Absorbable versus Permanent Suture for Vaginal Uterosacral Ligament Suspension for Treatment of Apical Prolapse

Study ObjectiveThe aim of this study was to compare surgical outcomes in women undergoing vaginal uterosacral ligament suspension using permanent as opposed to absorbable sutures. We also aimed to assess for specific risk factors for suture complications.DesignRetrospective cohort study.SettingFemale pelvic medicine and reconstructive surgery unit at a university-affiliated tertiary medical center.PatientsWomen with apical prolapse who underwent vaginal hysterectomy with uterosacral ligament suspension during the study period.Interventionsnone.Measurements and Main ResultsA total of 197 women were included in the study. Of them, 118 (59.9%) underwent the procedure using a permanent suture and 79 (40.1%) using an absorbable suture. Women in the permanent suture group were less sexually active and had less prolapse of point C on pre-operative exam.With regard to intra-operative and postoperative data, women in the permanent suture group had increased frequency of concomitant procedures, regional anesthesia, surgical time, duration of hospital stay, and change in hemoglobin. Clinical, anatomical, and composite success did not differ between groups. Patient satisfaction recorded using the Patient Global of Improvement Questionnaire was similar as well. Women in the permanent suture group had a higher frequency of suture exposure compared with the absorbable suture group (9.3% vs 0.0%, p = .006).In order to assess for risk factors leading to suture complications, a comparison was performed between women who had suture exposure or granulation tissue and those who did not. Increasing parity by 1 increased the odds of having suture exposure or granulation tissue by a factor of approximately 1.2 (adjusted odds ratio = 1.24; Confidence interval, 1.05–1.47). Women with stage IV prolapse had 3.4 times the odds of suture complication compared with women with stage III prolapse (adjusted odds ratio = 3.4; Confidence interval, 1.1–10.6).ConclusionUse of an absorbable suture affords comparable success and lower frequency of suture exposure compared with permanent sutures in women undergoing vaginal uterosacral ligament suspension for treatment of apical prolapse.     

Transvaginal Natural Orifice Transluminal Endoscopic Hysterectomy and Apical Suspension of the Vaginal Cuff to the Uterosacral Ligament

Study ObjectiveTransvaginal natural orifice transluminal endoscopic surgery (vNOTES) offers similar advantages of traditional vaginal surgery including no incisional pain as well as a better cosmetic outcome. Furthermore, vNOTES allows the surgeon to overcome the limited surgical space and lack of exposure when using the traditional vaginal instrumentation. Vaginal uterosacral ligament suspension subsequent to vaginal hysterectomy has the advantages of a mesh-free, minimally invasive approach for the treatment of pelvic organ prolapse. The objective of this video is to demonstrate a surgical technique and a few tips and tricks for vNOTES hysterectomy and uterosacral ligament suspension.DesignStepwise demonstration of the vNOTES technique for hysterectomy and vaginal apical suspension to the uterosacral ligament with narrated video footage.SettingAn academic tertiary referral center. The ethics committee ruled that approval was not required for this study.PatientsA 53-year-old woman.InterventionsvNOTES hysterectomy and apical suspension to the uterosacral ligament.Measurements and Main ResultsA 53-year-old woman (gravida 5, para 4) presented with Pelvic Organ Prolapse Quantification System stage III symptomatic uterine prolapse. The patient was selected to be operated on via a vaginal port. The video presents some tips and tricks to aid the surgeon to perform this surgery in a safe and timely manner using the vaginal GelPOINT system (Applied Medical, Rancho Santa Margarita, CA).ConclusionvNOTES for repair of POP by uterosacral ligament suspension via a vaginal port is a feasible technique with promising cosmetic results. This technique allows the surgeon to expose the ureter well and lower the risk of ureteric injury. Additionally, this approach avoids mesh complications and should also decrease the risk of abdominal wound infection because of the absence of incisions on the abdomen.     

