Uterosacral Ligament Research Articles

Intraoperative ultrasound assessment of ureteral patency after uterosacral ligaments apical suspension for prolapse surgical repair: A feasibility study.

To prospectively compare power Doppler ultrasound diagnostic performance with reference standard cystoscopy in evaluating ureteral patency in a population at high risk of ureteral lesions. We analyzed 100 women who underwent pelvic organ prolapse repair. All ultrasound scans were obtained, at the end of the procedures, before cystoscopic evaluation. Bilateral simultaneous ureteral jet evaluation with power Doppler was performed at the level of the ureterovesical junctions with a pulse repetition frequency set to detect low flow for a maximum of 3 min. According to the reference standard urethrocystoscopy, at least one ureter not ejaculating was observed in 6% of patients, for a total of seven ureters jets not visualized. No false-negative results were obtained. Ultrasound with power Doppler showed 100% sensitivity and 95.9% specificity in detecting the lack of ureteral jet. The negative predictive value was 100%, and the positive predictive value was 46.7%. Ultrasound with power Doppler represents an effective and reliable non-invasive screening test to exclude ureteral kinking and reduce the need for intraoperative cystoscopy.

The Utility of Rectal Water Contrast Transvaginal Ultrasound for Assessment of Deep Bowel Endometriosis.

Deep infiltrating endometriosis (DIE) is characterized by the presence of endometrial tissue outside the uterine cavity that infiltrates at least 5-mm deep below the peritoneal layer. Imagining examinations are the first-choice methods to detect DIE. The aim of this study is to assess whether rectal water contrast transvaginal sonography (RWC-TVS) can be a useful tool for the estimation of the size of deep bowel endometriotic nodules. This retrospective study includes 31 patients subjected to RWC-TVS who underwent surgery due to deep bowel endometriosis between January 2021 and December 2022. Nodule dimensions measured via ultrasound were compared to those of histopathological samples taken after surgery. In total, 52% of patients had endometriosis limited only to the intestines, 19% had endometriotic nodules located at uterosacral ligaments and posterior vaginal fornix, 6% at the anterior compartment, and 13% at a different location. Additionally, 6% of patients had nodules at more than two locations. In all but one case, the intestinal nodules could be seen on RWC-TVS images. The largest nodule dimension measured via RWC-TVS and the size of the equivalent histopathological sample correlated (R = 0.406, p = 0.03). Thus, RWC-TVS allows for the detection of DIE and moderate estimation of the nodule sizes and should be practiced during a diagnostic process.

ENDOMETRIOSIS OF THE CECUM AND APPENDIX: REVIEW OF LITERATURE.

Endometriosis is a benign, chronic, inflammatory and estrogen dependent pathology in which there is the implantation of functional extrauterine endometrial tissue. Pelvic and abdominal endometriosis are the most frequent presentations and, in these forms, ectopic endometrial implantation affects the lesser pelvis, uterosacral ligaments, ovaries, uterine tubes, urinary and gastrointestinal tracts. Some symptoms such as altered bowel habits, pelvic pain, infertility and bleeding during bowel movements are present. In this work the focus is on the manifestations of endometriosis in the appendix and cecum. The use of imaging tests, such as transrectal and transvaginal ultrasonography, magnetic resonance imaging and colonoscopy are important tools used, however, the gold standard is videolaparoscopy with biopsy to confirm the anatomopathological findings. The surgical strategy is related to the degree of impairment and must take into account the eradication of the disease together with the preservation of fertility. Therefore, the importance of evaluating and treating all areas that endometriosis affects is clear, with a multidisciplinary approach by general surgeons and gynecologists, in order to investigate, diagnose and correctly address the disease in an organized and correct way.

Vaginal Hysterectomy, Uterosacral Ligament Suspension, Anterior Repair, and Perineorrhaphy

Watch this full-length, narrated procedure of a vaginal hysterectomy, uterosacral ligament suspension, anterior repair, and perineorrhaphy on a 75-year-old multiparous female with stage 3 uterovaginal prolapse.

PROMIS pain intensity and interference after pelvic organ prolapse surgery.

