Transvaginal uterosacral ligament suspension for posthysterectomy vaginal vault prolapse repair

Introduction and hypothesis

Posthysterectomy vaginal vault prolapse repair represents a challenge for urogynecologists. Surgical management can be successfully achieved with native tissue using a vaginal approach with uterosacral ligament (USL) suspension. However, severe complications have been described, mainly related to ureteral injury.

Methods

A 57-year-old woman with symptomatic stage 2 vaginal vault prolapse underwent transvaginal USL suspension according to the described technique.

Results

Surgical procedure was successfully achieved without complications. Final examination revealed excellent apical support and preservation of vaginal length. However, ureteral damage represents the major pitfall of USL suspension. This step-by-step video tutorial may represent an important tool to improve surgical know how and minimize the risk of ureteral injury.

Conclusion

Transvaginal USL suspension provides an effective technique for apical support without the use of prosthetic materials. Intimate understanding of pelvic anatomy, direct visualization of ureter, and proper suture positioning are the key points to minimize the risk of complications.

     

Laparoscopic uterosacral ligament uterine suspension compared with vaginal hysterectomy with vaginal vault suspension for uterovaginal prolapse

This study compares the outcomes of laparoscopic uterosacral ligament uterine suspension (LUSUS) to those of vaginal vault suspension with total vaginal hysterectomy (TVH) for the treatment of symptomatic uterovaginal prolapse. We compared the outcomes of 25 LUSUS to those of 25 TVH with vaginal vault suspension among age-matched controls. No significant complications occurred in either group. EBL and hospitalization duration were significantly less in LUSUS patients (72 cc vs. 227 cc, P < .0001 and 1.05 vs. 1.65 days, P = .002). Vault support, as measured by postoperative pelvic organ prolapse quantitation system point D in the LUSUS group and point C in the TVH group, was better for the LUSUS group (D = –9 vs. C = –7.6, P = .002). No LUSUS group patient underwent reoperation for recurrent apical prolapse as compared to three TVH patients. LUSUS is an effective treatment for appropriately selected women with uterovaginal prolapse who desire uterine preservation     

Neural pain after uterosacral ligament vaginal suspension

Neural compromise has been reported after a wide variety of reconstructive pelvic procedures. We report on two women who had undergone a seemingly uncomplicated transvaginal uterosacral suspension for the treatment of pelvic organ prolapse. Both women presented shortly after surgery with a unilateral, shooting groin pain with radiation along the ipsilateral lumbosacral nerve distribution. Surgical removal of the permanent stitch and physical therapy provided prompt and near-complete relief. This case report describes the possibility of neural compromise after uterosacral ligament suspension.     

Demonstration of a box-stitch technique for laparoscopic uterosacral ligament suspension

Aim

We demonstrate a novel box stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension for apical prolapse in restorative pelvic reconstructive surgery.

Material and methods

We present a case of a 58yo female with symptomatic stage III pelvic organ prolapse with a history of a total abdominal hysterectomy 30 years prior. She strongly desired the usage of no synthetic or biologic mesh for her restorative surgical repair. This video provides a step-by-step guide on how to perform a laparoscopic box stitch as a technique for uterosacral ligament suspension as an apical native tissue option for patients with the need for post hysterectomy apical prolapse.

Conclusion

This video demonstrates a novel box-stitch technique of laparoscopic post-hysterectomy uterosacral ligament suspension as a native tissue option for minimally invasive reconstructive surgery. The procedure is a reasonable option to address apical prolapse in patients who do not desire or who are unable to have synthetic or biologic mesh placed for restorative reconstructive prolapse surgery.