Techniques for Apical Prolapse Management in Transvaginal Natural Orifice Transluminal Endoscopic Surgery High Uterosacral Ligament Suspension

Study ObjectiveTo demonstrate practical tips and tricks for successful use of the transvaginal natural orifice transluminal endoscopic surgery (NOTES) technique for performing high uterosacral ligament suspension (HUS).DesignStepwise demonstration with narrated video footage (Canadian Task Force classification III).SettingAn academic tertiary care hospital.InterventionsA 58-year-old G2P2, NSVDx2 with stage III anterior vaginal prolapse, stage II uterine prolapse, and posterior vaginal prolapse. The preoperative vaginal length was 7-cm. Transvaginal NOTES is a creative yet difficult approach that averts an abdominal incision while simultaneously providing enhanced visualization in comparison with traditional vaginal surgery [1]. However, this approach may be technically challenging.After performing transvaginal hysterectomy and anterior repair, the single-site port was placed, and bilateral salpingo-oophorectomy was subsequently performed. The following key techniques were used to perform NOTES-HUS: tagging the sutures for bilateral uterosacral ligament before single-site port placement, identifying the ischial spine and ureters, pulling the tagged uterosacral ligament suture to assist in locating the high uterosacral ligament, grasping and lifting the uterosacral ligament while placing a suture, and giving the suture a tug after placement to confirm the correct location 2, 3, 4.The procedure was successfully performed in approximately 160 minutes with a postoperative vaginal length of 5-cm. Postoperative pelvic organ prolapse quantification was stage 0.ConclusionTransvaginal NOTES-HUS is a feasible and practical technique for apical vaginal prolapse. There is an increased cost to using laparoscopically assisted NOTES surgery as well as a risk of pneumoperitoneum. Applying the tips and tricks presented here, such as tagging the uterosacral ligament before port placement and so on, the challenging transvaginal NOTES-HUS technique can be performed efficiently and safely.     

Effect of Uterine Preservation on Outcome of Laparoscopic Uterosacral Suspension

Study ObjectiveTo compare the objective outcome of laparoscopic uterosacral hysteropexy with that of hysterectomy combined with laparoscopic uterosacral colpopexy.DesignRetrospective cohort study, 1999–2010 (Canadian Task Force classification II-2).SettingUniversity hospital in South Australia.PatientsWomen with uterovaginal prolapse who had undergone laparoscopic uterosacral hysteropexy (n = 104) or laparovaginal hysterectomy with uterosacral colpopexy (n = 160). Apical suspension procedures were subdivided into prophylactic (Pelvic Organ Prolapse Quantification System [POP-Q] stage 1 apical descent, with stage ≥2 prolapse in an adjacent compartment) and therapeutic (POP-Q stage ≥2 apical descent, with or without adjacent compartment prolapse).InterventionsAll patients were assessed via POP-Q scoring preoperatively and postoperatively at 6 weeks, 6 months, annually, and then biannually. Recurrence of bulge symptoms and need for repeat treatment were recorded.Measurements and Main ResultsDemographic data, preoperative degree of prolapse, and percentages of prophylactic and therapeutic procedures were similar in both groups. With a median follow-up of 2.5 years, objective success rates (POP-Q stage <2 in all compartments) for uterosacral hysteropexy were 53% for prophylactic procedures and 41% for therapeutic procedures, and for hysterectomy with uterosacral colpopexy were 66% for prophylactic procedures and 59% for therapeutic procedures. Repeat operation rates overall were 28% for hysteropexy and 21% for hysterectomy with colpopexy. Failures at the apex specifically were 27% for hysteropexy and 11% for hysterectomy with colpopexy (p < .02).ConclusionHysterectomy with laparoscopic uterosacral colpopexy produced better objective success rates than did laparoscopic uterosacral hysteropexy; however, repeat operation rates were not significantly different.     

Uterosacral ligament fixation for vaginal vault suspension in uterine and vaginal vault prolapse

OBJECTIVE: The purpose of this study was to determine the simplicity, safety, anatomic, and functional success of using the uterosacral ligaments for correction of significant complex uterine and vaginal vault prolapse by the vaginal route. STUDY DESIGN: Fifty women with uterine or vaginal vault prolapse with descent of the cervix or the vaginal vault to the introitus or greater were treated between 1993 and 1996 by the same surgeon with bilateral uterosacral ligament fixation to the vaginal cuff by the vaginal route. Included were patients with significant enterocele, cystourethrocele, rectocele, and stress urinary incontinence who had concomitant repair of coexisting pelvic support defects. An etiology of vaginal vault prolapse is discussed. RESULTS: Uterosacral ligaments were identified and used for successful vaginal vault suspension by the vaginal route in all 50 consecutive patients without subsequent failure or significant complications with a maximum follow-up of 4 years. One patient had recurrent stress urinary incontinence and two had asymptomatic cystoceles. Three patients had erosion of monofilament sutures at the vaginal apex. CONCLUSIONS: In these 50 patients with significant complex uterine or vaginal vault prolapse, uterosacral ligaments could always be identified and safely used for vaginal vault suspension by the vaginal route with no persistence or recurrence of vaginal vault prolapse 6 to 48 months after surgery. Excessive tension by the surgeon on tagged uterosacral ligaments at the time of hysterectomy may be an etiologic factor in vaginal vault prolapse.(Am J Obstet Gynecol 1997;177:44)     

