Laparoscopic Sacral Colpopexy Research Articles

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.

Clinical Efficacy of Modified Nonmesh Sacral Colpopexy for Pelvic Organ Prolapse

Importance As an increasing number of mesh-related complications have been reported, the availability of nonmesh alternatives becomes crucial for situations where mesh is not desired or unavailable. A new modified procedure of nonmesh laparoscopic sacral colpopexy (LSC) was performed in our department, which used a nonabsorbable polyester suture (Ethibond) combined with uterosacral ligament suspension. Objective The aim of this study was to evaluate the clinical efficacy of the modified procedure in comparison with traditional LSC in patients with pelvic organ prolapse. Methods This retrospective study assessed the treatment outcomes of 60 patients who were underwent LSC with or without mesh from January 2017 to April 2019. Patients were divided into 2 groups based on the presence or absence of mesh during the operation: mesh group (n = 34) and nonmesh group (n = 26). General data, perioperative indexes, postoperative complications, and recurrence rates were comparatively analyzed between 2 groups. Results In perioperative indexes, the nonmesh group exhibited shorter operation time (P < 0.001) and less intraoperative blood loss compared with the mesh group (P = 0.004). There was no significant difference in postoperative indwelling urinary catheter duration (P = 0.425) and hospitalization time (P = 0.827) between the 2 groups. In postoperative complications, the incidence of postoperative complications showed no significant difference between the 2 groups (P > 0.05). No occurrences of mesh exposure and erosion were observed in the mesh group during at least a 2-year follow-up period. In postoperative recurrence, none of the patients in either group experienced prolapse recurrence. Conclusions In comparison with the traditional LSC with mesh, the modified laparoscopic nonmesh sacral colpopexy presents advantages of reduced surgical trauma, less pain, and lower cost. However, a long-term and large sample study is required for evaluating the surgery’s long-term efficacy.

Quality of Life and Sexual Function after Laparoscopic Posterior Vaginal Plication Plus Sacral Colpopexy for Severe Posterior Vaginal Prolapse.

Laparoscopic sacral colpopexy (LSC) is the gold standard treatment for women with apical/anterior pelvic organ prolapse (POP). For isolated posterior vaginal prolapse, instead, the literature suggests fascial native tissue repair. This is a retrospective 2-year quality-of-life follow-up study after laparoscopic posterior plication (LPP) combined with LSC in patients with anterior/apical prolapse combined with severe posterior colpocele. The primary endpoint was to evaluate the subjective outcomes quality of life (QoL), sexual function, and patient satisfaction rate. The secondary endpoint was to evaluate perioperative and anatomical outcomes at the 2-year follow-up. A total of 139 consecutive patients with anterior and/or apical prolapse (POP-Q stage ≥ II) and severe posterior vaginal prolapse (posterior POP-Q stage ≥ III) were retrospectively selected from our database among women who underwent, from November 2018 to February 2021, a "two-meshes" LSC. The patients were classified into Group A (81 patients; LSC plus LPP) and Group B (67 patients; LSC alone). The primary endpoint was evaluated using the Patient Global Impression of Improvement (PGI-I), the Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6), the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), the Female Sexual Distress Scale (FSDS), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), and the EuroQol (EQ-5D). The secondary endpoint was studied using the POP-Q study and an intra-, peri-, and post-operative complications assessment. Two-year follow-up data were analyzed for the study. At 2 years, all women showed a statistically significant amelioration of their symptoms on the QoL questionnaires. We found a statistical difference in favor of posterior plication in terms of the PGI-I successful outcome rate (Group A versus B: 85.3% versus 67.1%), FSDS (median 11 versus 21), and PISQ-12 (median 89 versus 62) (p < 0.05 for all comparisons). A significant improvement of all EQ-5D values was observed from baseline to 2-year follow-up, and only for the "pain/discomfort" domains did we observe a significant improvement in LSC plus LPP patients versus LSC alone (p < 0.05). LSC plus LPP women showed, at 2 years, a significant amelioration of their Ap and GH POP-Q points. We observed no statistical differences in terms of intra-post-operative complications or anatomic failure rate between groups. Our LPP approach to LSC appears to be a safe, feasible, and effective treatment for advanced pelvic organ prolapse with a significant impact on the patient's general health and sexual quality of life. Adding laparoscopic posterior vaginal plication to "two-meshes" sacral colpopexy is recommended in patients with apical/anterior prolapse and concomitant severe posterior colpocele. This surgical approach, in addition to improving the anatomical results of these patients, is associated with a significant improvement in sexual and quality of life indexes.