     

腹腔镜下行高位宫骶韧带悬吊术的手术配合

对6例子宫脱垂需保留子宫的年轻女性患者实施腹腔镜下高位宫骶韧带悬吊手术,手术顺利,手术时间(80.0±20.0)min;术中出血量平均120.0 ml。无一例并发症发生。提示该术式不仅能保证疗效,缓解患者子宫脱垂症状,又可以达到保留子宫的目的。手术室护士充分的术前准备,体位的合理摆放,娴熟的配合是手术成功的保障。     

腹腔镜阴道前后壁补片治疗女性盆腔脏器脱垂的疗效分析

目的 比较腹腔镜下阴道前后壁补片与开放性阴道前壁修补术治疗盆腔脏器脱垂的长期效果.方法 中山大学附属第三医院泌尿外科7年来共47例有症状的盆腔脏器脱垂患者被纳入研究.所有患者均存在阴道前壁膨出,膀胱脱垂和不同程度的尿路感染.另外,34例有阴道后壁膨出,8例子宫脱垂,14例合并压力性尿失禁.病人被随机分成两组.第1组病人行腹腔镜阴道前后壁补片术,腹腔镜下分离阴道前、后壁直至接近阴道外口.分别在阴道前、后壁置入1块100%聚脂的网状补片,远端与提肛肌固定,近端固定于骶岬,将盆腔脏器复位并固定.对存在压力性尿失禁患者实施了colposuspension手术.第2组病人采取Juma的阴道前壁修补术,所有病人修补阴道前壁,矫正膀胱脱垂并悬吊膀胱颈;5例行经阴道子宫切除术,17例修复直肠脱垂.结果 第1、2组病例的平均住院时间分别为5 d(3～7 d),8 d(3～11 d).总随访时间平均为48个月(13～83个月).所有行腹腔镜下阴道前后壁补片术的病例和22例(92%)阴道前壁修补术的病例术后阴道均获得良好的支持,没有出现膀胱脱垂、阴道后疝或直肠脱垂.第2组有2例(8%)患者阴道后疝复发.第1组23例(100%)患者和第2组22例(92%)术后没有出现压力性尿失禁.结论 腹腔镜技术应用于盆腔脏器脱垂的修复疗效满意,随访4年的调查显示此术式不仅具备开放手术治疗效果,还具有腹腔镜手术创伤小、并发症少的特点,病人满意度高.     

Laparoscopic uterosacral ligament suspension and sacral colpopexy: results and complications

Introduction and hypothesis

We describe our techniques, outcomes, and complications with laparoscopic procedures for correcting pelvic organ prolapse (POP). We hypothesized that laparoscopic abdominal sacrocolpopexy (ASC) gives better anatomic results than laparoscopic uterosacral ligament suspension (USLS), without increased complications.

Methods

This was a retrospective cohort study of 290 patients who underwent laparoscopic suspensions in a 2-year period. Anatomic measurements using the Pelvic Organ Prolapse Quantification (POP-Q) system were collected. Subjective data were obtained from the Pelvic Floor Distress Inventory Short-Form 20 (PFDI) questionnaire. The anatomic improvement for each stage and complication rates were analyzed. The difference in the risk of mesh erosion between patients undergoing concomitant total hysterectomy and those who had a prior hysterectomy was determined. In 102 patients with stage 2 prolapse, a comparison between ASC and USLS in anatomic and subjective results and complication rates was performed.

Results

Anatomic success rates ranged between 86 % and 95 %. Overall mesh erosion rate was 1.2 %, showing no difference between concomitant total laparoscopic hysterectomy (0 %) and prior hysterectomy (2.1 %, p?=?0.155). ASC resulted in statistically significantly better anterior-compartment support than USLS (p?=?0.043). There was no difference in apex or posterior compartment position or in PFDI scores.

Conclusion

Laparoscopic ASC may be better than USLS for correcting anterior-compartment prolapse, with only a minor risk of mesh erosion.     

Technique of extraperitoneal uterosacral ligament suspension for apical suspension

Aim of the video/introduction

Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky–Navratil retractor.

Methods

This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension.

Conclusions

This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.

     

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.     

