Long-term results of robotic assisted laparoscopic sacrocolpopexy for the treatment of high grade vaginal vault prolapse

PURPOSE: Transabdominal sacrocolpopexy is a definitive treatment option for vaginal vault prolapse with durable success rates. However, it is associated with increased morbidity compared with vaginal repairs. We describe a minimally invasive technique of vaginal vault prolapse repair and present our experience with a minimum of 1 year followup. MATERIALS AND METHODS: The surgical technique involves 5 laparoscopic ports: 3 for the da Vinci robot and 2 for the assistant. A polypropylene mesh is attached to the sacral promontory and vaginal apex using polytetrafluoroethylene sutures. The mesh material is then covered by peritoneum. Patient analysis focused on complications, urinary continence, patient satisfaction and morbidity with a minimum of 12 months followup. RESULTS: A total of 30 patients with post-hysterectomy vaginal vault prolapse underwent robotic assisted laparoscopic sacrocolpopexy at our institution and 21 have a minimum of 12 months followup. Mean followup was 24 months (range 12 to 36) and mean age was 67 years (range 47 to 83). Mean operative time was 3.1 hours (range 2.15 to 4.75). All but 1 patient were discharged home on postoperative day 1 and the 1 patient left on postoperative day 2. Recurrent grade 3 rectocele developed in 1 patient, 1 had recurrent vault prolapse and 2 had vaginal extrusion of mesh. All patients were satisfied with outcome. CONCLUSIONS: The robotic assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a decreased hospital stay, low complication rates and high patient satisfaction with a minimum of 1 year followup.     

Assessment of the durability of robot-assisted laparoscopic sacrocolpopexy for treatment of vaginal vault prolapse

Transabdominal sacrocolpopexy has been shown, in multiple long-term studies of its success and durability, to be the definitive treatment option for post-hysterectomy vaginal vault prolapse. It is, however, associated with greater morbidity than vaginal repair. We describe a minimally invasive technique for vaginal vault prolapse repair and present our experience with a minimum of one-year follow-up. The surgical technique involves five laparoscopic ports—three for the da Vinci robot and two for the assistant. After appropriate dissection a polypropylene mesh is attached to the sacral promontory and to the vaginal apex by use of Gore-Tex sutures. The mesh material is then covered by the peritoneum. Patient analysis focused on complications, urinary continence, patient satisfaction, and morbidity, with a minimum of 12 months follow-up. Forty-two patients with post-hysterectomy vaginal vault prolapse underwent robot-assisted laparoscopic sacrocolpopexy at our institute and 35 have a minimum of 12 months follow-up, with a mean follow-up of 36 months (range 12–48) in the group. Mean age was 67 (47–83) years and mean operating time was 3.1 (2.15–4.75) h for the entire cohort. All but one patient were discharged home on postoperative day one; one patient left on postoperative day two. One developed recurrent grade three rectocele, one had recurrent vault prolapse, and two suffered from vaginal extrusion of mesh. All patients were satisfied with their outcome. The robot-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the reduced morbidity of laparoscopy. We observed reduced hospital stay, low occurrence of complications, and high patient satisfaction, with a minimum of 1-year follow-up. Most importantly, the long-term results of the robotic repair are similar to those of open repair, but with significantly less morbidity.     

Management of vaginal vault prolapse repair with robotically-assisted laparoscopic sacrocolpopexy