Uterosacral Ligament Suspension Sec Shull by Vaginal Natural Transluminal Endoscopic Surgery (vNOTES)

This step-by-step video demonstrates the feasibility of the Shull technique via vaginal natural transluminal endoscopic surgery (vNOTES) in a patient experiencing pelvic organ prolapse (POP) with apical support loss.A 51-year-old woman with apical pelvic organ prolapse quantification (POP-Q) stage III and a right benign ovarian cyst underwent a total hysterectomy and bilateral adnexectomy with vaginal dome uterosacral ligament suspension performed via vNOTES. Total operating time was 82 minutes, with negligible blood loss. The patient remained in hospital for 2 days. There were no intra- or postoperative complications at 30 days post-surgery, and there was complete repair of the apical defect at 6-month follow-up.The advantages of NOTES include avoiding abdominal incisions, eliminating complications associated with the trocar sound, and reducing postoperative pain and length of hospital stay.vNOTES provides safe entry, easy access, and direct visualization of the peritoneal cavity and pelvic anatomy. The Shull technique by vNOTES is technically feasible and permits clear and safe identification of uterosacral ligaments.     

National Analysis of Perioperative Morbidity of Vaginal Versus Laparoscopic Hysterectomy at the Time of Uterosacral Ligament Suspension

Study ObjectiveThe objective of this study was to compare the morbidity of vaginal versus laparoscopic hysterectomy when performed with uterosacral ligament suspension.DesignRetrospective propensity-score matched cohort study.SettingAmerican College of Surgeons National Surgical Quality Improvement Program database.PatientsWe included all patients who had undergone uterosacral ligament suspension and concurrent total vaginal hysterectomy (TVH-USLS) or total laparoscopic hysterectomy (TLH-USLS) from 2010 to 2015. We excluded those who underwent laparoscopic-assisted vaginal hysterectomy, abdominal hysterectomy, other surgical procedures for apical pelvic organ prolapse, or had gynecologic malignancy.InterventionsWe compared 30-day complication rates in patients who underwent TVH-USLS versus TLH-USLS in both the total study population and a propensity score matched cohort.Measurements and Main ResultsThe study population consisted of 3,349 patients who underwent TVH-USLS and 484 who underwent TLH-USLS. Patients who underwent TVH-USLS had a significantly higher composite complication rate (11.4% vs 6.4%, odds ratio [OR] 1.9, 1.3–2.8; p <.01) and a higher serious complication rate (5.6% vs 3.1%, OR 1.8, 1.1–3.1; p = .02), which excluded urinary tract infection and superficial surgical site infection. The propensity score analysis was performed, and patients were matched in a 1:1 ratio between the TVH-USLS group and the TLH-USLS group. In the matched cohort, patients who underwent TVH-USLS had a higher composite complication rate than those who underwent TLH-USLS (10.3% vs 6.4%, OR 1.7, 95% confidence interval [CI], 1.1–2.7; p = .04), whereas the rate of serious complications did not differ between the groups (4.3% vs 3.1%, OR 1.4, 95% CI, 0.7–2.8; p = .4). On multivariate logistic regression, TVH-USLS remained an independent predictor of composite complications (adjusted OR 1.6, 95% CI, 1.0–2.6; p = .04) but not serious complications (adjusted OR 1.4, 95% CI, 0.7–2.8; p = .3).ConclusionIn this large national cohort, TVH-USLS was associated with a higher composite complication rate than TLH-USLS, largely secondary to an increased rate of urinary tract infection. After matching, the groups had similar rates of serious complications. These data suggest that TLH-USLS should be viewed as a safe alternative to TVH-USLS.     

