Laparoscopic sacrocolpopexy for post-hysterectomy vaginal vault prolapse

Laproscopic sacrocolpopexy offers a minimally invasive approach to correct post-hysterectomy vaginal vault prolapses. Herein we present our surgical technique and results. Through the transperitoneal approach, the retroperitoneal space was dissected along the right edge of the rectum and a polypropylene mesh is sutured to the vaginal apex and the anterior longitudinal ligament of the sacrum. We sutured the mesh to the sacrum with 2-0 PDS. To prevent bleeding from the pre-sacral vessels, occasionally we used a bone anchor system, Straight-In, in sacral fixation. Nine patients underwent this operation since August 19, 2005. The patient's age ranged from 48 to 78 years old. The median operation time was 250 minutes and the blood loss was 80.7 ml. The median post-operative hospital stay was 8.3 days. We experienced no peri- or post-operative complications. The vagina was well fixed post-operatively in all patients. Laparoscopic sacrocolpopexy is a minimally invasive treatment for vault prolapse and offers a high quality of life to patients.     

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.     

Trocar-guided total tension-free vaginal mesh repair of post-hysterectomy vaginal vault prolapse

Introduction and hypothesis  

The objective of this study was to report 1 year anatomical and functional outcomes of trocar-guided total tension-free vaginal mesh (Prolift™) repair for post-hysterectomy vaginal vault prolapse with one continuous piece of polypropylene mesh.     

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.     

A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study

Introduction and hypothesis

This prospective multi-centre true two-sided equivalence trial was designed to test the clinical equivalence of open (ASCP) and laparoscopic (LSCP) sacrocolpopexy using objective and subjective outcomes

Methods

The study was carried out in three urogynaecology units in England, UK and the patient population consisted of women referred with symptomatic and bothersome post-hysterectomy vaginal vault prolapse at least 1 cm above or beyond the hymeneal remnants. The interventions were either abdominal or laparoscopic sacrocolpopexy following randomisation to one of the types of surgery.

Results

For the primary outcome (point C on the POP-Q) the results at 1 year were ?6.63 cm for the open ASCP and ?6.67 cm for the LSCP respectively. Subjective outcomes at 1 year showed that 90% of the ASCP group and 80% of the LSCP group were “much better”. There were improvements with regard to blood loss, haemoglobin and shorter length of stay in the LSCP group compared with the ASCP group.

Conclusion

This fully powered randomised controlled trial comparing open and laparoscopic sacrocolpopexy has shown clinical equivalence.     

Anal incontinence and bowel dysfunction after sacrocolpopexy for vaginal vault prolapse

Introduction  

This study aimed to determine the prevalence of bowel dysfunction and anal incontinence in relation to vaginal vault prolapse surgery in women hysterectomized on benign indications.     

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.     

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.     

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.     

The treatment of post-hysterectomy vaginal vault prolapse: a systematic review and meta-analysis

Introduction and hypothesis

The treatment of post-hysterectomy vaginal vault prolapse (VVP) has been investigated in several randomized clinical trials (RCTs), but a systematic review of the topic is still lacking. The aim of this study is to compare the effectiveness of treatments for VVP.

Methods

We performed a systematic review and meta-analysis of the literature on the treatment of VVP found in PubMed and Embase. Reference lists of identified relevant articles were checked for additional articles. A network plot was constructed to illustrate the geometry of the network of the treatments included. Only RCTs reporting on the treatment of VVP were eligible, conditional on a minimum of 30 participants with VVP and a follow-up of at least 6 months.