Patient-Reported Outcome Measurement Information System (PROMIS) questionnaires provide valid comparisons across disciplines. Pain measures can be used to track functional outcomes. Limited PROMIS pain data exist in gynecological surgery. We sought to use pain intensity and pain interference short forms to assess pain and recovery after pelvic organ prolapse surgery. The PROMIS pain intensity and pain interference questionnaires were given to patients undergoing uterosacral ligament suspension (USLS), sacrospinous ligament fixation (SSLF) or minimally invasive sacrocolpopexy (MISC) at baseline, 1 week, and 6 weeks postoperatively. Clinical minimally important change was defined as a difference of 2-6T-score points. Mean pain intensity and pain interference T-scores were compared at baseline, 1 week and 6 weeks with ANOVA. Multiple linear regression assessed 1-week scores adjusted for apical suspension type, advanced prolapse, concurrent hysterectomy, concurrent anterior or posterior repair, and concurrent sling. At 1 week, all apical suspension groups showed minimally important change in pain intensity and pain interference T-scores. Between groups at 1 week, pain interference was higher in USLS (66.3±6.6) and MISC (65.5±5.9) than in SSLF (59.2±9.8), p=0.01. Multiple linear regression showed an association of hysterectomy with increases in pain intensity and pain interference. USLS had a higher proportion of concurrent hysterectomy (100%) than SSLF (0%) and MISC (30.8%), p<0.01. No difference was found based on apical suspension type alone. No differences were found in PROMIS pain intensity and pain at 1week postoperatively after apical suspension procedures.

Five-year surgical outcomes of transvaginal apical approaches in women with advanced pelvic organ prolapse.

In women with advanced prolapse, differences in vaginal apex anchoring sites may impact surgical outcomes over time. The primary aim was to compare 5-year surgical outcomes of uterosacral ligament suspension (ULS) versus sacrospinous ligament fixation (SSLF) in women with advanced (stage III-IV) prolapse. A secondary analysis was conducted in a subset of women with advanced prolapse from a multicenter randomized trial comparing ULS versus SSLF and its extended follow-up, using publicly accessible de-identified datasets. The primary outcome was time to failure, defined as any one of (1) apical descent > 1/3 into the vaginal canal or anterior/posterior compartment beyond the hymen, (2) bothersome vaginal bulge symptoms, or (3) re-treatment. Secondary outcomes include symptom severity measured by the Pelvic Organ Prolapse Distress Inventory (POPDI) and adverse events. Of 285 women, 90/147 (61.2%) in ULS and 88/138 (63.8%) in SSLF had advanced prolapse. Baseline characteristics did not differ between groups except for median-vaginal deliveries (3.0 [2.0, 5.0] versus 3.0 [2.0, 4.0], p < 0.01). The median time to failure was 1.7years ULS versus 2.0years SSLF (p = 0.42). Surgical failure increased over time in both groups with no intergroup difference; by year 5, the estimated failure rate was 67.7% ULS versus 71.5% SSLF (adjusted difference -3.8; 95%CI [-21.9, 14.2]). No differences were noted in individual failure components (p > 0.05). POPDI scores improved over 5years without intergroup difference (ULS -68.0 ± 61.1 versus SSLF -69.9 ± 60.3, adjusted difference -0.1 [-20.0, 19.9]). No difference in adverse events were observed (p > 0.05). In women with advanced prolapse, surgical failure, symptom severity, and adverse events did not differ between ULS and SSLF over 5years.

Expression profile analysis of lncRNA and mRNA in uterosacral ligaments of women with pelvic organ prolapse by RNA-seq

