Abdominal sacral colpopexy: Surgical pearls and outcomes

Vaginal vault prolapse is a challenging form of pelvic organ prolapse that occurs in combination with cystocele, rectocele, or enterocele in nearly 75% of affected patients. Clinical presentation will vary depending on the associated defects. Any successful therapy for vaginal vault prolapse will depend on a thorough evaluation of the vaginal compartments and concomitant lower urinary tract function. Surgical correction of vaginal vault prolapse can be achieved through a variety of vaginal or abdominal approaches. This review focuses on the abdominal approach for vaginal vault prolapse surgery. We review outcomes of abdominal sacral colpopexy (ASC) and available comparisons to vaginal vault suspension. We address the role of laparoscopy and robotics in ASC and examine the outcomes of such procedures. We also discuss available literature on the management of the lower urinary tract in combination with ASC.     

State of the Art of Robotic Surgery in Organ Transplantation

Within the last two decades the application of minimally invasive surgical technologies has shown significant benefits when it comes to complex surgical procedures. Lower rates of complications and higher patient satisfaction are commonly reported. Until recently these benefits were inaccessible for patients with solid organ transplantation, because conventional laparoscopy was seen as nonapplicable in such technically demanding procedures. The introduction of the da Vinci Robotic Surgical System, with its inherent advantages, has expanded the ability to complete solid organ transplantation in a minimally invasive fashion. Robotic applications in kidney, pancreas, and liver transplantation have been reported. The initial results showed the viability of this technique in the field. The most extensive experience has been described in kidney transplantation. Over 700 donor nephrectomies and more than 70 renal transplants have been performed successfully with the robotic system. The proven advantage of the robotic technique, especially in obese kidney recipients, is a significantly lower rate of surgical site infection, which in these highly immunosuppressed patients is reflected in superior outcomes. The first results in pancreas transplantation and living donor hepatectomy are very promising; however, larger series are needed in order to address the value of the robotic surgery in these areas of solid organ transplantation.     

Laparoscopic techniques for the repair of vaginal vault prolapse: Determining if less is more

Repair of vaginal vault prolapse remains a surgical challenge. Abdominal, vaginal, and combined procedures have been described. The ideal operation remains elusive with regard to outcomes, morbidity, and economics. As an extension of the abdominal approach, laparoscopy continues to gain favor as an access method and as a surgical advancement. Recent studies highlight a number of laparoscopic techniques for restoration of apical support that demonstrate feasibility and encouraging results. Further study is necessary to determine if the minimally invasive nature of laparoscopy can duplicate or surpass standard abdominal and vaginal approaches to the repair of pelvic organ prolapse.     

Female incontinence: a review of biomaterials and minimally invasive techniques

PURPOSE OF REVIEW: This article discusses the various grafts or biomaterials, minimally invasive techniques, and recent advances for the treatment of female stress urinary incontinence and pelvic organ prolapse. RECENT FINDINGS: The studies reviewed in this paper compared certain biologic grafts to synthetic grafts in clinical trials and histopathological studies. Data from long-term outcome studies for tension-free vaginal tape are evaluated. As tension-free vaginal tape is the foremost technique for stress urinary incontinence correction, many of the newer modalities such as transobturator tape and laparoscopy are compared with it. Immediate and long-term complications from mesh use in stress urinary incontinence and pelvic organ prolapse repair are examined. Correction of prolapse may eventually entail the use of specially designed 'kits' that allow total pelvic floor reconstruction with a single piece of mesh. SUMMARY: Although biological grafts are initially efficacious, the trend is to use synthetic grafts in repair of stress urinary incontinence and pelvic organ prolapse. Midurethral slings continue to be the front-line therapeutic modality for stress urinary incontinence. After analysis of long-term data, other surgical techniques may gain popularity. With increasing use of synthetic grafts, however, long-term complications such as de-novo urgency, erosion, and dyspareunia need to be assessed.     

女性盆底重建Prolift手术的解剖学研究

针对盆底功能障碍性疾病的手术包括传统的阴式子宫切除加单纯阴道前后壁折叠修补术、采用自身组织进行修复的曼氏手术、骶棘韧带固定术和髂尾肌筋膜悬吊术等。近年较为推崇的全盆底重建手术,系盆腔盲法穿刺并于阴道内放置网片的微创手术,该术式具有疗效好、手术时间短及术后恢复快的特点。本文就Prolift手术的产生过程与解剖学路径进行阐述。     

Genetics and the lower urinary tract

Many complex disorders have been found to have a heritable component, including lower urinary tract dysfunction. Twin studies have indicated that genetic contributions to urinary incontinence (UI) may be as important as environmental influences. Linkage to chromosome 9 has been demonstrated in families with pelvic organ prolapse and stress UI. An increasing number of incontinence specialists are studying subjects with lower urinary tract dysfunction using single nucleotide polymorphisms, linkage analyses of siblings, and large association studies. These findings have exciting implications for future prevention and treatment of UI. Neurourol. Urodynam. 29:609–611, 2010. © 2010 Wiley‐Liss, Inc.     