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines). Preoperative patients’ informationEach patient must be informed concerning the risks associated with POP surgery (EO). Hemorrhage, hematomaVaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO). Bladder injuryWhen a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO). Ureter injuryAfter ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO). Rectal injuryRegardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO). Vaginal wall injuryAfter vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO). Mesh infection (abscess, cellulitis, spondylodiscitis)Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO).When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO).When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient. Bowel occlusion related to non-closure of the peritoneumPeritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO). Urinary retentionPreoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO). Postoperative painBefore POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO).Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C).When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO).When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO).When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO).Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO).Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO). Postoperative dyspareuniaWhen de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO). Vaginal mesh exposureTo reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C).When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material.When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered.When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO).When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh.Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO).When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO). Suture thread vaginal exposureFor women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed. Bladder and ureteral mesh exposureWhen bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B).Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).

Surgery for women with apical vaginal prolapse.

Apical vaginal prolapse is the descent of the uterus or vaginal vault (post-hysterectomy). Various surgical treatments are available, but there are no guidelines to recommend which is the best. To evaluate the safety and efficacy of any surgical intervention compared to another intervention for the management of apical vaginal prolapse. We searched the Cochrane Incontinence Group's Specialised Register of controlled trials, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings and ClinicalTrials.gov (searched 14 March 2022). We included randomised controlled trials (RCTs). We used Cochrane methods. Our primary outcomes were awareness of prolapse, repeat surgery and recurrent prolapse (any site). We included 59 RCTs (6705 women) comparing surgical procedures for apical vaginal prolapse. Evidence certainty ranged from very low to moderate. Limitations included imprecision, poor methodology, and inconsistency. Vaginal procedures compared to sacral colpopexy for vault prolapse (seven RCTs, n=613; six months to f four-year review) Awareness of prolapse was more common after vaginal procedures (risk ratio (RR) 2.31, 95% confidence interval (CI) 1.27 to 4.21, 4 RCTs, n = 346, I2 = 0%, moderate-certainty evidence). If 8% of women are aware of prolapse after sacral colpopexy, 18% (10% to 32%) are likely to be aware after vaginal procedures. Surgery for recurrent prolapse was more common after vaginal procedures (RR 2.33, 95% CI 1.34 to 4.04; 6 RCTs, n = 497, I2 = 0%, moderate-certainty evidence). The confidence interval suggests that if 6% of women require repeat prolapse surgery after sacral colpopexy, 14% (8% to 25%) are likely to require it after vaginal procedures. Prolapse on examination is probably more common after vaginal procedures (RR 1.87, 95% CI 1.32 to 2.65; 5 RCTs, n = 422; I2 = 24%, moderate-certainty evidence). If 18% of women have recurrent prolapse after sacral colpopexy, between 23% and 47% are likely to do so after vaginal procedures. Other outcomes: Stress urinary incontinence (SUI) was more common after vaginal procedures (RR 1.86, 95% CI 1.17 to 2.94; 3 RCTs, n = 263; I2 = 0%, moderate-certainty evidence). The effect of vaginal procedures on dyspareunia was uncertain (RR 3.44, 95% CI 0.61 to 19.53; 3 RCTs, n = 106, I2 = 65%, low-certainty evidence). Vaginal hysterectomy compared to sacral hysteropexy/cervicopexy (six RCTS, 554 women, one to seven year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.01 95% CI 0.10 to 9.98; 2 RCTs, n = 200, very low-certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 0.85, 95% CI 0.47 to 1.54; 5 RCTs, n = 403; I2 = 9%, low-certainty evidence). Prolapse on examination- there was little or no difference between the groups for this outcome (RR 0.78, 95% CI 0.54 to 1.11; 2 RCTs n = 230; I2 = 9%, moderate-certainty evidence). Vaginal hysteropexy compared to sacral hysteropexy/cervicopexy (two RCTs, n = 388, 1-four-year review) Awareness of prolapse - No difference between the groups for this outcome (RR 0.55 95% CI 0.21 to 1.44; 1 RCT n = 257, low-certainty evidence). Surgery for recurrent prolapse - No difference between the groups for this outcome (RR 1.34, 95% CI 0.52 to 3.44; 2 RCTs, n = 345; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 0.99, 95% CI 0.83 to 1.19; 2 RCTs n =367; I2 =9%, moderate-certainty evidence). Vaginal hysterectomy compared to vaginal hysteropexy (four RCTs, n = 620, 6 months to five-year review) Awareness of prolapse - There may be little or no difference between the groups for this outcome (RR 1.0 95% CI 0.44 to 2.24; 2 RCTs, n = 365, I2 = 0% moderate-quality certainty evidence). Surgery for recurrent prolapse - There may be little or no difference between the groups for this outcome (RR 1.32, 95% CI 0.67 to 2.60; 3 RCTs, n = 443; I2 = 0%, moderate-certainty evidence). Prolapse on examination- There were little or no difference between the groups for this outcome (RR 1.44, 95% CI 0.79 to 2.61; 2 RCTs n =361; I2 =74%, low-certainty evidence). Other outcomes: Total vaginal length (TVL) was shorter after vaginal hysterectomy (mean difference (MD) 0.89cm 95% CI 0.49 to 1.28cm shorter; 3 RCTs, n=413, low-certainty evidence). There is probably little or no difference between the groups in terms of operating time, dyspareunia and stress urinary incontinence. Other analyses There were no differences identified for any of our primary review outcomes between different types of vaginal native tissue repair (4 RCTs), comparisons of graft materials for vaginal support (3 RCTs), pectopexy versus other apical suspensions (5 RCTs), continuous versus interrupted sutures at sacral colpopexy (2 RCTs), absorbable versus permanent sutures at apical suspensions (5 RCTs) or different routes of sacral colpopexy. Laparoscopic sacral colpopexy is associated with shorter admission time than open approach (3 RCTs) and quicker operating time than robotic approach (3 RCTs). Transvaginal mesh does not confer any advantage over native tissue repair, however is associated with a 17.5% rate of mesh exposure (7 RCTs). Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, and postoperative SUI than a variety of vaginal interventions. The limited evidence does not support the use of transvaginal mesh compared to native tissue repair for apical vaginal prolapse. There were no differences in primary outcomes for different routes of sacral colpopexy. However, the laparoscopic approach is associated with a shorter operating time than robotic approach, and shorter admission than open approach. There were no significant differences between vaginal hysteropexy and vaginal hysterectomy for uterine prolapse nor between vaginal hysteropexy and abdominal hysteropexy/cervicopexy. There were no differences detected between absorbable and non absorbable sutures however, the certainty of evidence for mesh exposure and dyspareunia was low.