Transabdominal sacrocolpopexy offers an excellent definitive treatment option for patients with high grade vaginal vault prolapse with long-term success rates ranging from 93-99%. However, because it is a transabdominal procedure it is associated with increased morbidity compared with vaginal repairs. We describe a novel minimally invasive technique of vaginal vault prolapse repair and present out initial experience. The surgical technique involves placement of five laparoscopic ports: three for the Da Vinci robot and two for the assistant. A polypropylene mesh is then attached to the sacral promontory and to the vaginal apex using Gortex sutures. At the end of the case, the mesh material is the covered by the peritoneum. We also present our initial experience with this technique in 18 consecutive patients. The analysis focused on complications, urinary continence, patient satisfaction, and morbidity. Follow-up was conducted by provider-patient interview. Twenty-five patients underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution in the past 24 months for severe symptomatic vaginal vault prolapse. 10/25 (40%) underwent a concomitant anti-incontinence procedure. Mean follow-up was 5. (1-12) months and mean age was 66 (47-82) years. Mean total operative time was 3.2 (2.25-4.75) hours. One patient had to be converted to an open procedure secondary to unfavorable anatomy. All but one patient were discharged from the hospital after an overnight stay; one patient left on postoperative day #2. Complications were limited to mild port site infections in two patients, which resolved with oral antibiotic therapy. One patient developed recurrent grade 3 rectocele, but had no evidence of cystocele or enterocele. We present a novel technique for vaginal vault prolapse repair that combines the advantages of open sacrocolpopexy with the decreased morbidity and improved cosmesis of laparoscopic surgery. It is associated with decreased hospital stay, low complication and conversion rates, and high patient satisfaction. While our early experience is encouraging, long-term data is needed to confirm these findings and establish longevity of the repair.     

Current status of robotics in female urology and gynecology

Currently, there has been limited reporting and research in the female urology and gynecological literature concerning the use of robotics. To date, robotics have been utilized only for the treatment of three benign gynecologic conditions: benign hysterectomy; repair of vesicovaginal fistula; and sacrocolpopexy which is a treatment for posthysterectomy vaginal vault prolapse. We describe a novel minimally invasive technique of vaginal vault prolapse repair and present our initial experience. The surgical technique involves placement of five laparoscopic ports: three for the daVinci® robot and two for the assistant. A polypropylene mesh is then attached to the sacral promontory and to the vaginal apex using Gortex sutures. Thirty-one patients underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution in the past 24 months for severe symptomatic vaginal vault prolapse. Complications were limited to mild port site infections in two patients, which resolved with oral antibiotic therapy. While our early experience utilizing robotic repairs in female urology and gynecology is encouraging, long-term data are needed to confirm these findings and establish longevity of the repair.Financial disclosure of authors: D.S. Elliott: none; G. Chow: none; M. Gettman: none     

Laparoscopic sacrocolpopexy: operative times and efficiency in a high-volume female pelvic medicine and laparoscopic surgery practice

Introduction and hypothesis

There has been a trend toward robotic sacrocolpopexy in the United States despite longer operating times and higher costs compared with traditional laparoscopy. The current study objective was to evaluate incision to closure times of laparoscopic sacrocolpopexy in a urogynecologic practice with extensive experience in the laparoscopic approach for pelvic reconstruction.

Methods

We conducted a single-center retrospective evaluation of consecutive patients undergoing laparoscopic sacrocolpopexy for vaginal vault prolapse using a permanent polypropylene Y-mesh over a 1-year period. Standard operative technique for sacrocolpopexy was used. Four to six sutures were placed on the anterior leaflet of the mesh, and six to eight sutures were placed posteriorly. Two sutures were placed in the presacral ligament. Mesh was retroperitonealized with a running 2–0 monocryl suture. Primary outcomes were total operating time and time to complete laparoscopic sacrocolpopexy.

Results

One hundred and twenty-seven consecutive patients with an average age of 60.04?±?10.14 years, body mass index (BMI) 25.79?±?4.52 kg/m², underwent laparoscopic sacrocolpopexy for vaginal vault prolapse. Ninety-two patients had other procedures performed intraoperatively: laparoscopic-assisted vaginal hysterectomy, laparoscopic paravaginal repair, laparoscopic enterocele repair, and/or laparoscopic enterolysis. Mean total operative time for all laparoscopic procedures completed was 107.45 ± 34.00 min. The average time to perform sacrocolpopexy, including incision and closure, was 52.78 ± 13.09 min.

Conclusion

This retrospective evaluation provides further evidence that traditional laparoscopic sacrocolpopexy should be considered a primary therapy for vaginal vault prolapse.