Minimally invasive treatment of stress urinary incontinence and vaginal prolapse

Stress urinary incontinence and pelvic organ prolapse are prevalent conditions that can have detrimental effects on a woman's quality of life. Surgically, this has often been approached by means of a transvaginal route. With recent advances in laparoscopic and robotic instrumentation and operating systems, there is increasing interest in minimally invasive techniques for correction of pelvic organ prolapse. In this article, the authors briefly describe the laparoscopic and robotic approaches in terms of surgical techniques, operative anatomy, and results published in the literature.     

Management of voiding dysfunction associated with pelvic malignancies

Voiding dysfunction is common after surgical and radiation treatments in patients diagnosed with non‐urological pelvic malignancies. Presentation might vary with lower urinary tract symptoms and/or overactive bladder, urinary retention, or incontinence. We reviewed the most recent literature with the aim of describing various types of urinary dysfunction that manifest after radical treatments for non‐urological pelvic malignancies. Radical surgical or radiation treatment adversely affect other adjacent pelvic organ function, including viscera, pelvic musculature and the peripheral nervous system. This results in direct organ and indirect functional damage to the genitourinary tract. Multiple surgical and radiation modifications are available nowadays, allowing urologists to offer various treatments for better functional lower urinary tract outcomes. Diagnosing and understanding the type and severity of voiding dysfunction plays a key role in tailoring an appropriate treatment plan. The objective to better functional results relies on maintaining adequate bladder compliance and capacity while permitting volitional emptying, ideally through voiding. Management should routinely start with conservative measures, including pelvic floor muscle training with or without a combination of oral medication for urgency incontinence and clean intermittent catheterization for the management of urinary retention. Concomitant or isolated urinary incontinence can be further managed through multiple established surgical approaches. We attempted to address various treatment available for known lower urinary tract symptoms that might have been caused secondary to non‐urological pelvic surgery or radiation. We discuss different diagnostic and treatment modalities individualized for patients with various entities, to help achieve optimal urinary function and improve quality of life.     

Minimally invasive treatment of male lower urinary tract symptoms

During the past decade, increasing numbers of minimally invasive treatments for managing male lower urinary tract symptoms caused by urinary tract obstruction have been positioned. On one hand, transurethral needle ablation and transurethral microwave thermotherapy bridge the gap between medical management and surgery, while on the other hand, outcomes of holmium laser enucleation of the prostate and Greenlight laser equal outcomes following transurethral resection of the prostate (TURP). With the introduction of the bipolar technology, however, TURP has reinforced its position.     

Overt rectal prolapse following repair of stage IV vaginal vault prolapse

Pelvic organ prolapse is an increasingly common problem as women are living longer. With the growing numbers of surgeries performed to correct this problem, further research is needed to understand the long-term success as well as possible complications of these procedures. One potential complication that needs further study is de novo rectal prolapse after repair of pelvic organ prolapse, specifically after colpocleisis. Defacography may be an important part of the preoperative workup in the patient with pelvic organ prolapse. Currently, there is a controversy as to whether internal, or occult, rectal prolapse on defacography should be repaired at the time of other pelvic reconstructive surgery. We report on a case of overt rectal prolapse after repair of Stage IV vaginal vault prolapse with a colpocleisis, levator ani plication, and a minimally invasive midurethral sling. We discuss the issues surrounding preoperative management of these patients and propose a theory explaining why prolapse in other areas of the pelvis may occur after reconstructive surgery.     

Pessary treatment for pelvic organ prolapse and health-related quality of life: a review

Pessaries have been used to treat women with pelvic organ prolapse (POP) since the beginning of recorded history. This review aims to assess the effect of pessary treatment on the disease-specific, health-related quality of life in women with pelvic organ prolapse. After a Medline search using the Mesh term ‘pessary’ and critical appraisal, 41 articles were selected and used in this review. Pessaries are widely used to treat pelvic organ prolapse. It is minimally invasive and appears to be safe. Although there is evidence that the use of pessaries in the treatment of pelvic organ prolapse is effective in alleviating symptoms and that patient satisfaction is high, the follow-up in many published papers is short, and the use of validated urogynaecological questionnaires is limited. Comparison with surgical treatment of pelvic organ prolapse is rare and not assessed in a randomised controlled trial.     

Laparoscopic hysteropexy in a patient with spina bifida and ventriculoperitoneal shunt

Laparoscopic repair of pelvic organ prolapse in patients with ventriculoperitoneal shunts has not been previously described. The optimum management of patients with ventriculoperitoneal shunts undergoing laparoscopy is uncertain. We describe the case of a 21-year-old female patient with spina bifida and ventriculoperitoneal shunt who underwent laparoscopic hysteropexy for severe pelvic organ prolapse. The implications of performing laparoscopy on patients with ventriculoperitoneal shunts are reviewed along with strategies to reduce potential intraoperative complications.     