Pelvic organ prolapse (POP) is a conventional gynecological condition and the mechanism is not entirely clear. Although an increasing number of studies revealed that long non-coding RNAs (lncRNAs) have essential functions in many diseases, little knowledge has been acquired in POP. The current study aimed to investigate the regulatory mechanism of lncRNA in POP. In this report, we investigated the expression profile of lncRNAs and mRNAs between POP and the control groups in human uterosacral ligament (hUSL) tissues through RNA-seq. Cytoscape was used to construct a POP-specific lncRNA-mRNA network and select key molecules. This RNA-Seq analysis uncovered a total of 289 lncRNAs, and 41 lncRNAs and 808 mRNAs were differentially expressed between the POP and non-POP groups. Four lncRNAs were identified and validated by real-time PCR. The result of gene ontology (GO) and Kyoto encyclopedia of genes and genomes (KEGG) indicated that differentially expressed lncRNAs were abundant in the biological processes and signaling pathways concerned in POP. The differentially expressed lncRNAs were mainly enriched in protein binding, the single-organism cellular process, and cytoplasmic part. The network was constructed based on the correlation analyses of the abnormally expressed lncRNAs and their target proteins to imitate their interactions. Taken together, this study was the first to demonstrate the differential expression profiles of lncRNA in POP and normal tissues by sequencing technology. Our study indicated that lncRNAs could correlate with the development of POP and may be as significant genes in the diagnosis and treatment of POP.

MP07-12 PELVIC FLOOR SUPPORT FOLLOWING FEMALE RADICAL CYSTECTOMY: A LONGITUDINAL OBSERVATIONAL STUDY

You have accessJournal of UrologyCME1 Apr 2023MP07-12 PELVIC FLOOR SUPPORT FOLLOWING FEMALE RADICAL CYSTECTOMY: A LONGITUDINAL OBSERVATIONAL STUDY Shree Agrawal-Patel, Sandip Vasavada, David Rapp, Sarah Martin, Lauren Gleich, Tracey Krupski, Byron Lee, and Jacqueline Zillioux Shree Agrawal-PatelShree Agrawal-Patel More articles by this author , Sandip VasavadaSandip Vasavada More articles by this author , David RappDavid Rapp More articles by this author , Sarah MartinSarah Martin More articles by this author , Lauren GleichLauren Gleich More articles by this author , Tracey KrupskiTracey Krupski More articles by this author , Byron LeeByron Lee More articles by this author , and Jacqueline ZilliouxJacqueline Zillioux More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Women are at risk of pelvic organ prolapse and sexual dysfunction following radical cystectomy (RC); however, these outcomes are under-appreciated and understudied. We aimed to assess the natural history of pelvic floor support and vaginal symptoms following female RC. METHODS: This is an interim analysis of an IRB-approved multicenter prospective observational study of pelvic floor support in women undergoing RC from 3/2021 to 5/2022. All women undergoing RC at 2 institutions were recruited. Participants underwent pelvic exam including Pelvic Organ Prolapse Quantification System (POP-Q) measurements by an FPMRS-trained urologist at baseline and routine postoperative visits. Participants completed validated questionnaires (Pelvic Floor Disability Index (PFDI-20); International Consultation on Incontinence Questionnaire Vaginal Symptoms (ICIQ-VS)) at each visit. Surgical details including amount of vaginal tissue removed during non-vaginal-sparing RC were recorded. RESULTS: Fourteen women enrolled and had at least one postoperative visit through 6-months. Median age was 69 years. Approach was robotic in n=9 (64%) and vaginal-sparing in n=5 (38%). Indication was benign for 3 patients and all underwent non-orthotopic diversion. One vaginal-sparing benign case had concomitant mesh sacrocolpopexy for baseline stage 3 apical prolapse, while one patient from sparing and non-sparing groups had concurrent uterosacral ligament plication. All non-vaginal-sparing cases had clamshell reconstruction following excision of a median of 4.0 [4.0, 6.0] cm length and 2.5 [2.0, 4.0] cm width vaginal tissue, representing median 48% of baseline total vaginal length removed. Table 1 illustrates longitudinal POP-Q exam and questionnaire scores of vaginal sparing and non-sparing cases. One patient had anterior vaginal wall dehiscence requiring debridement under anesthesia but ultimately not reconstruction. CONCLUSIONS: To our knowledge, this is the first prospective study of pelvic floor support following female RC. Though further study is needed, preliminary findings through 6-month follow-up suggest vaginal foreshortening in both vaginal-sparing and non-sparing cases. Both groups appear to have mild anterior/posterior prolapse progression, although without worsened symptom scores. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e89 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shree Agrawal-Patel More articles by this author Sandip Vasavada More articles by this author David Rapp More articles by this author Sarah Martin More articles by this author Lauren Gleich More articles by this author Tracey Krupski More articles by this author Byron Lee More articles by this author Jacqueline Zillioux More articles by this author Expand All Advertisement PDF downloadLoading ...