     

A new device for bone anchor fixation in laparoscopic sacrocolpopexy: The Franciscan laparoscopic bone anchor inserter

Background A laparoscopic modification of the sacrocolpopexy procedure with mesh and bone anchor fixation with the Franciscan laparoscopic bone anchor inserter was developed.Methods We developed a laparoscopic bone anchor inserter for the placement of a titanium bone anchor in sacral segment 3 as fixation for the mesh in laparoscopic sacrocolpopexy procedures performed in women with posthysterectomy vault prolapse.Results Surgery successfully corrected vaginal vault prolapse. Laparoscopic bone anchor insertion with this new and simple device took 2 minutes and provided a firm anchor for mesh fixation. MRI demonstrated an anatomically preferable vaginal axis toward the hollow of the sacrum.Conclusion Application of the newly developed Franciscan laparoscopic bone anchor inserter in laparoscopic sacrocolpopexy is an easy and safe procedure that provides firm fixation and excellent anatomical results.     

Sacrocolpopexy--a report on 262 consecutive operations.

OBJECTIVES: This report analyses the outcome and complications of 262 consecutive sacrocolpopexy procedures for the repair of vaginal vault prolapse and enterocele. METHODS: From March 1994 to February 2001, 262 patients underwent surgical repair using a standardised retroperitoneal technique. Initially dura mater strips were used and from the 19th patient onwards, Gore-tex soft tissue patch was used to suspend the vaginal apex to the anterior sacral ligament. Halban-type occluding sutures were placed in the pouch of Douglas. All patients were followed up and the minimum duration of follow-up was 16 months. RESULTS: Vaginal vault prolapse was successfully managed in 259 of 262 patients giving a success rate of 98.8%. In addition, 4 patients had a repeat enterocele that required surgical repair. The overall surgical complication rate was low. Erosion of the patch through the vaginal vault occurred in 10 patients, necessitating removal of the patch. Prolapse did not recur in any of these patients. CONCLUSION: Abdominal sacrocolpopexy is a very successful and safe surgical management of vaginal vault prolapse.     

Laparoscopic sacrocolpopexy for uterine and post-hysterectomy prolapse: anatomical results,quality of life and perioperative outcome—a prospective study with 101 cases

Our prospective study evaluates laparoscopic sacrocolpopexy for vaginal vault prolapse focusing on perioperative data, objective anatomical results using the pelvic organ prolapse quantification (POP-Q) system and postoperative quality of life using the Kings Health questionnaire. One hundred one patients completed the study. Fifty five had laparoscopic supracervical hysterectomy and sacrocolpopexy for uterine prolapse and 46 had laparoscopic sacrocolpopexy for post-hysterectomy prolapse. Median follow-up was 12 months. The subjective cure rate was 93% the objective cure rate (no prolapse in any compartment) according to the International Continence Society classification of prolapse was 98%. The main site of objective recurrence (6%) was the anterior compartment. No apical recurrences and no vaginal mesh erosion occurred. Postoperatively overall quality of life and sexual quality showed significant improvement with less than 1% de-novo dyspareunia. The procedure is recommended for experienced laparoscopic surgeons because of severe intraoperative complications like bladder or rectal injuries.     

Management of recurrent vault prolapse

In the ageing female population, recurrent vaginal vault prolapse is a significant healthcare burden. There is limited evidence regarding the optimal management strategy for recurrent vault prolapse. This paper aims to discuss treatment modalities available for recurrent vault prolapse. A literature search and analysis was performed using Medline, PubMed, Cochrane database, current texts and references from relevant articles. We found inconclusive evidence supporting conservative, mechanical and some surgical options for treating recurrent vault prolapse; including iliococcygeal fixation, McCall culdoplasty, and infracoccygeal sacropexy. Sacrospinous ligament fixation (SSLF), sacrocolpopexy, mesh implants and colpocleisis are shown to have good outcomes in Level II studies. Nevertheless, the first two are associated with haemorrhage, dyspareunia and scarring whilst colpocleisis is limited to selected patients. More well-designed studies are required for recurrent vault prolapse. Current evidence suggests SSLF, and sacrocolpopexy are alternative surgical options to colpocleisis in treating recurrent vault prolapse. Randomised trials are required to determine the efficacy and safety of trocar-guided mesh kits.     

