Laparoscopic Sacral Colpopexy: The “6-Points” Technique

To investigate whether ultrasonography coupled with clinical examination can help in understanding the mechanism of recurrence after transvaginal mesh repair of anterior and posterior vaginal wall prolapse. Ninety-one patients who had undergone surgery for anterior and/or posterior vaginal wall prolapse with the Prolift system had a clinical examination and introital/endovaginal two-dimensional ultrasonography a minimum of 1 year later. The retraction of anterior and posterior meshes was estimated relative to the original length of the mesh by transvaginal palpation. Patients with no, moderate (< 50%) or severe (> or = 50%) mesh retraction were compared. Anterior recurrence of prolapse was defined according to the International Continence Society by a Ba value > or = -1 and posterior recurrence by a Bp value > or = -1 (where Ba represents the most distal position of the anterior vaginal wall and Bp the most distal position of the posterior vaginal wall). On ultrasonography, two distances were measured in the midsagittal plane: Distance 1, from the distal margin of the anterior mesh to the bladder neck, and Distance 2, from the distal margin of the posterior mesh to the rectoanal junction. Seventy-five anterior and 62 posterior meshes were studied at a mean follow-up of 17.9 months. Patients with anterior recurrence presented significantly more often with severe anterior mesh retraction compared with patients without anterior recurrence (5/8 vs. 2/67, P < 0.001) and also had an increased Distance 1 (P < 0.001). Patients with posterior recurrence presented significantly more often with severe posterior mesh retraction compared with patients without posterior recurrence (3/4 vs. 3/58, P < 0.01) and also had an increased Distance 2 (P < 0.01). Recurrence of prolapse after transvaginal mesh repair appears to be associated with severe mesh retraction and loss of mesh support on the distal part of the vaginal walls.

Cystocele repair with interpositional grafting

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. 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. 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. 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.

Laparoscopic Sacrocervicopexy for Uterovaginal Prolapse: Step by Step for Safety and Efficiency

Letrozole and norethisterone acetate in rectovaginal endometriosis

This study was conducted to determine the extent of anatomical abnormalities in the urethral and vaginal wall support system of women with urethral hypermobility and anterior vaginal wall prolapse. The author presents the findings of detailed anatomical observations made during surgery in a series of 71 women who underwent surgical treatment of cystourethrocele and stress urinary incontinence (N = 68) or concomitant paravaginal defect repair and abdominal sacral colpopexy with urethral hypermobility to support the anterior vaginal wall in women without stress incontinence (N = 3). The physical features evaluated included 1) paravaginal defect (medial displacement of the vaginal wall and pubocervical fascia from the pelvic sidewall); 2) integrity of pubic and ischial attachments of the arcus tendineus fascia pelvis (ATFP), which is the fibrous band stretched between the pubic bone and ischial spine (Fig. 1); 3) the appearance of the ATFP on the pelvic sidewall where it attaches to the pubic bone, normally 1 cm above the arcuate pubic ligament; and 4) abnormalities in the pubococcygeal muscle. The diagnosis of stress urinary incontinence was confirmed by full-bladder cough test. Vaginal support was measured using the Baden-Walker system. Paravaginal defect was found in 62 (87%) patients on the left and 63 (89%) on the right. No left side defect was seen in five (7%) women, and four (6%) had no right side defect. The condition was bilateral in 62 women and unilateral in 1 patient on the left and in 2 patients on the right. Three women had atypical or unevaluable findings. Split detachment, with part of the ATFP attached to the pubocervical fascia and part connected to the remnant of the arcus on the pelvic wall, was seen in 16% of women on the left side and 14% on the right side. Only one and four women had a fragmented detachment on the left and right sides, respectively, and only one and two, respectively, had complete detachment. In three patients an evaluation was not possible. The attachment of the ATFP to the pubic bone was normal in more than three fourths of the women (79% on the left side and 75% on the right). There were no instances of bilateral detachment. In 41 women it was possible to evaluate the posterior attachment of the ATFP to the ischial spine. Only 1 had no paravaginal defect. The fascia was detached form the ischial spine bilaterally in 37 patients, and unilateral detachment was found in 1 patient. The pubococcygeal muscle was more often abnormal than normal. General atrophy was seen in 20 patients (28%) on the left side and 18 (26% ) on the right; localized atrophy, with part of the muscle missing, was present in 16 (23%) and 21 (30%) patients, respectively.

