Uterosacral Ligament Colpopexy Research Articles

10 Small bowel entrapment during pelvic reconstructive surgery

The objectives of this video are to describe a case of a small bowel strangulation resulting from bowel entrapment within a uterosacral ligament suspension (USL) suture, to discuss the pathophysiology of small bowel obstruction (SBO), to discuss early recognition of this rare complication, and to recommend practice changes that may help prevent small bowel entrapment during USL procedures. This video presents a case of a small bowel strangulation resulting from bowel entrapment within a uterosacral ligament suspension suture. After reviewing the literature pertaining to the incidence of early small bowel obstruction in gynecology, we will discuss our patient's clinical presentation with a focus on her CT imaging and findings on diagnostic laparoscopy. Next, we use original illustrations throughout the video to illustrate the pathophysiology of small bowel obstruction, closed loop obstructions, and bowel strangulation. Finally, using original illustrations, we discuss practice changes which we have adopted to prevent this rare complication. Through this video we hope to teach clinicians about the presentation and Croton pathophysiology of closed loop small bowel obstruction, which are uncommon complications following uterosacral ligament colpopexy. We hope that this video will encourage clinicians to maintain a very high index of suspicion for this complication in patients who present with obstructive symptoms in the acute postoperative period following a uterosacral ligament colpopexy. In addition to suture removal, we emphasize that abdominal exploration with bowel examination is essential as a necrotic segment of bowel warrants urgent intervention with excision and anastomosis. Through this video we hope to teach clinicians about the presentation and pathophysiology of closed loop small bowel obstruction, which are uncommon complications following uterosacral ligament colpopexy. We hope that this video will encourage clinicians to maintain a very high index of suspicion for this complication in patients who present with obstructive symptoms in the acute postoperative period following a uterosacral ligament colpopexy. In addition to suture removal, we emphasize that abdominal exploration with bowel examination is essential as a necrotic segment of bowel warrants urgent intervention with excision and anastomosis.

Preliminary evaluation of the short-term outcomes of polytetrafluoroethylene mesh for pelvic organ prolapse.

Tension-free vaginal mesh (TVM) surgery using synthetic polypropylene (PP) soft mesh had spread rapidly. However, the frequency of mesh-related postoperative complications had increased, and PP was banned in April 2019. In Japan, however, transvaginal surgery using polytetrafluoroethylene (PTFE) mesh had been approved. In this study, we evaluated the clinical outcome and quality of life (QOL) of the postoperative course using PP mesh and PTFE mesh (named "ORIHIME™" ) in a combination surgery for utero-sacral ligament suspension and anterior vaginal support using anterior TVM. The vaginal hysterectomy and utero-sacral ligament colpopexy augmented by anterior vaginal mesh implants using PP mesh and PTFE mesh were performed on patients with stage III to IV cystocele and uterine prolapse. The clinical outcome and QOL changes in their postoperative course were evaluated by comparing 15 cases of PP mesh and 13 cases of PTFE mesh. There was no difference between the PP group and PTFE group in characteristics. No mesh-related complications occurred during the follow-up period. With regard to the pelvic organ prolapse quantification (POP-Q) score, no significant difference was found between the two groups. Comparing the postoperative QOL of both groups, the PTFE group had significantly higher values in two domains than PP group (SF-12v2 questionnaire). We used the world's first PTFE mesh to compare PP mesh with postoperative POP-Q and QOL after the same surgery, with the same operator, and at the same institution. The results showed no significant difference between both mesh materials in the short-term.

Risk factors for ureteral obstruction and the diagnostic value of the "cysto-under-tension" technique at the time of uterosacral colpopexy.

The objective is to determine the incidence of ureteral obstruction and delayed ureteral injury and to identify risk factors for ureteral obstruction following uterosacral colpopexy. The secondary objective is to evaluate the diagnostic value of the "cysto-under-tension" technique, when a cystoscopy is performed prior to vaginal cuff closure with the uterosacral sutures on tension. This was a retrospective review of patients undergoing uterosacral ligament colpopexy between 2007 and 2012 with a nested case-control analysis. Patients with documented ureteral obstruction on cystoscopy or a delayed ureteral injury were identified. Cases were defined as patients with a ureteral obstruction on cystoscopy and controls as those who did not; a multivariable regression analysis was performed. A total of 551 patients underwent uterosacral ligament colpopexy. Twenty-four (4.3% [95% CI = 2.94-6.40]) patients had a ureteral obstruction on cystoscopy, and two (0.4% [95% CI = 0.09-1.31]) patients experienced a delayed ureteral injury. The "cysto-under-tension" technique was used in 40 (7.3%) cases, with a sensitivity of 50.0% (CI = 1.26-98.74) and specificity of 97.4% (CI = 86.2-99.9) to detect ureteral obstruction. On logistic regression for the case-control analysis, increased age remained associated with increased odds of ureteral obstruction (adjOR 1.06, 95% CI = 1.02-1.11) and a higher BMI had lower odds (adjOR 0.89, 95% CI = 0.79-0.98). In this large cohort study, older age was associated with higher odds of obstruction at the time of colpopexy while a higher BMI might have been protective. The "cysto-under-tension" technique overall may not be that useful in detecting ureteral obstructions but has high negative predictive value.