Laparoscopic sacral colpopexy without the robot: Safe, effective and easier than you think

Objective:The purpose of the study is to evaluate the outcomes of laparoscopic sacral colpopexy operations performed by faculty and resident surgeons using simple laparoscopic suturing and tying techniques, and to compare those results with those reported by other institutions performing laparoscopic and robotic sacral colpopexy. Methods:This is a retrospective cohort study of 206 consecutive laparoscopic sacral colpopexy cases (with or without concomitant procedures) between October 2014 and July 2020. Laparoscopic sacral colpopexies were performed using a carefully selected set of instruments and techniques which are quickly mastered by trainees. Residents performed up to 50% of the work in each operation. Descriptive statistics were used to compare primary outcomes with published literature. Results:The average operative time was 153.3 minutes. The overall complication rate was 16.5%, including 3.4% cystotomy, 0.5% enterotomy, 0.5% small bowel obstruction, 2.4% mesh complications including erosion, detachment and removal. Most recent follow up occurred at a mean of 325.5 days (SD 397.9) and median of 183 days (IQR 48-471) postoperatively. Recurrent prolapse was noted in 6.3% of patients and 3.9% underwent a subsequent prolapse repair. These results compare favorably with those published by other institutions. Conclusion:Using simple suturing and tying techniques, laparoscopic sacral colpopexy can be performed without robotic assistance by a large portion of laparoscopically trained surgeons, including trainee co-surgeons. Significant cost savings accrue from the use of conventional laparoscopy in place of robotic technology. Residents can participate in laparoscopic sacral colpopexy cases with comparable operative times and favorable surgical outcomes.

RECURRENT SINUS ARREST DURING LAPAROSCOPIC SACRAL COLPOPEXY IN PATIENTS WITH SICK SINUS SYNDROME : A CASE REPORT

Sick sinus syndrome (SSS) is a disease in which the SA node fails to perform the function of pacemaking. ECG shows various rhythms including sinus arrest. We report recurrent sinus arrest during laparoscopic sacral colpopexy in a 77-year-old female patient with SSS. The patient was diagnosed with SSS, but as there were no symptoms, the operation was performed without pacemaker implantation. After induction of anesthesia, vital signs were stable, but sinus arrest repeatedly appeared due to elevated vagal tone during uterine traction. After operation, the patient underwent pacemaker implantation, and to this day, she is doing well without any symptoms. The anesthesiologist should pay close attention to the progress of the operation through much communication with operator during the surgery. Also, we recommend to considering temporary pacemaker implantation for patients with SSS who undergo surgery that can increase vagal tone.