Abdominal sacral colpopexy with Mersilene mesh.

INTRODUCTION: This study focussed on abdominal sacral colpopexy with Mersilene mesh to correct total vaginal vault prolapse. Our aim was to describe and explain our operative modifications. MATERIALS AND METHODS: From 1992 and 1999, we performed sacrocolpopexy on 25 patients for vaginal vault prolapse. We proposed a change by interposing a mesh between the vaginal vault and the sacral promontory shaped as an inverted 'V'. RESULTS: No intraoperative or postoperative complications were encountered; to date the outcome of all patients was satisfactory. CONCLUSION: Based on the results of the follow-up, this new surgical approach of abdominal sacral colpopexy can be considered as effective surgery for vaginal vault prolapse.     

Minimally Invasive Sacrocolpopexy: How to Avoid Short- and Long-Term Complications

Sacrocolpopexy remains the “gold standard” procedure for management of posthysterectomy vaginal vault prolapse with improved anatomic outcomes compared to native tissue vaginal repair. Despite absence of clinical data, sacrocolpopexy is increasingly being offered to women as a primary treatment intervention for uterine prolapse. While reoperation rates remain low, recurrent prolapse and vaginal mesh exposure appear to increase over time. The potential morbidity associated with sacrocolpopexy is higher than for native tissue vaginal repair with complications including sacral hemorrhage, discitis, small bowel obstruction, port site herniation, and mesh erosion. Complications are more common during the learning curve of minimally invasive sacrocolpopexy. Appropriate case selection is paramount to balancing the potential for prolapse recurrence with the risk of surgical complications. Use of ultra-lightweight polypropylene mesh and vaginal mesh attachment with delayed absorbable suture may reduce the risks of vaginal mesh exposure.     

Will hysterectomy at the time of sacrocolpopexy increase the rate of polypropylene mesh erosion?

Will total abdominal hysterectomy with concomitant sacrocolpopexy lead to polypropylene (Prolene, Ethicon, Somerset, NJ) mesh erosions? Sixty-seven patients demonstrating a stage 2 or more International Continence Society cystocele, rectocele, and uterine prolapse underwent combined sacrocolpopexy and polypropylene mesh fixation and total abdominal hysterectomy. Surgical failure was noted as prolapse of any of the three pelvic compartments with a stage 2 or more recurrence. Sixty-four patients were available for examination, and none demonstrated mesh erosion or recurrent vault prolapse with a median follow-up of 27 months. Four patients experienced a recurrent stage 2 rectocele without any cystoceles or vault prolapse. Performing abdominal hysterectomy with concomitant sacrocolpopexy with polypropylene extensions does not increase the occurrence of synthetic material erosions in the vaginal vault or the anterior or posterior vaginal walls.     

Use of a bidirectional barbed suture in robot-assisted sacrocolpopexy

Abdominal sacrocolpopexy is an effective and durable surgical procedure that is conventionally reserved for management of vaginal vault prolapse. With the availability of robotic technology in recent years, sacrocolpopexy has become more commonly performed in a minimally invasive fashion. Peritoneal closure can be a tedious and time-consuming step in robot-assisted sacrocolpopexy. We describe a novel technique utilizing a bidirectional barbed suture to re-approximate the peritoneum in robot-assisted sacrocolpopexy, making the procedure more time-efficient.     

Long-term outcomes of robotic-assisted laparoscopic sacrocolpopexy with a minimum of three years follow-up

We describe efficacy and safety of robotic-assisted laparoscopic vaginal vault prolapse repair with long-term follow-up. We reviewed the records of 40 consecutive patients with posthysterectomy vaginal vault prolapse who underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution between September 2002 and September 2006. Patient analysis focused on complications, patient satisfaction, and morbidity, with a minimum of 36 months’ follow-up. Median follow-up was 62 months (range 36–84) and mean age was 67 (43–83) years. Mean operating time was 3.1 (2.15–5) h with a median operating time of 2.9 h. All but four were discharged home on postoperative day one; three patients left on postoperative day two and one left on postoperative day seven. Three developed recurrent grade 3–4 rectoceles and two vaginal extrusion of mesh. Thirty-eight of the 40 patients (95%) were satisfied with their outcome. Robotic-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a short hospital stay, low complication rates, and high patient satisfaction with a minimum of 3 years’ follow-up.     