Background: Laparoscopy has the potential of making procedures less invasive with a lower complication profile while being more appealing to patients due to ease of recovery and cosmesis. Sacrocolpopexy has traditionally been performed through the abdominal route with limited reports of transvaginal applications. Methods: Our study aims to provide a step-by-step approach to performing a vNOTES sacrocolpopexy with appropriate tensioning and peritoneal coverage of the mesh used based on both cadaveric and live patient experience. This systematic description of a fully laparoscopic transvaginal apical suspension with mesh attachment to the sacrum being completely retroperitoneal and the mesh retroperitoneal and covered at the conclusion of the case. Results: Successful vNOTES Sacrocolpopexy is performed and reproduced, with transvaginal complete peritoneal coverage and tensioning of the mesh. Total vaginal length (TVL) of 9 cm in both live and cadaveric patients. The steps of the procedure include 1. A vNOTES laparoscopic-assisted vaginal hysterectomy is completed. 2. A 0-Prolene suture is attached longitudinally to the sacral arm of a precut (Y) mesh or any single layer Type I polypropylene mesh piece, placed from the sacral arm to the distal edge of the mesh forming a “U” shape with the bottom of the “U” ultimately attaching to the anterior longitudinal ligament. 3. To begin the SCP procedure after completion of the vaginal hysterectomy, dissection of the presacral mesh attachment site begins by entering the retroperitoneal space, slightly right of midline at the level of the ischial spine, lateral to the rectum and medial to the uterosacral ligament. 4. Once the dissection is completed with appropriate exposure of the anterior longitudinal ligament at the sacral promontory, the sacral mesh is attached to the anterior longitudinal ligament at the S1-2 level, ideally with a tacker under direct visualization. 5. Two sutures, one on each side of the tunnel, are placed on the cephalad edge of the sacral peritoneal incision and labeled. After removing the Gelport, two more absorbable sutures are attached to the anterior peritoneum of the anterior vaginal wall in the proximity of the bladder, around 3 cm on each side of the midline. These peritoneal sutures in each of the above two steps will later be tied together to help cover the arms of the mesh. 6. Before mesh arm attachment, each area on the anterior and posterior vaginal walls is dissected off respective tissue (bladder and perineal body/rectovaginal fascia) and then everted for mesh attachment. 7. Both anterior and posterior mesh pieces are sutured to their respective vaginal walls with six interrupted sutures. Each mesh arm will have several centimeters of mesh freely hanging off both anterior and posterior cuff edges. These edges can be trimmed to 2 cm past the vaginal cuff edge. 8. All three pieces of mesh are stacked together and serially threaded from anterior mesh to posterior mesh, ensuring each mesh piece remains aligned (Figure 1). Each U suture is then passed through the free ends of the anterior and posterior mesh pieces and then secured with a hemostat. The cut edges of the suture can either be aligned at the back of the posterior arm to permit retroperitonealization of the knot or placement at the vaginal apex abutting the vaginal cuff. 9. Peritoneal closure is achieved by tying a posterior tunnel suture to each respective anterior vaginal wall suture at each lateral edge of the tunnel incision. 10. The vaginal cuff closure begins with a Vicryl suture anchored at the patient’s right forniceal edge running it to midline while anchoring another suture at the left forniceal edge to permit the surgeon to tension the vaginal apex appropriately. 11. Mesh tensioning is achieved by placing a single digit through the remaining space left in the tunnel incision. A knot using the Prolene suture securing the overlapping mesh is tied extracorporeally and pushed through the vaginal cuff to mobilize the mesh crux cephalad, thus elevating the vaginal apex towards the sacrum. The elevation of this knot guides the vaginal length. 12. The remainder of the vaginal cuff is then closed while avoiding incorporation of the mesh into the suture line (the ideal distance from mesh Y-junction to cuff is 1-2cm). Conclusion: By describing an innovative and reproducible technique to perform vNOTES sacrocolpopexy based on cadaveric and live patient experience, we successfully demonstrate how to perform a laparoscopic transvaginal apical suspension with mesh attachment to the sacrum through retroperitoneal placement. The vNOTES approach for sacrocolpopexy may offer a viable alternative to the transabdominal approach for candidates with difficult transabdominal access while avoiding trocar injuries and reducing surgical costs.