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

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.

Laparoscopic sacral hysteropexy versus laparoscopic sacral colpopexy plus supracervical hysterectomy in patients with pelvic organ prolapse.

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. 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. 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. 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.

48 You can do it: Laparoscopic repair of a recurrent vesicovaginal fistula

This video demonstrates how the skill set required to perform laparoscopic sacral colpopexy can be used to repair a vesicovaginal fistula. The video describes the case of a 43-year-old woman who presented with a recurrent post-hysterectomy fistula after a Latzko-style repair. It then demonstrates how the bladder dissection required for fistula repair resembles the dissection required for sacral colpopexy, and how repairing the bladder wall after excision of the fistula tract is similar to repairing an accidental cystotomy of the type that occurs during sacral colopexy. Vesicovaginal fistulas are rare in the developed world, which means that few surgeons have extensive experience in repairing them. Despite this, surgeons who have the skills to perform laparoscopic and robotic sacral colopexy should feel confident that they have the requisite skills to approach fistulas in a minimally invasive way when required.

49 Laparoscopic sacral colpopexy without the robot: Safe, effective, and easier than you think

49 Laparoscopic sacral colpopexy without the robot: Safe, effective, and easier than you think

35 Mesh erosion risk for laparoscopic sacral colpopexy with total hysterectomy

35 Mesh erosion risk for laparoscopic sacral colpopexy with total hysterectomy

Acute spondylodiscitis - A rare presentation of sacrocolpopexy complicated with chronic left iliac fossa discharging sinus

Spondylodiscitis following sacrocolopopexy is a rare complication. Many cases of spondylodiscitis are preceded by infection elsewhere, most commonly the genitourinary tract. Inadvertent placement of bone anchors into the L5-S1 disc space likely results in an L5-S1 inflammatory process with infection often tracking along the suspension sutures attached to the bone anchors. Commonly onset of spondylodiscitis is in <1 year of index surgery (average 4 months) but is reported as late as 8 years. However, the patient presenting with chronic discharging sinus (6 years) and acute spondylodiscitis following sacrocolpopexy is not reported in the literature to the best of our knowledge. To report a case of lumbosacral (L5-S1) discitis in a patient who had a discharging sinus at the left iliac fossa following a sacral colpopexy procedure 6 years back. A 44-year-old female underwent laparoscopic sacral colpopexy for uterovaginal prolapse approximately 6 years back. Approximately 4 months after the surgery, she had abdominal pain and fever, followed by discharge from the left iliac fossa. She presented to the spine surgery outpatient department with severe back pain and difficulty in walking for the last 2 weeks. Magnetic resonance imaging revealed L5-S1 spondylodiscitis. She was managed collectively by a spine surgeon, gynecologist, and gastro surgeon. The principal aims of surgery are to debride infected disc tissue, which is avascular, and excision of the sinus tract along with the removal of the sling along with its anchor. To minimize L5-S1 spondylodiscitis during sacrocolpopexy, it is recommended to start the presacral dissection at the sacral promontory, which generally lies just below the steep lumbosacral angle.

Comparison between Delayed Absorbable and Permanent Sutures in Laparoscopic Sacral Colpopexy: A Randomized Controlled Trial

