Laparoscopic Technique of Vagino-Sacropexy for Treatment of Vaginal Vault Prolapse and Urinary Urge Incontinence

Abstract

Introduction: Pelvic organ prolapse is a common problem in women, especially in elderly. Many women with pelvic organ prolapse also suffer from urinary incontinence. Based on the studies of de Lancey, three levels of vaginal support are important for maintaining pelvic organ support and continence.1,2 Uterosacral and cardinal ligaments are the main structures in level 1 support that suspends the cervix and upper vagina. Uterosacral ligaments extend between upper vagina and sacrum at the level of S2 through S4 and maintain length and horizontal axis of the vagina. Horizontal axis of the vagina is essential for continence by supporting bladder base. Laxity or defects in the uterosacral ligaments are frequently associated with apical utero-vaginal descensus, urgency, and urge incontinence.3,4 It was proved that urgency or urge incontinence may be caused by anatomical defects of the posterior compartment and could be treated with surgery.5,6 Vagino-sacropexy (VASA) is a new surgical technique that was described for correcting vaginal stump descensus, prolapse, and/or urge incontinence in a hysterectomized patient.7 Cure rates in urge incontinence were reported as 70% to 77%.7 In this operation, vaginal vault is fixed to sacrum at the level of S2 bilaterally by using a one-piece polyvinylidene fluoride (PVDF) mesh. Although promontory is accepted to be the simplest localization for attachment of mesh in unilateral sacrocolpopexy, it is not the safest area for fixation.8,9 However, bilateral fixation of mesh on S2 results in a more anatomic suspension of vaginal vault when compared with unilateral mesh attachment on sacral promontory. In VASA, restoring vaginal horizontal axis improves urge incontinence. In this video, our aim was to demonstrate the laparoscopic surgical technique of VASA in a hysterectomized patient with vaginal vault prolapse and urge incontinence. According to our knowledge, this is the first report in the literature. Video run time is 05 mins 7 secs. Materials and Methods: Laparaoscopic VASA was performed in a 65-year-old woman with POP-Q stage 4 vaginal prolapse and urge incontinence (Video 1). The purpose of VASA is to re-create synthetic uterosacral ligaments to support vaginal vault by placing a one-piece mesh implant between vaginal cuff and second sacral vertebrae (S2) on the left side and right side of the pelvis. Vaginal part of the mesh implant should be fixed to the vaginal cuff with three or four nonabsorbable or late-absorbable multifilament sutures. Results and Conclusions: Vaginal vault prolapse was corrected anatomically by replacement of uterosacral ligaments with a synthetic PVDF surgical mesh by laparoscopic VASA operation. Postoperative term was uneventful and the patient was discharged at the first day following operation. In the first follow-up visit at 15th day postsurgery, the patient had no symptom of urge incontinence. Long-term anatomic and functional outcomes were also satisfactory. Laparoscopic vagino sacropexy is a little bit more difficult procedure than conventional laparoscopic unilateral sacrofixation because the normal anatomic position of the sigmoid colon challenges the placement of mesh implant on the left side. So, sigmoid colon should be deviated to the right side, and then the left arm of the mesh implant is placed under peritoneum in a similar manner to the right side. In addition, pelvic curve challenges formation of peritoneal tunnels from the sacrum to the level of insertion of uterosacral ligaments on the vaginal cuff, bilaterally. To facilitate this step, we prefer to use a flexible dissector for passing the pelvic curve. If a rigid dissector is used in this step, the peritoneum over the rigid instrument can easily be torn and then shortened. The average time taken to perform laparoscopic VASA is ~90 to 100 minutes and is mainly related to level of expertise. Intermediate or advanced surgical skills in laparoscopic pelvic surgery are required before one may attempt laparoscopic VASA. In conclusion, in surgical treatment of pelvic organ prolapse, pelvic organs should be restored to their original anatomic positions to restore their normal functions. In surgical treatment of apical prolapses, defective uterosacral ligaments should be replaced in original anatomic planes to restore normal bladder functions and improve urge incontinence. Laparoscopic approach for VASA also provides better access and identification of pelvic structures and rapid postoperative recovery. No competing financial interests exist. Runtime of video: 5 mins 7 secs