V12-10 COMPLETE BLADDER PROLAPSE THROUGH THE URETHRA: ROBOTIC-ASSISTED LAPAROSCOPIC BURCH COLPOSUSPENSION AND BLADDER NECK RECONSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023V12-10 COMPLETE BLADDER PROLAPSE THROUGH THE URETHRA: ROBOTIC-ASSISTED LAPAROSCOPIC BURCH COLPOSUSPENSION AND BLADDER NECK RECONSTRUCTION Connie Wang, Rainjade Chung, Miyad Movassaghi, and Doreen Chung Connie WangConnie Wang More articles by this author , Rainjade ChungRainjade Chung More articles by this author , Miyad MovassaghiMiyad Movassaghi More articles by this author , and Doreen ChungDoreen Chung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003347.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present a unique case report of complete bladder prolapse through the urethra. We additionally demonstrate the surgical technique of robotic-assisted Burch Colposuspension and bladder neck reconstruction to address multiple urologic problems for a patient who was not a candidate for a mid-urethral sling, and who required concomitant pelvic organ prolapse repair. METHODS: The patient’s initial presentation of bladder prolapse through the urethra was repaired with manual reduction, urethroplasty, bladder neck closure, and cystorrhaphy. Her subsequent Burch Colpopsuspension was performed robotically. The Da Vinci Xi robot was used with a 5-port configuration, including an assistant port. Surgical steps described in this video include dissection of vagina off bladder, apical uterosacral ligament suspension, dropping the bladder, bladder neck reconstruction, Burch Colposuspension, paravaginal repair, and new suprapubic tube placement. RESULTS: A successful treatment of a freely mobile, prolapsing bladder and near absent urethra causing severe urinary incontinence is achieved. The patient remains continent and her bladder remains well reduced post-operatively. CONCLUSIONS: Robotic-assisted laparoscopic Burch Colposuspension represents a minimally-invasive, effective option for patients who present with multiple different urologic issues, including pelvic organ prolapse and stress urinary incontinence. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1067 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Connie Wang More articles by this author Rainjade Chung More articles by this author Miyad Movassaghi More articles by this author Doreen Chung More articles by this author Expand All Advertisement PDF downloadLoading ...

MP07-01 MESH-FREE MANAGEMENT OF APICAL PELVIC ORGAN PROLAPSE: A COMPARATIVE STUDY OF VAGINAL SACROSPINOUS FIXATION V ROBOTIC UTEROSACRAL LIGAMENT SUSPENSION