Results

Nine RCTs reporting 846 women (ranging from 95 to 168 women) met the inclusion criteria. All surgical techniques were associated with good subjective results, and without differences between the compared technique, with the exception of the comparison of vaginal mesh (VM) vs laparoscopic sacrocolpopexy (LSC). LSC is associated with a higher satisfaction rate. The anatomical results of the sacrocolpopexy (laparoscopic, robotic [RSC]. and abdominal [ASC]) are the best (62–91%), followed by the VM. However, the ranges of the anatomical outcome of VM were wide (43–97%). The poorest results are described for the sacrospinal fixation (SSF; 35–81%), which also correlates with the higher reoperation rate for pelvic organ prolapse (POP; 5–9%). The highest percentage of complications were reported after ASC (2–19%), VM (6–29%), and RSC (54%). Mesh exposure was seen most often after VM (8–21%). The rate of reoperations carried out because of complications, recurrence prolapse, and incontinence of VM was 13–22%. Overall, sacrocolpopexy reported the best results at follow-up, with an outlier of one trial reporting the highest reoperation rate for POP (11%). The results of the RSC are too small to make any conclusion, but LSC seems to be preferable to ASC.

Conclusions

A comparison of techniques was difficult because of heterogeneity; therefore, a network meta-analysis was not possible. All techniques have proved to be effective. The reported differences between the techniques were negligible. Therefore, a standard treatment for VVP could not be given according to this review.

     

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.     

Perioperative outcomes after robotic versus vaginal surgery for pelvic organ prolapse

Journal of Robotic Surgery - The objectives of the study were to compare post-anesthesia care unit opioid use and pain scores, surgical and hospitalization times, and perioperative adverse events...     

Perioperative complications in abdominal sacrocolpopexy and vaginal sacrospinous ligament fixation procedures

This study assessed perioperative complications in abdominal sacrocolpopexy and vaginal sacrospinous ligament fixation procedures. Perioperative complications were defined as any complication occurring during surgery or the first 6 weeks postoperatively. Forty-five patients underwent abdominal procedures (20 sacrohysteropexy and 25 sacrocolpopexy) and 60 patients underwent vaginal sacrospinous fixation. Of the 105 patients, 13 had vaginal vault prolapse. In the abdominal group, one bladder injury, four hemorrhages, and three wound dehiscences occurred. In the vaginal group, one rectal injury and one postoperative vaginal vault infection occurred. Major and minor complications were more frequent in the abdominal group than in the vaginal group. Blood loss was not significantly different. The operating time and hospital stay in the abdominal group were significantly longer than in the vaginal group. In conclusion, abdominal sacrocolpopexy had a higher rate of perioperative complications and longer hospital stay and operating time.     

Colpocleisis for the treatment of vaginal vault prolapse

Most females with total vault prolapse undergo reconstructive procedures to restore normal anatomy and function; however, elderly patients who no longer desire sexual intercourse or are medically unstable can be treated effectively with a vaginal closure or colpocleisis. The traditional approach to colpocleisis has been to simply invert the vagina using pursestring sutures after removing the vaginal mucosa. Although simple to perform, after repairing referred treatment failures who used this approach, we began to use a different approach that emphasizes the strength of an anterior repair and extensive posterior repair that then is sutured together. This vaginal closure is reinforced with a strong perineorrhaphy. This multicompartment colpocleisis was performed in 38 elderly females (mean age 77, range 68 to 88) with total vault prolapse. No treatment failures were noted with a mean follow-up of 24 months (range 3 to 52 months), and all patients were satisfied with the results of the procedure. No significant complications occurred, and no patient has regretted the loss of sexual function. The aim of this article is to discuss the indications, procedural aspects, and results of performing a multicompartment colpocleisis and partial colpocleisis for total vault prolapse in elderly females.     

Marlex mesh prosthesis for massive vaginal vault prolapse

A case of repeatedly recurrent massive vaginal vault prolapse is presented. Representative articles on various ingenious modalities for the repair of this condition are reviewed. An additional safe and simple procedure is described. Criteria for the ideal prosthetic material are listed. Marlex mesh prosthesis, which appears to fulfil all the criteria required for use in vaginal surgery, is recommended not only as an onlay graft to support the soft tissues approximated, but also to cover wide gaps, as was presented in this case.