Clinical outcome after laparoscopic assisted vaginal hysterectomy with transvaginal uterosacral ligament fixation

ObjectiveWe report here the clinical outcome of a simplified method to suspend the vaginal cuff during laparoscopic assisted vaginal hysterectomy.Materials and MethodsThis is a retrospective study. Fifty patients underwent laparoscopic assisted vaginal hysterectomy and received transvaginal uterosacral ligament fixation for vaginal cuff support (LAVHUS). Follow-up examinations were conducted for at least 24 months and included vaginal examination with prolapse grading using the POP-Q system. Subjective outcomes were measured using a questionnaire that asked patients to describe postoperative lower urinary tract symptoms and satisfaction with the procedure.ResultsThe mean follow-up duration was 106 weeks (range 102–120 weeks).The postoperative POP-Q point C and total vaginal length were effectively sustained during this period. There were no intraoperative or postoperative complications, and no adverse postoperative lower urinary tract symptoms were reported.ConclusionThe present study demonstrated satisfactory subjective and objective clinical outcomes following LAVHUS.     

Mesh-Free Laparoscopic High Uterosacral Ligament Suspension during Total Laparoscopic Hysterectomy for Uterine Prolapse

Study Objective

To demonstrate a mesh-free approach for uterine prolapse during a hysterectomy.

Transvaginal Natural Orifice Transluminal Endoscopic Uterosacral Ligament Hysteropexy: An Innovative Approach for Treatment of Uterine Prolapse

Study ObjectiveTransvaginal natural orifice transluminal endoscopic surgery (vNOTES) was previously described as a feasible approach to perform several procedures including hysterectomy followed by uterosacral ligament suspension [1,2]. Approaching the cul-de-sac with vNOTES while the uterus is intact allowing access to the uterosacral ligaments. This enables attainment of apical support by placing sutures on the ligaments, shortening them, and reinforcing their attachment to the cervix. The objective of this video is to demonstrate a surgical technique for vNOTES uterosacral ligament hysteropexy (ULH).DesignStepwise demonstration of the technique with narrated video footage. This video report is part of an institutional, investigational review board–approved study.SettingAcademic tertiary referral center.InterventionsThis video presents our team's vNOTES technique for ULH in a woman aged 37 years (gravida 3 para 3) who presented with pelvic organ prolapse quantification stage 3 symptomatic uterine prolapse. The patient requested uterine prolapse repair surgery while retaining the uterus. After performing a posterior colpotomy and entering the posterior cul-de-sac, the alexis and then the GelPOINT V-path transvaginal access platform (Applied Medical, Rancho Santa Margarita, CA) were placed into the vagina. Three trocars were inserted into the port. We used a 10-mm scope with a 30°-angle view. The instruments included a needle driver and a clinch grasper. The next step was to identify the uterosacral ligamentous structures. Once identified, 2 absorbable vicryl sutures and 1 nonabsorbable Ti-cron suture were placed on each ligament and then secured with large bites into the junctional portion of the uterosacral ligament with the posterior aspect of the cervix. The GelPOINT was then extracted, and the sutures locked in place to shorten the uterosacral ligaments and reinforce their attachment to the cervix. After all the suspensory sutures were tied, cystoscopy was performed to assess ureteral patency. The vaginal incision was then reapproximated in a horizontal manner, using continuous absorbable suture.ConclusionvNOTES ULH appears to be feasible in women with uterine prolapse when uterus conservative treatment is desired. Advantages of this technique include good exposure of the ureter, lowering the risk of ureteric injury. In addition, the absence of incisions on the abdomen eliminates the risk of abdominal wound infection and incisional pain and yields a better cosmetic outcome. Further studies are needed to appraise the long-term outcomes and demonstrate the ultimate use of this modality.     