You have accessJournal of UrologyCME1 Apr 2023MP07-01 MESH-FREE MANAGEMENT OF APICAL PELVIC ORGAN PROLAPSE: A COMPARATIVE STUDY OF VAGINAL SACROSPINOUS FIXATION V ROBOTIC UTEROSACRAL LIGAMENT SUSPENSION Sandra Elmer, Omar Salehi, Niranjan Sathianathen, Jodie McDonald, Nathan Lawrentschuk, and Caroline Dowling Sandra ElmerSandra Elmer More articles by this author , Omar SalehiOmar Salehi More articles by this author , Niranjan SathianathenNiranjan Sathianathen More articles by this author , Jodie McDonaldJodie McDonald More articles by this author , Nathan LawrentschukNathan Lawrentschuk More articles by this author , and Caroline DowlingCaroline Dowling More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pelvic organ prolapse (POP) significantly impacts quality of life for many women. Mesh sacral colpopexy (SCP) has a recurrence rate up to 23%, and vaginal procedures to correct apical POP up to 41%. After the FDA warnings and restrictions of transvaginal mesh, increasing concerns regarding mesh have resulted in a need for mesh-free alternatives. This study compares 2 mesh-free techniques, robotic/laparoscopic uterosacral ligament suspension (RUSL) and vaginal sacrospinous fixation (SSF) in managing apical POP. METHODS: A prospective clinical audit of 115 women with apical POP who underwent RUSL (n=61) or SSF (n=54) by a single surgeon. Demographic data included age, parity, and previous POP surgery. A pre-operative (preop) pelvic floor (PF) questionnaire was used to identify prevalence of bladder, bowel and vaginal symptoms. POP-Q was recorded at surgery and at post-operative (postop) reviews. The absolute change in POP-Q scores were recorded as objective measures of PF support. Other postop metrics used include symptomatic vaginal bulge, need for repeat POP surgery (reop) and subjective improvement in symptoms based on patient-reported outcome measures (PROMs). Postop adverse events (AE) were recorded (Clavien Dindo grading scale). Wilcoxon rank sum test, Pearson’s Chi-squared test and Fisher’s exact test were used to compare groups, and univariate analysis to predict factors for success/reop. RESULTS: Baseline demographics were similar (Table 1). Mean time from surgery was 736 (RUSL) and 565 days (SSF). Difference in postop C points was not significant (RUSL: median -8 (IQR 2), SSF: median -7cm (IQR 2), p=0.279). Procedure success rates (postop C point <0) were not different (RUSL 90.2%, SSF 92.5%, p=0.92). Reop rates for apical recurrence were SSF 1.9%, RUSL 6.6%, p=0.21; univariate odds ratio 0.26 [95% CI 0.03 to 2.43]. Univariate analysis for reop found that age, parity and surgery type were not predictors of reoperation (p=0.26, p=0.92, p=0.78). The most common postop AE was urinary tract infection (RUSL 10.2%, SSF 10.5%). CONCLUSIONS: RUSL and SSF are safe and effective mesh-free techniques for management of apical POP based on objective improvements in POP-Q score and PROMs. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e84 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sandra Elmer More articles by this author Omar Salehi More articles by this author Niranjan Sathianathen More articles by this author Jodie McDonald More articles by this author Nathan Lawrentschuk More articles by this author Caroline Dowling More articles by this author Expand All Advertisement PDF downloadLoading ...

A preoperative predictive model for stage IV endometriosis

This was a retrospective study that evaluated a total of 280 patients who underwent surgery for complete removal of endometriosis to develop and validate the predictive model for stage IV endometriosis. The differences between stage I-III and stage IV endometriosis were performed by logistic regression. A model for the prediction of stage IV endometriosis was constructed, which was subsequently validated. The independent variables were visual analogue scale (VAS)≥4 [3.855, 95% confidence interval (CI): 1.675–8.871, p = 0.002], painful nodularity on uterosacral ligaments (13.954, 95% CI: 1.658–117.423, p = 0.015), and bilateral endometriosis (5.933, 95% CI: 1.931–18.225, p = 0.002). The AUC of the model was 0.777, with a sensitivity of 71.9% and specificity of 76.3% for stage IV endometriosis. Therefore, a complete collection of patient information prior to surgery, asking about pain and VAS scores, careful completion of pelvic examinations, and application of imaging techniques are conducive to better diagnosis and prediction of advanced endometriosis. IMPACT STATEMENT What is already known on this subject? Endometriosis, a chronic disease causing pain and infertility, is characterised by endometrial-like tissue outside the uterine cavity, which is often treated via surgery at present. Considering the risks of surgery, it is necessary to identify patients with stage IV endometriosis through non-invasive predictive models for adequate preparation for surgery. However, there is no reliable non-invasive predictive model now, despite utilisation of patient medical history, symptoms especially pain-related ones, pelvic examinations, laboratory examinations, and images in the preoperative diagnosis of endometriosis in the clinic. What do the results of this study add? A model developed based on three simple, accessible and non-invasive indicators displays good performance in predicting stage IV endometriosis. What are the implications of these findings for clinical practice and/or further research? It is conducive to diagnosing and predicting advanced endometriosis before surgery, so as to reduce the difficulty and improve the safety of surgery.