Apical vault repair, the cornerstone or pelvic vault reconstruction

Pelvic organ prolapse remains a difficult problem for pelvic reconstructive surgery. Before new surgical procedures can be developed a good understanding of pelvic anatomy is necessary. It is widely held that the etiology of pelvic organ prolapse is secondary to stretch neuropathy following childbirth and chronic cough or constipation. Several transvaginal and transabdominal procedures have been developed over the years. With the increasing use of laparoscopy, a new variation on existing culdeplasty techniques has been developed. Following anatomical principles, the apical vault repair reestablishes the pericervical ring at the vaginal apex. The incorporation of pubocervical fascia, uterosacral-cardinal ligament and the rectovaginal fascia provides a strong anchor for the vaginal apex. In addition, the repair should help prevent future transverse cystocele, rectocele, enterocele and apical vault prolapse. Early outcome studies suggest that the apical vault repair should be used routinely with laparoscopic urethropexy, laparoscopic hysterectomy and the repair of pelvic organ prolapse. Good apical vault support is considered the cornerstone of pelvic reconstruction.     

The use of robotic surgery in abdominal organ transplantation: A literature review

Minimally invasive surgical approaches in transplantation are gaining increasing interest, and many centers are reporting their, mainly laparoscopic, experiences. Robotic surgery (RS) has some hypothetical advantages over traditional laparoscopy and has been successfully applied, although infrequently to organ transplantation. Our goal was to review and critique the publications reporting RS use in organ transplantation. Most of the RS experience has been with living renal donor organ procurement and, to a lesser extent, with RS procedures in the transplant recipient. The available literature suggests that RS appears to be a safe surgical alternative to standard open procedures. RS in living liver donor surgery remains limited, and more experience is required before commenting on RS‐related outcomes RS in pancreatic transplantation is exceedingly rare. The enhanced precision and ergonomics of RS may expand its applicability to liver living donation and pancreas transplantation at some point in the future.     

泌尿系结石微创手术治疗进展

目的:随着科学技术的发展,泌尿系结石的治疗方法发生了显著变化,传统的开放性手术几乎被体外冲击波碎石、经皮肾镜取石术、输尿管镜、逆行肾内手术、腹腔镜手术所取代。近年来,新的设备和器械不断出现,使泌尿系结石治疗的手段和方法也不断进步。本文旨在对泌尿系结石微创手术进展作一阐述。     

Twenty years of laparoscopic sacrocolpopexy: where are we now?

Introduction and hypothesis  

Laparoscopic sacrocolpopexy (LSC) was first described almost 20 years ago. This technique aims to provide the outcomes of the gold standard abdominal approach while offering the benefits of minimally invasive surgery. However, the widespread diffusion of LSC in the management of pelvic organ prolapse (POP) is hampered by its presumed length and technical difficulties due to the inherent need for laparoscopic suturing skills.     

Bladder erosion after 2 years from cystocele repair with type I polypropylene mesh

Type I polypropylene mesh have been widely used in gynaecologic surgery for the treatment of pelvic organ prolapse and stress urinary incontinence. Such devices produced positive results compared to the equivalent non-mesh-based operation but erosions into adjacent viscera, especially the vagina, have also been reported. We describe the case of bladder erosion that manifested two years after the initial cystocele repair surgery and the management adopted.     

Open versus minimally invasive surgery for suspected adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis. Although laparoscopy has been widely adopted for management of benign adrenal tumors, minimally invasive surgery for ACC remains controversial. Retrospective analyses, frequently with fewer than one hundred participants, comprise the majority of the literature. High-quality data regarding the optimal surgical approach for ACC are lacking due to the rarity of the disease and the fact that determination of tumor type (e.g., adenoma or carcinoma) is determined after adrenalectomy, since adrenal tumors are generally not biopsied. While the benefits of minimally invasive surgery including lower intra-operative blood loss and decreased hospital length-of-stay have been consistently demonstrated, clinical equipoise for long-term survival and recurrence outcomes between open and minimally invasive adrenalectomy (MIA) remains. This review examines retrospective studies that directly compare patients with ACC who underwent either open or laparoscopic adrenalectomy, and considers these findings in the context of current guideline recommendations for surgical management of ACC.     

Surgery for Pelvic Organ Prolapse: A Historical Perspective

Surgical treatment of pelvic organ prolapse has evolved from the use of pomegranates as pessary devices to contemporary robot-assisted laparoscopic sacral colpopexy. Symptomatic pelvic organ prolapse requires correction of all the defects to achieve optimal outcomes. Factors to consider in selecting the appropriate repair include patient's age; stage of prolapse; vaginal length; hormonal status; desire for uterine preservation and coitus; symptoms of sexual, urinary, or bowel dysfunction; and any comorbidities that influence her eligibility for anesthesia or chronically increase intra-abdominal pressure. There is currently no consensus as to the best surgical approach for advanced pelvic organ prolapse. Reconstructive surgery for pelvic organ prolapse is currently performed by vaginal or abdominal (open, laparoscopic, and robotic approaches) approaches or a combination. It is important to maintain skills in proven procedures such as abdominal sacrocolpopexy and sacrospinous ligament suspension. This paper discusses the historical evolution of surgery for pelvic organ prolapse from antiquity to date.