Bilateral extraperitoneal uterosacral suspension: a new approach to correct posthysterectomy vaginal vault prolapse

Restoration of apical vaginal support remains a challenging problem for the pelvic reconstructive surgeon. The transvaginal use of the uterosacral-cardinal ligament complex is gaining increasing popularity in the surgical treatment of uterovaginal and posthysterectomy vault prolapse. We describe an extraperitoneal surgical approach using this ligamentous complex to reattach the vaginal apex in women with posthysterectomy vault prolapse and report our surgical experience with this procedure in 123 women over 5 years. The relevant anatomy related to the procedure and risk of ureteric injury with uterosacral suspension is also reviewed. Extraperitoneal vault suspension can be combined with the use of polypropylene mesh if required. The extraperitoneal approach is an alternative procedure in women with vault prolapse with or without concomitant enterocele or where access to the Pouch of Douglas is difficult particularly after previous pelvic surgery. We believe this procedure to have less risk of ureteral injury than the intraperitoneal approach.     

Long-term outcomes of modified high uterosacral ligament vault suspension (HUSLS) at vaginal hysterectomy

Introduction and hypothesis  

The aim of this study was to prospectively evaluate long-term outcomes of a modified high uterosacral ligament suspension (HUSLS) at vaginal hysterectomy for pelvic organ prolapse (POP).     

High uterosacral ligament vaginal vault suspension: comparison of absorbable vs. permanent suture for apical fixation

Introduction and hypothesis

The primary objective of this study was to compare outcomes of absorbable and permanent suture for apical support with high uterosacral ligament vaginal vault suspension (HUSLS). The secondary objective was to investigate the rate of suture erosion.

Methods

This was a retrospective study of patients who underwent HUSLS with delayed absorbable and primarily permanent suture. Apical support was calculated as a new variable: Percent of Perfect Ratio (POP-R). This variable measures apical support as the position of the apex in relation to vaginal length.

Results

At 1-year follow-up, there was no significant difference in apical support between the two groups. The number of patients who suffered from suture erosion in the cohort that received permanent suture was 11 (22%).

Conclusions

Permanent suture, in comparison with delayed absorbable suture, for HUSLS does not offer significantly better apical support at short-term follow-up. It is also associated with a high rate of suture erosion.     

Outcomes of vaginal vault prolapse repair with a high uterosacral suspension procedure utilizing bilateral single sutures

The aim of this study was to describe an approach for performing a high uterosacral vaginal vault suspension and to report anatomical and subjective results. Anatomic measures and validated symptom-specific questionnaires were performed pre- and postoperatively. Patient satisfaction was also ascertained. Thirty-five women, who underwent a two-suture high uterosacral suspension, participated. Mean follow-up interval was 23.1 ± 10.1 months. Postoperative point C was −7.8 ± 1.60 (median, −8.0, range, −4.0 to −10.0), and the mean preoperative to postoperative change in point C was 5.9 ± 5.56 cm (median 4.75, range −3.0 to 20.0, p-value < 0.0001). Patient satisfaction was high with 88.9% indicating that they would have the surgery again. There were no ureteral injuries or kinks noted on intraoperative cystoscopy. No patient required reoperation for recurrent prolapse or urinary incontinence. Overall, the two-suture high uterosacral vaginal vault suspension is an acceptable technique for repairing apical prolapse.     

High levator myorraphy versus uterosacral ligament suspension for vaginal vault fixation: a prospective, randomized study

Introduction and hypothesis  

Our study compared high levator myorrhaphy (HLM) and uterosacral ligament suspension (USLS) for vaginal apex fixation from both an anatomical and functional point of view, and assessed the impact of surgery on quality of life (QoL) and sexuality.     

The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication

Introduction and hypothesis  

The objective of this study is to evaluate cervical amputation with uterosacral ligament plication (modified Manchester) and compare it to vaginal hysterectomy with high uterosacral ligament plication procedure with special regard to the middle compartment.     