经阴道子宫骶骨韧带高位悬吊术治疗子宫脱垂的临床探讨

目的探讨经阴道子宫骶骨韧带高位悬吊术（HUS）治疗子宫脱垂的解剖生理基础、适应证、手术技巧、输尿管损伤的预防及临床近、中期疗效。方法2003年6月至2007年9月,采用经阴道HUS悬吊阴道穹隆、重建耻骨宫颈筋膜及直肠阴道筋膜,治疗中、重度子宫脱垂50例。患者平均年龄60．1岁,术后平均随访时间24个月（4～51个月）。同时采用盆腔器官脱垂定量分度（POP-Q）法对子宫脱垂程度及手术后结果进行评价,以术后C点值≤POP-QⅠ度计算成功率。结果术中50例中、重度子宫脱垂患者的宫骶韧带均可在后腹膜坐骨棘内后侧、经长组织钳钳夹牵拉、清楚触及和辨认,并均成功对阴道穹隆进行了悬吊和筋膜重建。术中应根据对输尿管解剖部位和相邻关系的准确认识、术中触摸、掌握缝合进针深度及方向、膀胱镜检查并确认输尿管开口位置等方法避免输尿管损伤。50例中,无一例输尿管损伤。术后平均随访时间24个月,POP-Q法C点值由术前1．5cm降为术后的-7．5cm;主、客观成功率均达100％。结论经阴道HUS悬吊并重建阴道穹隆、耻骨宫颈筋膜、直肠阴道筋膜是利用自身组织作为悬吊点治疗子宫脱垂,符合恢复解剖生理、保留功能及微创原则,主、客观成功率高。     

vNOTES Hysterectomy,Adnexectomy, and Uterosacral Ligament Suspension: A Walk-Through Guide

ObjectiveTo provide a stepwise guide to performing vNOTES hysterectomy, adnexectomy, and vault suspension, using 2 access platform methods.DesignNarrated surgical video based on 2 cases of vNOTES for abnormal uterine bleeding and endometrial intraepithelial neoplasia.SettingA single tertiary-care academic center.InterventionsStep-by-step walk-through is shown to demonstrate the successful completion of a hysterectomy, adnexectomy, and vault suspension. Use of a traditional glove platform and that of an advanced access system, the GelPOINT Access System (Applied Medical), are illustrated. The surgical steps are summarized as follows: (1) colpotomy and abdominal entry, (2) transection of the uterosacral ligaments, (3) placement of an access platform, (4) upper abdominal survey, (5) transection of the uterine and cornual pedicles, (6) identification of the ureters, (7) bilateral salpingo-oophorectomy, (8) uterosacral ligament suspension, (9) cystoscopy, and (10) vaginal vault closure and tying of the suspension sutures.ConclusionThis video demonstrates the steps to safely reproduce a vNOTES hysterectomy, adnexectomy, and uterosacral ligament suspension with 2 access techniques. vNOTES offers scar-free surgery, improved access to high pedicles and surgical fields, and a favorable recovery profile, making it an attractive surgical route in appropriate candidates.     

Suture Complication Rates and Surgical Outcomes According to the Nonabsorbable Suture Materials Used in Vaginal Uterosacral Ligament Suspension: Polyester versus Polypropylene

Study ObjectiveTo evaluate suture complication rates and surgical outcomes according to the nonabsorbable suture materials used in vaginal uterosacral ligament suspension (USLS) surgery. Multifilament polyester (polyethylene terephthalate [PET]) and monofilament polypropylene (PP) sutures were compared.DesignRetrospective cohort study.SettingSingle teaching hospital.PatientsTotal of 229 patients who underwent transvaginal USLS and completed a 1-year follow-up.InterventionsUse of PET and PP sutures for transvaginal USLS procedures.Measurements and Main ResultsPP sutures were used in 149 patients, and PET sutures were used in 80 patients. The suture-related complication rates, including granulation tissue and suture erosion at the vaginal apex, were significantly higher in the PET suture group than in the PP suture group (46.3% vs 20.1%, p <.01). However, there was no significant difference in the rates of surgical failure (defined as the presence of vaginal bulging symptoms, apical descent ≥ half of the total vaginal length, anterior or posterior vaginal wall descent beyond the hymen, or retreatment for prolapse) between the 2 groups (p = .84).ConclusionCompared with the use of multifilament PET sutures, the use of monofilament PP sutures in transvaginal USLS may reduce suture-related complications without increasing surgical failure rates.     

