A new method of adjusting mesh tension using cystoscopy during laparoscopic sacrocolpopexy

Yukiko Nomura,Yoshiyuki Okada,Kumiko Kato,Aya Hiramatsu,Yasukuni Yoshimura,Eiji Matsubara

doi:10.1007/s00192-021-04791-1

Abstract

We aimed to examine the usefulness of cystoscopic findings to guide mesh tension adjustment during laparoscopic sacrocolpopexy (LSC) to promote better repair of pelvic organ prolapse (POP) and prevent de novo stress urinary incontinence (SUI). In this technique, the bladder wall was observed using a cystoscope when various traction pressures were applied by pulling the mesh arm with forceps before fixation to the promontory during LSC. Adjustment was performed on 20 patients, and postoperative outcomes of POP repair and development of de novo SUI were evaluated. When excessive traction was applied on the mesh arm, a bladder neck opening and a cord-like elevation in the center of the trigone and posterior wall were observed in all cases. The tension was gradually loosened, and precisely when the above-mentioned cystoscopic finding (“Central Road”) disappeared, an anatomically appropriate elevation of the vaginal apex was achieved; the mesh arm was fixed to the promontory. At 6 months after LSC, anterior wall recurrences were diagnosed in four patients (beyond the hymen in one) with few symptoms, while no occurrence of de novo SUI. Cystoscopic findings during mesh tension adjustment in LSC could be useful in achieving improved POP repair.

Highlights

Laparoscopic sacrocolpopexy (LSC) is considered an excellent option for apical vaginal prolapse owing to its superior correction rates in treating pelvic organ prolapse (POP) [1]
Since no objective indicators have been identified and few reports have described mesh tension adjustment during LSC [7], excessive traction pressure may be inadvertently applied on the LSC mesh to achieve sufficient prolapse repair
A cord-like appearance caused by excessive tension on the LSC mesh was revealed in the center of the bladder trigone and posterior wall, and it was named the “central road” (CR)

Summary

Introduction

Laparoscopic sacrocolpopexy (LSC) is considered an excellent option for apical vaginal prolapse owing to its superior correction rates in treating pelvic organ prolapse (POP) [1]. De novo stress urinary incontinence (SUI) is a potential complication that occurs with a high incidence. Presented at This video has been discussed as a Video Presentation at the 45th annual meeting of IUGA, Haag, The Netherlands(virtual), on August 31, 2020. Applying undue pressure on the LSC mesh toward the sacrum may cause excessive straightening (de-kinking) of the bladder neck and proximal urethra, subsequently increasing SUI. This study aimed to examine the usefulness of cystoscopic findings to guide mesh tension adjustment during LSC to promote POP repair and prevent de novo SUI.

Objectives

Methods

Results