et al. in Int Urogynecol J Pelvic Floor Dysfunct 21(2): 209-16, 2010). Available data suggest vaginal mesh hysteropexy is as effective as vaginal mesh with hysterectomy, with lower rates of mesh exposure. (Maher et al., 2017) To date, no RCTs have been published comparing sacral hysteropexy to hysterectomy with sacral colpopexy. Overall, there is a higher reoperation rate for sacral hysteropexy and a higher mesh exposure rate for hysterectomy with sacral colpopexy. (Maher et al., 2017) No RCTs have been published comparing hysteropexy surgical approaches. Although hysteropexy data is expanding, there is a need for more information regarding long-term surgical durability, appropriate patient selection, and whether one approach is superior to another.

Transvaginal Single-Port Laparoscopy Sacrocolpopexy.

STUDY OBJECTIVE: More and more patients are pursuing minimally invasive surgery, which is becoming the trend for gynecologic surgery today. Pelvic organ prolapse (POP) is no exception. With the application of natural orifice transluminal endoscopic surgery, minimally invasive transvaginal sacrocolpopexy surgery assisted by single-port laparoendoscopy for POP becomes feasible. Here we describe our technique of transvaginal sacrocolpopexy using single-port laparoscopy for middle compartment POP. DESIGN: Step-by-step explanation of the procedure using video. SETTING: University hospital. PATIENT: A 59-year-old woman from China. INTERVENTIONS: Transvaginal single-port laparoscopy sacrocolpopexy. MEASUREMENTS AND MAIN RESULTS: We performed transvaginal single-port laparoscopy sacrocolpopexy on a 59-year-old woman from China who was diagnosed with POP-Q stage II anterior compartment, stage III middle compartment, stage II posterior compartment. This patient complained of a vaginal mass that had been prolapsed for 3 months. Institutional Review Board/Ethics Committee approval was obtained. Vaginal hysterectomy was performed first. Preventative bilateral salpingo-oophorectomy was done after a single-port platform was established. Right pelvic peritoneum was incised, from the promontory to the vault. Then, we exposed the rectovaginal and vesicovaginal spaces after injection of a water cushion (normal saline, 0.9% Nacl). A Y-shaped mesh (ARTISYN; Johnson & Johnson international, c/o European Logistics Centre, Diegem, Belgium) was fixed to the posterior vaginal wall and then to the sacral promontory (S1). After closing the pelvic peritoneum the anterior mesh was sutured. Before finishing the surgery we closed the vaginal cuff. The operation last for about 2 hours, with a blood loss of 50 mL. The patient was discharged with complete recovery. A 5-month follow-up showed no prolapse, mesh erosion, or other complications. CONCLUSION: Transvaginal single-port laparoscopic sacrocolpopexy is a considerable choice for middle compartment POP. However, more cases should be enrolled, and additional studies are required.

Vaginal Sacral Colpopexy: A Natural Orifice Approach to a Gold Standard Procedure.

STUDY OBJECTIVE: A transvaginal approach to sacral colpopexy has a natural appeal to those interested in minimally invasive pelvic reconstructive surgery. Development of an effective technique has been frustrated because of the technical difficulty of confining the dissection and placement of mesh to the retroperitoneal space. The objective of this prospective study is to describe the technique and report the outcomes of a transvaginal, retroperitoneal sacral colpopexy. DESIGN: Prospective cohort study (Canadian Task Force Design classification II-2). SETTING: Urogynecology of Southern Alabama private practice. PATIENTS: Women with stage 2 or greater apical prolapse. INTERVENTIONS: Surgical repair of apical prolapse using vaginal sacral colpopexy. MEASUREMENTS AND RESULTS: Over a 1-year period, 15 posthysterectomy patients with stage 2 or greater vaginal prolapse were recruited and consented to vaginal sacral colpopexy. Primary outcome was success of the repair, with success defined as a combination of objective and subjective parameters using pelvic organ prolapse quantification measures, and quality of life questionnaires. Secondary outcomes were complications and operating time. One case converted to a native tissue repair. The vaginal sacral colpopexy was completed in the remaining 14. Eleven patients have been followed for 1 year or longer. Two patients did not return after their 6-week examination because of chronic illness. They were contacted by telephone over 2 years after the surgery and expressed total satisfaction with the operation and the outcome. One patient was seen at 3 months and was noted to have an excellent anatomic result; however, a pelvic organ prolapse quantification evaluation was not done. She has been totally lost to further follow-up. There was 1 mechanical failure in which the titanium tacks securing the apex to the anterior longitudinal ligament dislodged and a second case with a stage 2 posterior compartment defect. One incidental cystotomy, and 1 incidental proctotomy occurred. These were both small, remote from the site of the vaginal mesh, and did not prevent completion of the procedure. There were no mesh-related complications. Mean operating time was 123 minutes. CONCLUSION: In this small pilot study, a transvaginal retroperitoneal sacral colpopexy is described and is demonstrated to be feasible and safe. Based on the experience gained, changes in technique have been implemented to prevent future mechanical tack failures. Assuming that these changes will be successful in preventing apical recurrence due to dislodgement of mesh from the anterior longitudinal ligament, a larger study is planned to determine efficacy. Inherent advantages of the transvaginal approach are discussed, including a favorable morbidity profile, full access to all compartments, short operating times, and decreased costs.