When treating anterior and apical prolapse, laparoscopic sacral colpopexy is the gold standard. Currently, it is suggested that the anterior mesh must be the lowest possible to better treat the prolapse and lower the risk of recurrence. The objective of our study was to determine the possibility of using intraoperative transperineal ultrasound measurements during laparoscopic sacral colpopexy in order to better localize the mesh positioning. We conducted a prospective double-blinded single-center study where patients included had intraoperative ultrasounds by an independent ultrasonographer, un-informed of the surgeon's clinical observations. The postoperative measures were performed by another independent ultrasonographer, which was un-informed of the intraoperative measurements. A total of 16patients were included. The anterior prosthesis was visualized in 81% of patients during laparoscopic sacral colpopexy and in all patients postoperatively. However, intraoperative measures and comparison between intraoperative and postoperative measures significantly varied. None of the patients included had a recurrence of prolapse. LEVEL OF EVIDENCE: 4.

This study was conducted to assess the subjective outcome, complications and cure rates of prolapse surgery with a standardized trocar-quided polypropylene mesh in the first 100 patients. A follow-up visit was made after 2 months after the operation and the subjective outcome was assessed with a postal questionnaire 1 year postoperatively. An anterior mesh was used in 48, posterior mesh in 45, total mesh in five and combined anterior and posterior mesh in two patients. All patients had one or more subjective symptoms. Forty-seven percent of the patients had undergone prolapse surgery and 16% an anti-incontinence operation previously. Two patients had peroperative bleeding of more than 1,000 ml, antibiotic treatment was needed in 28 patients and two hematomas were evacuated. A total of 16 patients underwent an anti-incontinence operation for de novo stress urinary incontinence. Four patients needed cystocele repair after a posterior mesh and eight patients posterior repair after an anterior mesh. The mesh exposure was diagnosed in 14 patients. No serious complications occurred. Fifty-three (60%) patients reported all preoperative symptoms cured, 27 (30%) reported persistent symptoms and five patients were hesitant. Of the respondents, 63 (71%) were satisfied with the operation. We found that the mesh procedures were associated with a quite high amount of minor postoperative problems.

Background: This report describes a retroperitoneal abscess occurring 5 years after laparoscopic sacral colpopexy, and its treatment. Case: A 35-year-old woman complained of malodorous abnormal vaginal discharge and chronic abdominal pain. At vaginal examination, mesh erosion was observed on the anterior vaginal wall. Magnetic resonance imaging showed a retroperitoneal abscess between the cervix and the posterior bladder wall. Vaginal surgery combined with antibiotic therapy was chosen to drain the abscess and remove a large part of the mesh. Prolonged antibiotic therapy was maintained after the treatment. Results: At 1 year follow-up no recurrence of apical prolapse was observed. Conclusions: Vaginal surgery combined with antibiotic therapy was safe, minimally invasive, and successful in treating a retroperitoneal abscess related to mesh erosion after sacral colpopexy. (J GYNECOL SURG 30:126)

IntroductionLaparoscopic 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 MethodsIn 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.ResultsThree 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.ConclusionBoth 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.

IntroductionThe Lichtenstein repair has been synonymous with “open” inguinal hernia repair (IHR) for 40 years. However, international guidelines have suggested that posterior mesh placement results in advantageous biomechanics and reduced risk of nerve-related chronic pain. Additionally, the use of local anesthetics has been shown to reduce postoperative pain and complication risks. An open transrectus preperitoneal/open preperitoneal (TREPP/OPP) repair combines posterior mesh placement with the use of local anesthetic and as such could be the ideal repair for primary inguinal hernia. Using the Abdominal Core Health Quality Collaborative (ACHQC) registry, we compared open anterior mesh with open posterior mesh repairs.MethodsWe performed a propensity score matched analysis of patients undergoing open IHR between 2012 and 2022 in the ACHQC. After 1:1 optimal matching, both the TREPP/OPP and Lichtenstein cohorts were balanced with 451 participants in each group. Outcomes included patient-reported quality of life (QoL), hernia recurrence, and postoperative opioid use.ResultsImprovement was seen after TREPP/OPP in EuraHS QoL score at 30 days (OR 0.558 [0.408, 0.761]; p = 0.001), and the difference persisted at 1 year (OR 0.588 [0.346, 0.994]; p = 0.047). Patient-reported opioid use at 30-day follow-up was significantly lower in the TREPP/OPP cohort (OR 0.31 [0.20, 0.48]; p < 0.001). 30-day frequency of surgical-site occurrences was significantly higher in the Lichtenstein repair cohort (OR 0.22 [0.06–0.61]; p = 0.007). There were no statistically significant differences in hernia recurrence risk at 1 year, or rates of postoperative bleeding, peripheral nerve injury, DVTs, or UTIs.ConclusionOur analysis demonstrates a benefit of posterior mesh placement (TREPP/OPP) over anterior mesh placement (Lichtenstein) in open inguinal hernia repair in patient-reported QoL and reduced opioid use.