Laparoscopic uterosacral ligament colpopexy for apical support in addition to hysterectomy for pelvic organ prolapse.

To evaluate the perioperative complications and the anatomical outcomes of our laparoscopic uterosacral ligament (USL) colpopexy, which is a novel laparoscopic technique for the management of uterine prolapse. The objective was to report on outcome after 2 years of a technique using laparoscopic USL colpopexy. A total of 152 uterine prolapse patients underwent laparoscopic USL colpopexy from May 2013 to April 2015. We described the surgical technique and performed a retrospective analysis of this laparoscopic technique. Patients underwent standardized assessment and examination using pelvic organ prolapse quantification (POP-Q) score. The dependent values of Ba point (bladder), C point (vaginal cuff) and Bp point (rectum) were recorded preoperatively, and at 1, 3, 6, 12 and 24 months of postoperative examination. Pre/postoperative data were compared using the Kaplan-Meier method. Mean age, operative time and amount of hemorrhage were 68.2 ± 7.5 years, 118.3 ± 36.4 min and 60.5 ± 73.3 mL, respectively. Overall recurrent prolapse, which was defined as POP-Q stage II or higher, was noted in 29 patients (19%). However, only 2 patients presented recurrent rectocele among 51 patients with preoperative POP-Q stage II of uterine prolapse alone (recurrence rate; 3.9%). The pre/postoperative average POP-Q scores were -0.2/-2.7 cm (P < 0.05) at Ba point, -1.9/-5.1 cm (P < 0.05) at C point and -2.4/-2.3 cm (P = 0.06) at Bp point. Laparoscopic visualization of uterosacral ligaments may result in safe colpopexy. Our results show this will be a useful procedure for apical support as native tissue repair.

Surgical Anatomy of the Uterosacral Ligament Colpopexy

(Abstracted from Female Pelvic Med Reconstr Surg 2017;24:380–382) The most frequent complication in reports of uterosacral ligament (USL) colpopexy is ureteral compromise, resulting from either kinking or direct ureteral injury. The incidence of this complication was 3% to 5% in a number of studies.

Surgical Anatomy of the Uterosacral Ligament Colpopexy.

The aim of this study was to describe the relationship of the uterosacral ligament (USL) to the ureter and rectum along a surgeon's target location for suture placement under conditions simulating live surgery. Dissections were performed in 11 unembalmed female cadavers. Steps were taken to identify the USL simulating USL colpopexy. Pins were placed in the midportion of the USL at the level of the IS, and at 1-cm, 2-cm, and 3-cm increments traveling proximally toward the sacrum (Fig. 1). We measured minimum distances from the USL to the ureter and rectum at each target location. In general, the ureters range from 1.3 to 2.0 cm lateral to the USLs along the target length. The rectum ranges from 1.9 to 2.6 cm from the right USL and remains 1.5 cm from the left USL. The mean change in distance between the ureter and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% confidence interval [CI], 0.19-0.24) on the right and 0.2 cm (95% CI, 0.18-0.27) on the left. The mean change in distance between the rectum and USL for every 1 cm advanced toward the sacrum is 0.2 cm (95% CI, 0.19-0.24) on the right and 0.0 cm (95% CI, 0-0) on the left. For every centimeter traveled along the bilateral USLs from the IS toward the sacrum, the ureter moves 0.2 cm laterally away from the ligament, the rectum moves 0.2 cm medially away from the right USL, but maintains its position from the left USL.

03: Uterosacral ligament colpopexy: The way we do it

To describe our technique for performing uterosacral ligament colpopexy, including the key points we consider essential to a successful procedure. A successful uterosacral ligament colpopexy is performed by visualizing and identifying the anatomy of the uterosacral ligaments in relation to the ischial spines, ureters, and rectum, ensuring a firm grasp of the ligaments at or above the level of the ischial spines, placing sutures through the uterosacral ligaments while avoiding injury to surrounding structures, orderly anchoring and suspending of the sutures to the vaginal cuff, avoiding ureteral kinking with a planned strategy for managing ureteral obstruction, and performing concomitant surgical procedures as indicated to treat incontinence and restore normal vaginal anatomy. Uterosacral ligament colpopexy is a safe and effective procedure resulting in a high apical suspension of the vagina in its natural, anatomic axis with adequate vaginal length.