The Manchester-Fothergill procedure versus vaginal hysterectomy with uterosacral ligament suspension: a matched historical cohort study

Introduction and hypothesis

This study compares vaginal hysterectomy with uterosacral ligament suspension (VH) with the Manchester-Fothergill procedure (MP) for treating pelvic organ prolapse (POP) in the apical compartment.

Methods

Our matched historical cohort study is based on data from four Danish databases and the corresponding electronic medical records. Patients with POP surgically treated with VH (n?=?295) or the MP (n?=?295) in between 2010 and 2014 were matched for age and preoperative POP stage in the apical compartment. The main outcome was recurrent or de novo POP in any compartment. Secondary outcomes were recurrent or de novo POP in each compartment and complications.

Results

The risk of recurrent or de novo POP in any compartment was higher after VH (18.3%) compared with the MP (7.8%) (Hazard ratio, HR?=?2.5, 95% confidence interval (CI): 1.3–4.8). Recurrence in the apical compartment occurred in 5.1% after VH vs. 0.3% after the MP (hazard ratio (HR)?=?10.0, 95% confidence interval (CI) 1.3–78.1). In the anterior compartment, rates of recurrent or de novo POP were 11.2% after VH vs. 4.1% after the MP (HR?=?3.5, 95% CI 1.4–8.7) and in the posterior compartment 12.9% vs. 4.7% (HR?=?2.6, 95% CI 1.3–5.4), respectively. There were more perioperative complications (2.7 vs. 0%, p?=?0.007) and postoperative intra-abdominal bleeding (2 vs. 0%, p?=?0.03) after VH.

Conclusions

This study shows that the MP is superior to VH; if there is no other indication for hysterectomy, the MP should be preferred to VH for surgical treatment of POP in the apical compartment.

     

Anatomical correction of vaginal vault prolapse by uterosacral ligament fixation in women who also require a pubovaginal sling

PURPOSE: We describe the anatomical and functional outcome in patients who underwent vaginal vault fixation to the proximal uterosacral ligaments for the treatment of vault prolapse and who also required a concomitant pubovaginal sling for associated stress urinary incontinence as well as the repair of other sector defects. MATERIALS AND METHODS: We retrospectively analyzed the records of 33 patients who underwent such repairs between November 1998 and December 2001. Endopelvic fascial defects were described using the pelvic organ prolapse quantitative system (POPQ). Outcome measures included anatomical and functional assessment of pelvic floor defects and urinary incontinence. RESULTS: Preoperatively all patients complained of a vaginal bulge and stress urinary incontinence, while 17 of the 33 had urge incontinence, and 24 and 9 had POPQ stage III or IV and stage II prolapse, respectively. Mean followup was 28 months (range 6 to 43). There was significant improvement in all POPQ measurements (p <0.05). Most notably vaginal cuff support improved by a mean of 7 cm. Stages IIAp (rectocele) and IIC (cuff) prolapse developed in 4 and 2 failed cases, respectively. Stress urinary incontinence was cured in all 33 patients and urge incontinence was cured in 14 of 17, while in 27 vaginal prolapse symptoms resolved and most had improved defecation dysfunction. No patients had urinary obstructive symptoms. There were no ureteral, bladder or rectal complications but 1 patient required blood transfusion. CONCLUSIONS: Suspension of the vaginal cuff to the proximal uterosacral ligaments with site specific repair of other associated endopelvic fascial defects provides excellent anatomical and functional correction of vault prolapse. Furthermore, a concomitant pubovaginal sling is a compatible repair for associated stress urinary incontinence. It did not compromise vaginal repair and prolapse repair did not jeopardize the outcome of the sling.     

Suture complications in a teaching institution among patients undergoing uterosacral ligament suspension with permanent braided suture

Introduction and hypothesis  

Our study aimed to identify the rate of suture complications over a 5-year period using braided permanent suture for uterosacral ligament suspension (USLS) surgery.     

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.