Study Objective To demonstrate the non-inferiority of delayed absorbable sutures compared to non-absorbable sutures in laparoscopic sacrocolpopexy (LSC) for correction of pelvic organ prolapse. Design It is a randomized 1:1 non-inferiority surgical clinical trial (NCT03582410). Setting Obstetric and Gynecological Department of “Ospedale Regionale F. Miulli”. Patients or Participants 160 patients, who required surgical treatment for symptomatic prolapse were assessed for eligibility. 6 patients declined to participate and 4 patients did not meet inclusion criteria. 150 patients were enrolled and all completed follow up. Interventions Patients were randomized to receive LSC with delayed absorbable (group A: 75 patients) and non-absorbable sutures (group B: 75 patients) for anterior and posterior mesh fixation to vagina. Primary outcome was the correction of the prolapse at 1, 6 and 12 months after surgery. Intraoperative parameters, intraoperative and postoperative characteristics and long term morbidity were considered as secondary outcomes. Measurements and Main Results Baseline characteristics were comparable between groups. There were no differences in terms of blood loss, operation time, intraoperative complications. No cases of failure and no differences in terms of prolapse correction were observed. There was bowel symptoms gradual reduction in both groups. Rate of de novo urinary incontinence and persistent urinary incontinence after 12 months was similar (respectively 7% in group A vs 5% in group B, p: 1,00 and 11 %in group A vs 5% in group B, p: 0,229). Rate of mesh erosion at 12 months was higher in group B though not statistically significant (4% vs 0%, p:0,24). Conclusion Delayed absorbable sutures are comparable to non-absorbable sutures for mesh fixation in LSC in terms of success of procedure, operative parameters, intraoperative and post-operative characteristics. Other studies are needed to clarify if absorbable sutures can be associated to a decreased rate of mesh erosions.

Laparoscopic monolateral suspension for vaginal vault prolapse: a report of an exit surgical strategy during sacralcolpopexy

BackgroundVaginal vault prolapse is the most frequent long-term complication in patients undergoing hysterectomy and sacralcolpopexy is considered the gold standard. We report our surgical strategy maintaining single-arm mesh when the sacral promontory is not accessible to fix the mesh for an unknown sacral osteophytosis during a laparoscopic sacralcolpopexy. This is significant because, to our knowledge, the bone variant as a procedure limiting factor has never been described before. This opens new horizons for the sacralcolpopexy surgery, because it becomes necessary to know of a valid surgical alternative with mesh maintenance if this complication occurs again or to perform an assessment of the accessibility of the sacral promontory immediately after its dissection.Case presentationWe present a case of a 75-year-old woman with recurrence of vaginal vault prolapse. A laparoscopic sacralcolpopexy was recommended. During surgery, we found that the procedure was not feasible due to the presence of an unknown osteophytosis of the sacrum which prevented the fixing of the mesh to the sacral promontory. We decided to proceed with a single-arm lateral suspension by using a modified approach of the original technique, maintaining the mesh originally shaped for the sacral colpopexy. At follow-up, the vaginal vault is well suspended.ConclusionThis exit strategy may represent a valid surgical alternative when laparoscopic sacral colpopexy is not possible for anatomical variants, allowing to keep the laparoscopic approach using mesh. To our knowledge, cases in which the anatomical bone variant prevented access to the sacral promontory have never been described in the literature, as bone evaluation has never been considered a limiting element of this procedure.

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

ObjectivePelvic 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 designMedical 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. ResultsAll 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. ConclusionLSCP 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.

Laparoscopic uterosacral ligament suspension vs laparoscopic sacral colpopexy in patients with pelvic organ prolapse: intermediate term follow-up of a retrospective study

Laparoscopic uterosacral ligament suspension vs laparoscopic sacral colpopexy in patients with pelvic organ prolapse: intermediate term follow-up of a retrospective study

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

To demonstrate laparoscopic mesh repair of perineal hernia (PH) by a modified sacral colpopexy technique. Step-by-step demonstration of the technique used for the surgical repair of PH after gynecologic surgery. 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. 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. Laparoscopic mesh repair by the modified sacral colpopexy technique is safe and effective to manage PH.

Titanized polypropylene mesh in laparoscopic sacral colpopexy.

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). 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. 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. 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.

EDITORIAL COMMENT

There is a lot to like about this well-designed, prospective RCT comparing robot-assisted and laparoscopic sacral colpopexy by a high-volume, experienced surgeon. Compared to 2 previous similar RCTs, 1 Paraiso MF Jelovsek JE Frick A et al. Laparoscopic compared with robotic sacrocolpopexy for vaginal prolapse: a randomized controlled trial. Obstet Gynecol. 2011; 118: 1005-1013 Crossref PubMed Scopus (293) Google Scholar ,2 Anger JT Mueller ER Tarnay C et al. Robotic compared with laparoscopic sacrocolpopexy: a randomized controlled trial. Obstet Gynecol. 2014; 123: 5-12 Crossref PubMed Scopus (174) Google Scholar the current paper offers a longer mean follow-up period and a higher number of recruited patients. The use of standardized questionnaires, as well as the utilization of both objective and subjective outcome criteria for pelvic support, incontinence, and sexual function, is a plus. Not surprisingly, the anatomic outcomes at a mean of 2 years are excellent and symptomatic improvements have followed suit.