10: Surgical anatomy of the uterosacral ligament colpopexy

10: Surgical anatomy of the uterosacral ligament colpopexy

Laparoscopic fixation of the vaginal cuff to the uterosacral ligaments at the time of hysterectomy

Transvaginal ipsilateral uterosacral ligament colpopexy for pelvic organ prolapse (POP), which was reported by Shull et al. (Shull's colpopexy) in 2000, is one of the most frequently performed non-mesh pelvic floor reconstructive surgical procedures. Despite its excellent anatomical outcomes, ureteral injury and difficulty in uterosacral ligament detection (especially in patients with severe POP) are typical issues with this procedure. This video demonstrates the procedure in a 58-year-old woman, gravida 2 para 2, with POP-Q stage II uterine prolapse and stage I cystocele. At the beginning of the operation, the bilateral uterosacral ligaments were confirmed and separated from the ureters after entering the retroperitoneal space. The inferior hypogastric nerve and pelvic nerve plexus were also separated from the uterosacral ligament. After total laparoscopic hysterectomy, three ipsilateral delayed absorbable monofilament sutures were placed between the uterosacral ligament and the vaginal cuff. Retroperitonealization was then performed using a continuous suture with closure of the Douglas pouch. Laparoscopic Shull's colpopexy for POP is a secure procedure with the advantages of laparoscopy (magnification and sharing the operative field). This may become one of the most useful operations for apical support as native tissue repair.

Vaginal hysterectomy, vaginal salpingoophorectomy and uterosacral ligament colpopexy: a view from above (in English and Spanish).

The aim of this video is to make vaginal hysterectomy (TVH), vaginal salpingoophorectomy and uterosacral ligament (USL) colpopexy approachable by showing the key procedural steps from both the vaginal and abdominal perspectives. This production shows TVH with salpingoophorectomy and USL colpopexy that was performed on a cadaver and filmed simultaneously from the vaginal and abdominal views. The video begins with an anatomy overview from the open abdomen and proceeds with the TVH. The anterior and posterior peritoneal entries, a technique to safely and easily access the adnexa, as well as the placement of USL suspension sutures are highlighted. The proximity of the ureter and its distance from the three locations most vulnerable to injury during this procedure (the uterine artery pedicle, the infundibulopelvic ligament and the USL) are illustrated. The location of the USL suspension sutures in relation to the ischial spine, the rectum and the sacrum are demonstrated. For all of these crucial steps, a series of picture-in-picture views simultaneously showing the abdominal and vaginal perspectives are presented so that the viewer may better understand the spatial anatomy. This video provides the viewer with a unique anatomic perspective and helps more confidently perform TVH, vaginal salpingooophorectomy and USL colpopexy.

7: Surgical anatomy and steps of the uterosacral ligament colpopexy

7: Surgical anatomy and steps of the uterosacral ligament colpopexy

Combined reconstructive surgery involving uterosacral colpopexy and anterior vaginal mesh implantation for pelvic organ prolapse.

The optimal treatment for pelvic organ prolapse has been the subject of much discussion. The aim of this study was to assess the utility of a combination of uterosacral colpopexy and anterior vaginal mesh implantation. A single-center prospective cohort study was conducted. Twenty-eight patients with stage III-IV cystocele and uterine prolapse underwent reconstructive surgery. A combination of vaginal hysterectomy, McCall culdeplasty, and trocar-guided anterior vaginal mesh implantation was performed, and the patients' postoperative outcomes were analyzed. Patient satisfaction was investigated using the modified Short Form 12 version 2 (SF-12v2) questionnaire, and interviews regarding sexual behavior were conducted at 1 postoperative year. A bladder injury occurred during the dissection in one case (3.6%). Recurrent vaginal vault prolapse beyond the hymen was observed in one patient (cure rate: 96.4%), and further mesh augmentation was required in this case. Another patient developed mild cystocele (Ba = 0), but was simply observed because she did not complain of any symptoms caused by vaginal descent. We did not experience any other mesh-related complications, such as protrusion, chronic pain, or chronic inflammation, during the follow-up period. The patients' modified SF-12 scores at 12 months were significantly better than their preoperative scores in all eight domains. The satisfactory correction of pelvic organ prolapse was achieved using a combination of vaginal hysterectomy and uterosacral ligament colpopexy augmented by anterior vaginal mesh implantation. © 2016 Japan Society of Obstetrics and Gynecology.

Granulation Tissue Formation at the Vaginal Cuff after Total Laparoscopic Hysterectomy or Davinci Assisted Total Hysterectomy with Uterosacral Ligament Colpopexy for Surgical Correction of Pelvic Organ Prolapse

The aim of this study was to look at the prevalence of vaginal cuff granulation tissue formation after total laparoscopic hysterectomy or Davinci assisted total hysterectomy with laparoscopic uterosacral ligament colpopexy.

Laparoscopic uterosacral ligament colpopexy in management of vaginal vault prolapse

Laparoscopic uterosacral ligament colpopexy in management of vaginal vault prolapse