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. 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. A total of 42 patients for group completed the study. Baseline characteristics were similar between the groups. Overall mesh fixation time (24 vs. 39min; p < 0.01), and operative time (121 vs. 138min; 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. 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.

Aims: The aim of this study is to investigate the frequency and characteristics of multi-compartment prolapse in women evaluated with pelvic floor complaints. Methods: The data of 259 patients who applied to our hospital with pelvic floor complaints between May 2022 and March 2023 were evaluated retrospectively, and after the exclusion criteria were applied, the remaining 69 patients were included. Patients were grouped according to their primary complaints as those presenting with anterior compartment symptoms (ACS), those presenting with middle compartment symptoms (MCS), those presenting with posterior compartment symptoms (PCS), those presenting with proctological symptoms (PS) and those presenting with chronic pelvic pain (CPP). Results: A total of 69 patients were included in the study. The mean age was 49.8±13.1 years and the median symptom duration was 60 months. When patients are evaluated in terms of main complaint; The primary complaint was ACS in 16 patients, MCS in 4 patients, PCS in 26 patients, PS in 20 patients, and CPP in 3 patients. According to MRI defecography findings, ACS was detected in 1 patients, MCS in 1 patients, PCS in 13 patients and multicompartment prolapse in 54 patients. In patients with a history of vaginal delivery, in patients with a history of previous pelvic surgery and as the number of vaginal delivery increases multi-compartment prolapse rate was significantly increased. Conclusion: Regardless of the underlying primary complaint, the presence of multicompartment prolapse should be investigated through examination and tests in pelvic floor diseases. History and number of vaginal deliveries, previous pelvic surgery history carry a higher risk for multi-compartment prolapse.

The objective of this study was to investigate the ultrasound characteristics of vaginal mesh in women with vaginal mesh complications. This was a cross-sectional study of women presenting with extrusion complications from vaginal mesh kit for prolapse at our tertiary care center between years 2009 and 2014. We included women who concurrently underwent a 3-dimensional endovaginal ultrasound (EVUS) as part of the clinical evaluation. We excluded women with incomplete charts and poor imaging quality. Subjects were categorized by the presence or absence of associated pelvic pain. Based on ultrasound findings, we compared the location of mesh, the appearance of mesh pattern (flat, folding, prominence, convoluted), and other EVUS characteristics of mesh. Forty-six women with vaginal mesh complications and good image quality were included. When comparing mesh length between posterior and anterior compartments, the posterior meshes were significantly longer than the anterior meshes (42.1 [SD, 11.9] mm vs 25.8 [SD, 9] mm; P < 0.0001) and more often associated with pain. In the posterior compartment, the mean mesh length seen on EVUS was significantly longer in women with pain than in women without pain (46.5 [SD, 9] mm vs 31.8 [SD, 12.1] mm; P = 0.0001). There was also a higher proportion of a "flat" mesh pattern, 14 (58.3%) of 25, in the posterior compartment associated with the presence of pain (P = 0.013). In the posterior compartment, a smaller distance between the distal edge of the mesh and the anal sphincter was significantly associated with the presence of pain (8 mm [0-37] vs 21 mm [8-35], P = 0.024). In both compartments, the EVUS had 100% sensitivity for detection of mesh extrusions. In this population of patients presenting with mesh complications, the posterior meshes were more often visualized as a "flat" pattern with a higher frequency of pain. Mesh complications of the anterior compartment had a higher frequency of folding and shrinkage.