Laparoscopic sacrocolpopexy for the correction of vaginal vault prolapse

BACKGROUND AND PURPOSE: Laparoscopic sacrocolpopexy offers a minimally invasive approach to correcting vaginal vault prolapse. We describe our operative technique and review our experience. PATIENTS AND METHODS: A retrospective study of 10 patients who underwent laparoscopic sacrocolpopexy between February 2000 and June 2002 for posthysterectomy vaginal vault prolapse was performed. Data collected included operative time, complications, hospital stay, and postoperative morbidity. RESULTS: One patient underwent primary laparoscopic repair of an intraoperative bladder injury. Conversion from a laparoscopic to an open procedure was required in one patient because of dense bowel adhesions in the pelvis. The mean analgesic (morphine sulfate equivalent) requirement was 7.3 mg (range 5-21 mg). With a mean follow-up of 16 months (range 5-32 months), prolapse recurred in one patient. CONCLUSION: In the short term, laparoscopic sacrocolpopexy appears to be an effective approach for the treatment of vaginal vault prolapse with minimal postoperative pain and morbidity.     

Transvaginal strangulated small intestinal hernia after abdominal sacrocolpopexy: case report and literature review

Purpose

To report a case of transvaginal small intestinal hernia following abdominal sacrocolpopexy and review this clinical presentation in the current literature.

Methods

A review of our case and a literature review of vaginal evisceration were carried out.

Results

The patient underwent sacrocolpopexy and a Burch procedure. Six months later, a recurrent enterocele through a 1 cm defect in the vaginal vault was diagnosed. Several weeks later she presented with an incarcerated and strangulated loop of small intestine extending beyond the introitus. This required an urgent exploratory laparotomy, ileocecal resection, and vaginal vault closure. Postoperatively, she experienced gradual prolapse recurrence and is currently successfully managed with a pessary. Risk factors that include vaginal atrophy, chronic constipation, and previous pelvic surgery may have contributed to the evisceration, mesh erosion, and may have caused the breakdown in the vaginal vault mucosa ultimately responsible for the evisceration. In addition, placement of the sacrocolpopexy mesh without tension, and utilization of an interposition graft to reinforce the weakened vaginal vault tissue, are aspects of the surgical procedure that may influence outcomes. At the time of evisceration repair, the best approach to resuspend the vaginal vault, and prevent recurrent prolapse or evisceration, is currently unknown.

Conclusion

Vaginal evisceration is a potential complication of abdominal sacrocolpopexy. Early recognition and treatment of this complication is critical, and prolapse recurrence may occur even after surgical repair.     

Abdominal Sacral Colpopexy with Prolene Mesh

The objective was to evaluate abdominal colposacropexy using Prolene mesh to correct total vaginal vault prolapse or total procidentia. Between 1994 and 1997 we performed colposacropexy on 15 patients for simple vaginal vault prolapse (in 7 cases after hysterectomy) and for total uterine prolapse in 8 cases. In these cases a simple abdominal hysterectomy was performed. We simultaneously performed colposacropexy with colposuspension according to the Burch technique for urinary stress incontinence in 6 cases. The colposacropexy technique consisted of isolating the vaginal apex and creating a retroperitoneal tunnel from the vagina to the sacral promontory. Between the vaginal cul de sac and the sacrum, a mesh of Prolene is inserted and fixed with non-absorbable sutures. The Foley catheter was removed after 4–12 days (average 5). Average follow-up was 15 months. No intraoperative complications occurred, and all patients who were sexually active have resumed normal sexual activity; no infections or rejections of the prostheses have been verified. We believe that it is very important to restore the normal anatomic support of the vaginal vault after prolapse. This strong support is assured by fixing the vaginal apex to the periosteum of the sacrum using Prolene mesh. Colposacropexy with Prolene mesh is a safe and effective technique for the surgical therapy of vaginal vault prolapse.     