Laparoscopic sacral colpopexy and a new approach to mesh fixation: a randomized clinical trial.

PURPOSE: Laparoscopic sacral colpopexy (LSC) plus supracervical hysterectomy (LSH) for pelvic organ prolapse (POP) is a high-complexity surgical procedure. The aim of the present study was to evaluate a new approach to vaginal-mesh fixation during LSC with continuous locked suture. METHODS: This is a prospective randomized double-blinded clinical trial enrolling 90 patients with severe POP from January 2016 to April 2017. Patients underwent LSH plus a "two-meshes" LSC and were randomized, regarding mesh fixation, in Group 1 (extracorporeal interrupted 3-0 delayed absorbable sutures) and Group 2 (running locked 3-0 delayed absorbable suture). Our primary endpoints were the operative times and the secondary endpoints the incidence of intra- or post-operative complications. RESULTS: A total of 42 patients for group completed the study. Baseline characteristics were similar between the groups. Overall mesh fixation time (24 vs. 39 min; p < 0.01), and operative time (121 vs. 138 min; p < 0.05) resulted significantly lower in Group 2. No differences were found in terms of anatomic failure, vaginal mesh erosion or intra- or post-operative complications. CONCLUSIONS: Laparoscopic continuous locked 3-0 absorbable suture for anterior and posterior mesh fixation during LSC guaranteed a faster and effective alternative to multiple interrupted sutures. The significant operative time reduction linked to this technique should be considered even more helpful when performing a highly complex surgery such as LSC.

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.

A new approach to supracervical hysterectomy during laparoscopic sacral colpopexy for pelvic organ prolapse: A randomized clinical trial.

AIMS: Laparoscopic sacral colpopexy (LSC) for pelvic prolapse is a complex procedure, characterized by long operative times and, when combined with supracervical hysterectomy, by a high risk of spreading of unsuspected cancerous tissue. The aim of the present study was to compare, in patients who underwent hysterectomy plus LSC for severe POP, different methods for cervical incision and uterine morcellation. METHODS: This is a prospective single Institution randomized double-blinded clinical trial enrolling 124 patients with severe POP from June 2014 to May 2015. Patients underwent laparoscopic supracervical hysterectomy (LSH) plus LSC for pelvic organ prolapse and were randomized in Group 1 (monopolar hook and conventional mechanical morcellator) and Group 2 (bipolar laparoscopic loop and bipolar morcellator), for supracervical incision and uterine morcellation, respectively. Our primary endpoints were the operative times and the secondary endpoints the incidence of intra- or post-operative complications. RESULTS: A total of 50 patients for group completed the study. Baseline characteristics were similar between the groups. Cervical cutting time (32 vs. 3.10 sec; P <0.01), morcellation (4.10 vs. 2.13 min; P <0.01) and operative time (131 vs. 118 min; P <0.05) resulted significantly lower in Group 2. No differences were found in terms of intra- or post-operative complications. CONCLUSIONS: Laparoscopic bipolar loop and morcellator guaranteed a faster and hemostatic tool during supracervical incision and a controlled and rotation-free uterine extraction. The significant surgical time reduction linked to these devices should be considered even more helpful and effective to perform a complex procedure represented by LSH plus LSC. Neurourol. Urodynam. 36:798-802, 2017. © 2016 Wiley Periodicals, Inc.