高位宫骶韧带悬吊术治疗中盆腔缺陷的研究进展

中盆腔缺陷是盆腔器官脱垂的常见类型,严重影响女性的生活质量。目前临床上治疗中盆腔缺陷的手术方式众多,但缺乏统一的术式选择标准,高位宫骶韧带悬吊术即在坐骨棘水平上1~3 cm缝合骶韧带,悬吊阴道穹隆并重建耻骨宫颈和阴道直肠筋膜,其作为采用自体组织修复中盆腔缺陷的手术,因能较好地恢复顶端支持结构、并发症少、再手术率低、费用低等优点,逐渐广泛应用于临床。就高位宫骶韧带悬吊术不同手术入路的操作步骤、临床效果及围手术期情况等进行综述。     

Positive symptom improvement with laparoscopic uterosacral ligament repair for uterine or vaginal vault prolapse: interim results from an active multicenter trial

STUDY OBJECTIVE: To evaluate the use of laparoscopic uterosacral ligament repair for long-term patient symptom improvement in patients with uterine prolapse or posthysterectomy vaginal vault prolapse and to evaluate how laparoscopic instrumentation kits facilitate procedure performance for the surgeon. DESIGN: Nonrandomized, prospective, multicenter case series (Canadian Task Force classification II-2). SETTING: Five clinical sites consisting of 4 community hospitals and 1 university medical center. PATIENTS: Seventy-two patients with stage II or worse uterine prolapse (58%, n = 42) or posthysterectomy vaginal vault prolapse (42%, n = 30). One patient with stage I vaginal vault prolapse was included in the group due to her significant symptoms. INTERVENTIONS: Laparoscopic uterosacral ligament repair was performed on all patients; round ligament truncation was also performed selectively on patients with uterine prolapse. Fifty-seven percent (41 patients) had concomitant pelvic procedures. MEASUREMENTS AND MAIN RESULTS: At 12-month follow-up, Pelvic Organ Prolapse Quantification (POP-Q) scores and patient self-reported symptom scores were significantly improved over baseline after laparoscopic repair of pelvic organ prolapse. Positive mean change in POP-Q score was 14.4 (p = .0003) for uterine prolapse repair and 9.28 (p = .017) for vaginal vault prolapse repair. Positive mean change in total symptom score was 20.36 (p <.0001) for uterine prolapse repair and 11.43 (p = .005) for vaginal vault prolapse repair. Surgeons reported a mean procedure time of 31.6 minutes for uterine prolapse repair and 21.7 minutes for vaginal vault prolapse repair. A mean rating of 7.5 was documented for ease of use for the uterine prolapse kit and 4.1 for the vaginal vault prolapse kit on a scale of 1 to 10. CONCLUSION: Laparoscopic uterosacral ligament repair improves symptoms and POP-Q scores over the long term in patients with uterine or vaginal vault prolapse. Laparoscopic instrumentation kits facilitate procedure performance for the surgeon with expedited surgery times.     

Uterosacral ligament vaginal vault suspension: anatomy, outcome and surgical considerations

PURPOSE OF REVIEW: With aging populations, primary pelvic organ and recurrent pelvic organ prolapse have become a large-scale public health concern. Surgical options for patients include both abdominal and vaginal approaches, each with its own safety and efficacy profiles. This review summarizes the most recent anatomic, surgical and outcome data for uterosacral ligament vault suspension. It offers data on methods to avoid complications and difficult surgical scenarios. RECENT FINDINGS: Uterosacral ligament suspension allows reattachment of the vaginal vault high within the pelvis. New modifications in technique including the extraperitoneal and laparoscopic approaches allow surgeons more freedom when planning surgery. Five-year data on the durability of the procedure make it a viable surgical option. SUMMARY: As a technique widely used by many pelvic reconstructive surgeons, uterosacral ligament vault suspension provides a safe, anatomically correct and durable approach to uterine and vault prolapse. It requires advanced surgical training and an intimate understanding of pelvic anatomy to avoid and identify ureteral injury.     

Uterosacral Ligament Hysteropexy for Uterine Didelphys: A Case Report

Surgical approach to pelvic organ prolapse has traditionally included hysterectomy; however, in the past decade, uterine sparing prolapse surgery (hysteropexy) has become increasingly popular within female pelvic medicine and reconstructive surgery. The current literature demonstrates comparable outcomes for hysteropexy and traditional approach. As these procedures become more common, it is important to consider how to approach patients with unique anatomy such as uterine anomalies who desire uterine sparing surgery. In our case, we describe a woman aged 77 years with uterine didelphys who underwent a successful vaginal uterosacral ligament hysteropexy for stage 2 pelvic organ prolapse and was followed for 12 months postoperatively. Our case demonstrates that vaginal uterosacral ligament hysteropexy is feasible in a patient with uterine didelphys.     