Laparoscopic radical hysterectomy and total vaginectomy for vaginal malignant melanoma with cervical metastasis

The presented case is a 63-years-old multiparous woman admitted with the complaint of postmenopausal bleeding. On gynecologic examination multifocal lesions were detected, including 1 cm on lateral vaginal wall, 4 cm on posterior vaginal wall and 0.5 cm on the left lateral part of the cervix. Histopathology examination gave a diagnosis of epithelioid malignant melanoma. Consequently, laparoscopic radical hysterectomy and total vaginectomy with bilateral pelvic and inguinofemoral lymph node dissection were planned. On both sides, pararectal and paravesical spaces were created and the ureter was identified. Then, the vesicouterine and vesicovaginal spaces were developed. Uterine artery and superior vesical artery were coagulated, cut and the lateral parametrium was prepared. The left ureter was dissected and the ureteral tunnel was unroofed up to the bladder entrance. Subsequently, the anterolateral parametrium was transected. Then, the infundibulopelvic and sacrouterine ligaments were sealed and transected. At this time, the rectovaginal space was developed. Bilateral paracolpos were transected. The endopelvic fascia with the levator muscles were sealed and cut circumferentially. Anteriorly, the pubovesicocervical fascia was transected and the bladder was mobilized up to the uretrovesical junction. Thereafter, through a vaginal approach, the cervix and vagina were inverted by grasping the cervix with a tenaculum. An incision on the posterior vaginal wall at the introitus was made and the urogenital diaphragm was dissected to connect with the pelvic cavity. The vaginal entrance was cut circumferentially and the surgical specimen was extracted. In conclusion, laparoscopy can be considered as a feasible approach for radical hysterectomy and total vaginectomy in selected patients.

Mild endometriosis of the uterosacral ligaments: a retrospective study of magnetic resonance imaging performance for diagnosis

Research questionWhat are the diagnostic performances of magnetic resonance imaging (MRI) scans when used to identify mild endometriosis of the uterosacral ligaments (USL)? DesignMonocentric retrospective study of patients who underwent a pelvic MRI followed by laparoscopy for determination of endometriosis between January 2016 and December 2020. Patients were included whether endometriosis of USL was suspected or not, but patients presenting large lesions that left no doubt as to their endometriotic nature on the MRI were excluded. Six criteria for the description of USL on MRI were studied to determine their diagnostic performances in predicting the presence of endometriosis on laparoscopy as follows: asymmetry, thickening, irregularity, straightness, the presence of a nodule or a hypersignal T1 spot. ResultsSeventy-seven patients were included. Among the criteria, ‘asymmetry’ and ‘thickening’ had the highest sensitivities (0.69 [95% confidence interval 0.54–0.80] and 0.51 [0.40–0.63], respectively) but moderate specificities (0.52 [0.31–0.73] and 0.62 [0.50–0.72]). Conversely, ‘irregularity’, ‘nodule’, ‘straightness’ and ‘hypersignal T1 spot’ were associated with high specificities (0.81 [0.70–0.89], 0.96 [0.89–0.99], 0.95 [0.87–0.99] and 0.99 [0.93–1.00], respectively) but poor sensitivities (0.22 [0.14–0.33], 0.12 [0.06–0.21], 0.08 [0.03–0.16] and 0.08 [0.03–0.16], respectively). The presence of at least one criterion for the description of the USL was associated with good sensitivity (0.80 [0.66–0.89]) but poor specificity (0.35 [0.16–0.57]). ConclusionsThe results suggest that the identification of minimal changes in the normal appearance of USL should not automatically lead to a conclusion of mild endometriosis at this location.

Isolation and Characterization of the Murine Uterosacral Ligaments and Pelvic Floor Organs.

Pelvic organ prolapse (POP) is a condition that affects the integrity, structure, and mechanical support of the pelvic floor. The organs in the pelvic floor are supported by different anatomical structures, including muscles, ligaments, and pelvic fascia. The uterosacral ligament (USL) is a critical load-bearing structure, and injury to the USL results in a higher risk of developing POP. The present protocol describes the dissection of murine USLs and the pelvic floor organs alongside the acquisition of unique data on the USL biochemical composition and function using Raman spectroscopy and the evaluation of mechanical behavior. Mice are an invaluable model for preclinical research, but dissecting the murine USL is a difficult and intricate process. This procedure presents an approach to guide the dissection of murine pelvic floor tissues, including the USL, to enable multiple assessments and characterization. This work aims to aid the dissection of pelvic floor tissues by basic scientists and engineers, thus expanding the accessibility of research on the USL and pelvic floor conditions and the preclinical study of women's health using mouse models.