The UK National Prolapse Survey: 10 years on

Introduction and hypothesis

To assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners and changes in practice since a previous similar survey.

Methods

An online questionnaire survey (Typeform Pro) was emailed to British Society of Urogynaecology (BSUG) members. They included urogynaecologists working in tertiary centres, gynaecologists with a designated special interest in urogynaecology and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP and was a revised version of the questionnaire used in the previous surveys. The revised questionnaire included additional questions relating to the use of vaginal mesh and laparoscopic urogynaecology procedures.

Results

Of 516 BSUG members emailed, 212 provided completed responses.. For anterior vaginal wall prolapse the procedure of choice was anterior colporrhaphy (92% of respondents). For uterovaginal prolapse the procedure of choice was still vaginal hysterectomy and repair (75%). For posterior vaginal wall prolapse the procedure of choice was posterior colporrhaphy with midline fascial plication (97%). For vault prolapse the procedure of choice was sacrocolpopexy (54%) followed by vaginal wall repair and sacrospinous fixation (41%). The laparoscopic route was preferred for sacrocolpopexy (62% versus 38% for the open procedure). For primary prolapse, vaginal mesh was used by only 1% of respondents in the anterior compartment and by 3% in the posterior compartment.

Conclusion

Basic trends in the use of native tissue prolapse surgery remain unchanged. There has been a significant decrease in the use of vaginal mesh for both primary and recurrent prolapse, with increasing use of laparoscopic procedures for prolapse.

     

A NEW LAPAROSCOPIC PROCEDURE FOR THE CORRECTION OF VAGINAL VAULT PROLAPSE

Purpose

We verified the feasibility and results of a new laparoscopic technique for repairing vaginal vault prolapse.

Materials and Methods

Laparoscopic repair of vaginal vault prolapse was done in 12 women 46 to 82 years old. Stage 1 consisted of culdoplasty similar to that of Moschowitz. Stage 2 included a transverse incision of the peritoneum covering the vaginal vault to expose the vaginal fascia. Two sutures were then fixed to the vaginal corners, passed through the subperitoneal connective tissue and attached to the fascia of the abdominal muscles with multiple stitches.

Results

No intraoperative or postoperative complications occurred and anatomical repair was complete in all women. Followup ranged from 9 to 28 months. Sexual function was recovered in all cases.

Conclusions

If these results are confirmed in larger series with a longer followup, our laparoscopic approach would be considered a valid alternative to current surgical techniques.     

Comparison of laparoscopic and abdominal sacrocolpopexy for the treatment of vaginal vault prolapse

BACKGROUND AND PURPOSE: Laparoscopic sacrocolpopexy (LSCP) offers a minimally invasive treatment for vaginal vault prolapse. We describe the surgical technique and offer insight into the learning curve. In addition, we performed a case series review comparing the laparoscopic procedure with its open surgical counterpart with respect to various demographic and perioperative parameters. PATIENTS AND METHODS: The Institutional Review Board-approved continence database at our institution was queried to identify all patients undergoing sacrocolpopexy between August 1999 and October 2004. The LSCP was performed in 25 patients, and open abdominal sacrocolpopexy (ASCP) was performed in 22 patients. Data were analyzed using Student's t-test and the Fisher exact test. RESULTS: No significant difference was observed in the demographic characteristics of the patients undergoing the two approaches. The mean estimated blood loss (P = 0.0002) and mean length of hospitalization (P < 0.0001) were significantly less for LSCP, whereas the operative time was significantly longer (219.9 minutes v 185.2 minutes; P = 0.045). The success rate for LSCP at 5.9 months was 100%; the ASCP success rate at 11.0 months was 95%. CONCLUSIONS: Laparoscopic sacrocolpopexy led to shorter hospitalization, better hemostasis, and less pain than the open procedure. Early follow-up suggests that LSCP is as effective as ASCP for the treatment of vaginal vault prolapse.