Comparison of Trendelenburg Angles in Vaginal,Laparoscopic, and Robotic Uterovaginal Apical Prolapse Repairs

Study ObjectiveTo compare the Trendelenburg angle used in laparoscopic uterovaginal apical prolapse repairs with the angles used in vaginal and robotic uterovaginal apical prolapse repairs.DesignProspective, multicenter cohort study from May 2015 to December 2016.SettingTwo academic teaching hospitals.PatientsSixty patients who underwent vaginal high uterosacral ligament suspension, laparoscopic sacrocolpopexy, or robotic sacrocolpopexy performed by 6 surgeons board-certified in female pelvic medicine and reconstructive surgery.InterventionsMeasurement of Trendelenburg angle and time spent in Trendelenburg during surgery.Measurements and Main ResultsTwenty patients were enrolled in each procedure group. The median maximum angle of Trendelenburg was significantly greater in the laparoscopic group (22° [20–25]) than in the vaginal group (15° [6–19]; p <.001) and the robotic group (19° [16–21]; p = .02). The participants in the laparoscopic group spent significantly more time overall in Trendelenburg (176 minutes [143–221]) than those in the robotic group (150 minutes [127–161]; p = .01) and those in the vaginal group (120 minutes [86–128]; p <.001). The participants in the laparoscopic and robotic groups spent similar amounts of time in maximum Trendelenburg (116 minutes [52–164] and 117 minutes [61–134], respectively; p = .56), whereas the participants in the vaginal group spent significantly less time in maximum Trendelenburg (10 minutes [7–38]) than those in the laparoscopic group (p <.001). The total median operative time was highest for the laparoscopic approach (211 minutes [173–270]), followed by the robotic approach (181 minutes [165–201]) and the vaginal approach (162 minutes [128–186]; p = .008).ConclusionThe median maximum angle of Trendelenburg was highest in laparoscopic sacrocolpopexy—followed by robotic sacrocolpopexy—and lowest in vaginal high uterosacral ligament suspension. Patients who underwent robotic sacrocolpopexy spent less time in Trendelenburg than those who underwent the laparoscopic approach. Prolonged, steep Trendelenburg is often not required for any of the 3 surgical procedures, but a vaginal approach should be considered for those at high risk of complications from Trendelenburg position.     

Laparoscopic Approach for Shull Repair of Pelvic Floor Defects

Study Objective

To prove the feasibility of the Shull technique by a laparoscopic approach in a patient affected by pelvic organ prolapse (POP) with apical loss of support.

McCall culdoplasty vs. vaginally assisted laparoscopic sacrocolpopexy in the treatment of advanced uterine prolapse: A randomized controlled study

ObjectiveThe primary aim of this study was to compare the anatomic outcomes of vaginally assisted laparoscopic sacrocolpopexy (VALS) with those of McCall culdoplasty (McCC) in patients undergoing concurrent vaginal hysterectomy.Materials and methodsThis randomized controlled study presents the outcomes of 68 patients who underwent hysterectomy and vaginal suspension for apical prolapse ≥ Stage III according to the Pelvic Organ Prolapse Quantification (POP-Q) system between October 2017 and December 2020. Among these patients, 33 underwent VALS and 35 underwent McCC. Clinical features, surgical data, concomitant surgical procedures, postoperative complications, and recurrence rates were assessed. Before and after one year of surgery, the short form of the Pelvic Floor Impact Questionnaire and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire were used to evaluate subjective symptoms. Patient Global Impression of Improvement Questionnaire was used to assess patient satisfaction.ResultsThe mean follow-up durations were 25.5 ± 7.63 months and 25.6 ± 5.96 months in the VALS and McCC groups, respectively. Prolapse recurrence occurred in 3 (9.1%) women in the VALS group versus 12 (34.3%) women in the McCC group (p = 0.031).ConclusionThe McCC operation was associated with a shorter operation time, whereas the VALS operation had a significantly higher objective success rate. Based on this study, it may be concluded that McCC is not an effective procedure for advanced uterine prolapse.