Laparoscopic Retrieval of a Retained Foreign Body Embedded in the Retroperitoneum

A 38-year-old nulliparous woman without surgical history with enlarging uterine fibroids underwent laparoscopic myomectomy. A routine abdominal X-ray performed on postoperative day 2 showed a foreign body in the pelvis. Computed tomography revealed a metallic object, which was located outside the bowel. A planned laparoscopic exploration was undertaken on postoperative day 42. The foreign body was difficult to find, but unidimensional fluoroscopy revealed that it was embedded in the retroperitoneum. Local angiogenesis of the peritoneum, which rose on the right uterosacral ligament (USL), was noted in its location (Fig. 1). Laparoscopic retrieval of the foreign body was performed, along with an excision of surrounding connective tissue under the USL (Fig. 2), and it was confirmed that a 4 × 2 × 1 mm metallic object was removed (Fig. 3A). The object was confirmed to be a broken part of laparoscopic needle holder (Fig. 3B) which had been subsequently used in other surgeries following the index procedure. Fig. 2Laparoscopic image. The foreign body was retrieved by excising surrounding connective tissue en bloc. View Large Image Figure Viewer Download Hi-res image Fig. 3(A) A removed metallic object measuring 4 × 2 × 1 mm in size. (B) The jaw of laparoscopic needle holder. The object was confirmed to be a broken part (red arrow) of needle holder. View Large Image Figure Viewer Download Hi-res image

Impact of 4 versus 6 apical suspension sutures for uterosacral ligament suspension

Impact of 4 versus 6 apical suspension sutures for uterosacral ligament suspension

Outcomes after vaginal versus robot assisted uterosacral ligament suspension for pelvic organ prolapse repair

Outcomes after vaginal versus robot assisted uterosacral ligament suspension for pelvic organ prolapse repair

A Vagino-Laparoscopic Strategy for Hysterectomy of Large Uteri to Ease Surgical Challenges.

To develop a vagino-laparoscopic strategy for hysterectomy (VLH) to treat uteri with large fibroids at ≥ 16 weeks of gestation to ease surgical challenges. This was an observational study conducted in our private general hospital on 64 consecutive cases involving uteri with large and benign fibroids at ≥ 16 weeks of gestation. We excluded cases with an associated ventro-fixed uterus and large cervical fibroids. The VLH strategy involves vaginal separation of the uterosacral with the uterine arteries followed by laparoscopic separation of the remaining upper pedicles. The uterus was then removed vaginally. The largest uteri receiving treatment was at 26 weeks of gestation and the mean uterus weight was 869.60 ± 275.10 g (range: 500-1900 g). The VLH strategy was successful in 63 (98.43%) cases irrespective of the configuration of the uterus. One case (1.56%) required mini-laparotomy conversion due to the need for adhesiolysis; this case exhibited extensive adhesion of the rectum to the posterior wall of the uterus due to a history of previous myomectomy of the posterior wall. There were no conversions due to failed laparoscopic exposure of the adnexal or uterine vascular pedicles, or due to uncontrolled intraoperative bleeding. There were no cases of urinary tract injury or other major complications. The vaginal detachment of uterosacral ligaments before the laparoscopic phase of the VLH strategy increased upwards mobility and dislodged the cervico-isthmic level of large uteri from the narrow lower aspect of the pelvis to the upper wider part of the pelvis; this eased the surgical challenges associated with such cases and avoided complications during laparoscopy. We developed a vagino-laparoscopic strategy for hysterectomy that can ease the technical challenges associated with the majority of large uteri.

Apical repositioning: a strategy to reduce large anterior defects at the time of uterosacral ligament suspension

Apical repositioning: a strategy to reduce large anterior defects at the time of uterosacral ligament suspension

Simulation of uterosacral ligament suspension after vaginal hysterectomy using a validated model

Simulation of uterosacral ligament suspension after vaginal hysterectomy using a validated model